1. Chronic Opiate Therapy Benjamin Meeks, FNP

2. Agenda History of Opiate Therapy Risks of Opiate Therapy Benefits of Opiate Therapy Guidelines for Opiate Therapy Case Studies

3. “Give strong drink to those who are about to perish” - Solomon

4. Modern History Portenoy and Foley 1986 –Study of 38 chronic pain patients – 4 – 7 years duration –66% maintained on 40mg to 60mg morhpine

5. Modern History 1989 Weissman and Haddox introduce concept of pseudoaddiction 1995 Introduction of time released oxycodone Titrate to effect or side effect

6. Modern History 97% increase in opioid sales from 1997 to 2010 2010 Misuse or abuse of pharmaceuticals overtakes alcohol in reason for ED visits Drug overdose deaths increase 250% 2000 – 2010 15.1% increase in American population over the age of 65 from 2000 - 2010 Estimated 116 million American with chronic pain

7. Ethical Imperatives Treat your patients pain. Do no harm by contributing to abuse and diversion.

8. Risks of Opiate Therapy Constipation/Urinary Retention – 41% Tolerance Hypogonadism – 11% Addiction Death Falls/Accidents

9. Tolerance Reversible physiologic response to the persistent presence of opiate agonists leading to diminishing therapeutic effect Mechanism not fully understood Poorly studied

10. Addiction Addiction/Medication Misuse Addiction rates vary by study 5% to 41% of chronic pain patients 20% of general population reports “non-medical use” of opiates Aberrant behaviors in 11.5% to 24% Aberrant behaviors/Addiction appear greater in those aged <56 years, smokers and unemployed

11. Falls/Accidents Exposure to opiates increased fall risk by 38% Greater than 50mg morphine equivalent doubled risk of falls More common with new opioid prescription Greatest in 18 – 29 year old age group

12. What risks does my patient have?

13. Benefits of Opiate Therapy Pain Control Improved Social Function Improved Mental Health Improved Physical Function

14. Benefits of Opiate Therapy Meta-analysis of 28 studies with chronic nonmalignant pain demonstrated improvements in pain and function studies only up to five weeks Very little long term evidence no studies longer than 2 years, many not controlled No long term studies demonstrate strong evidence for opiate therapy No evidence showing benefit of long acting versus short acting opiates

15. Guidelines – ASIPP 2012 Comprehensive Assessment –Pain Condition –Medical History –Physical Exam –Psychosocial History –Functional Status –Sleep –Psychological Evaluation –Prescription Monitoring Program –Urine Drug Screening

16. Case Study 65 year old married white male, 5’10”, 275 lbs, disabled coal miner, 1 ppd smoker, denies alcohol usage, reports chronic worsening back pain without extremity pain, medical history significant for O2 dependent COPD, HTN, diabetes and mild kidney disease, lives with wife and teenage grandchild, no current medications for pain, no recent radiology Do you prescribe opiates for this patient?

17. Case Study 40 year old co-habitating white male, 5’10”, 250 lbs, disabled construction worker, 2 ppd smoker, denies alcohol usage, reports five year history of worsening back pain without extremity pain, medical history significant for COPD, lives with girlfriend, failing over the counter NSAIDS/APAP, MRI reveals multilevel disc degeneration and faect arhtropathy without foraminal stenosis. Do you prescribe opiates for this patient?

18. Case Study 30 year old married female, 5’5”, 140lbs, non-smoker, employed as elementary school teacher 6 week history of worsening low back and right leg pain began after lifting a box of books, numbness right lateral foot, not improving with physical therapy, missing work due to pain, sleep is disturbed due to pain, MRI demonstrates right L4-5 herniation, lives with husband and 2 children ages 4 and 6. Ibuprofen 800 TID not helpful and causing GI upset. Do you prescribe opiates for this patient?

19. Summary Long term opiate therapy has medically proven significant life altering risks Long term opiate therapy has not been as yet proven in the research to improve function, mood and reduce pain over a period of years Consider risks, benefits and potential duration fo therapy before writing the first prescription for opiates