1. CDC Guideline for Prescribing Opioids for Chronic Pain- United States-2016 Gisele J. Girault, M.D. First Choice Healthcare Columbia, SC

2. Scope and Audience of the Guidelines Targeted for primary care physicians PCPs account for almost 50% of all dispensed opioid prescriptions Growth in PCP prescribing has been above average PCPs report concern over their insufficient training in opioid prescribing

3. Other Opioid guidelines SC Medical Board Federation of State Medical Boards American Pain Society American Dental Association American Academy of Family Physicians

4. Rationale behind the CDC Guidelines? In 2012, >259 million scripts written 2007-2012 prescribing increased by 7.3% Prescribing varies greatly across states Significant increase in opioid prescribing in pediatric ages 12-17 years PCPs have concerns about abuse and addiction Lack of consensus on how to use opioids

6. Goals of the CDC Recommendations To improve communication between providers and patients To improve effectiveness of pain treatment To reduce the risks of long term opioid therapy including opioid use disorder and overdose

7. Specific Recommendations Determining when to initiate or continue opioids for chronic pain Opioid selection, duration, follow up, and discontinuation Assessing risk and addressing harms of opioid use.

8. Determining When to initiate or Continue opioids for chronic pain Opioids are not a first line or routine therapy for chronic pain Establish and measure goals for pain and function Discuss the risks and benefits of non-opioid therapies with patients

9. Pain Management Therapies Pharmacological Therapies Psychological Therapies Physical Therapies Procedural Therapies

10. Opioid selection, dosage, duration, follow-up, and discontinuation Use short acting opioids when starting Start low and go slow In acute pain prescribe no more than needed Do not prescribe ER/LA opioids in acute pain Follow up and re evaluate risk of harm; reduce or taper and discontinuation if needed

11. LA/ER opioids vs. Short acting ***Abuse Deterrent formulations Ultram ER MS Contin, Kadian, **Embedda **Oxycontin **Nucynta ER **Opana ER **Exalgo Ultram MSIR OxyIR, Percocet Nucynta Opana Dilaudid/Hydromorph one

12. Assessing Risk and addressing Harms of Opioid Use Evaluate risk factors for opioid related harms Check PDMP for scripts from other sources Using UDS to identify all substances Avoid using benzos and opioids concurrently Arrange treatment for Opioid Use Disorder (OUD) if needed

13. Risk Assessment Tool Screener and Opioid Assessment for Patients in Pain-Revised, (SOAPP-R) Current Opioid Misuse Measure, (COMM) Opioid Risk Tool, (ORT) Stratify patients on opioids or considering opioids into low, medium and high risk based on predicting risks of aberrant behaviors

15. Urine Drug Screens Use risk stratification tool to put patients in high, medium or low risk Test frequency based on risk category Examples –High risk test q 1-3 months –Medium risk test every 3-6 months –Low risk test every 6-12 months Test more frequently if needed

16. Opioid Use Disorder, (OUD) DSM-V A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, (criteria) occurring within a 12-month period:

17. Medication-Assisted Treatment for Opioid Addiction (MAT) Methadone-outpatient clinic Schedule II Need special license to prescribe for opioid addiction Liquid form, daily dosing from clinics Buprenorphine/Naloxone Suboxone, Zubsolv, Probuphine Schedule III DATA 2000 license ;limit of 275 patients

18. Abuse-Deterrent forms of Buprenorphine

19. Opioids and Co-morbidities Sleep disturbances Reduced renal or hepatic function Concurrent use of benzodiazepines Pre existing depression or psychiatric dx Concurrent use of psychotropic drugs Age >65 History of OUD or aberrant substance use

20. Opioid Dose and Risk factors ASE increase with increasing doses –<50 morphine mg equivalents (MME) –50 - 90 MME –> 100 MME MME is a conversion from one opioid to mg of Morphine For example 20 mg Oxycodone = 30 MME

21. Opioid Dose and Risk Factors 80% of overdoses are in the > 100 MME range Opioid hyperalgesia increased at higher doses Higher risks of respiratory depression >50MME used as a trigger for prescribing Naloxone

22. Naloxone

23. What is the problem? 2013 est. 1.9 million people abusing prescription opioid medications H/o getting a script increases the risk for OUD and overdose Recent study showed 550 died from overdose at 2.6 years after initial script 1 in 32 over 200 MME died of overdose

24. What’s the problem? Death rates from CAD, and cancer have declined Opioid associated death rates have increased dramatically Roughly 20% of physicians prescribe 80% of opioid scripts Opioid prescribing has increased with opioid sale$ Each day over 5000 new non-medical users

25. Overdose Statistics

27. Sources of diverted opioids

30. How do we turn this around? Better education for physicians in opioid management Mandates for physicians to use PDMP Limit the number/amount/time frame for prescribing opioids? Limit who can prescribe opioids, DEA? Pressure on TPP to pay for abuse deterrent drugs

31. Conclusions CDC Guidelines are a good start in improving the safety of opioid prescribing Stricter mandates for physicians who prescribe opioids Pressure TPP and drug companies to make better opioids financially accessible