1. Practical Approaches to Opioid Prescribing: Working Within the Guidelines Brenda Lau MD, FRCPC, FFPMANZCA, MM

2. 2  Incorporate the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain and apply elements into a busy practice  Help you effectively utilize supporting tools such as the › Brief Pain Inventory (BPI) and the › Opioid Risk Tool (ORT), and  Implement improved opioid monitoring practices, including documenting the › 6 A’s and using the Opioid Manager* › Weaning guidelines Learning Objectives

3. 3  What is it? › An evidence-based guideline with 24 recommendations outlining how to use opioids to treat patients with CNCP  Why was it developed? › Existing treatment information and guidelines were found to be outdated  Why was it necessary? › To improve the safety and care of CNCP patients being treated with opioids, and to safely manage potential side effects (including addiction) and the risk of opioid misuse The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain http://nationalpaincentre.mcmaster.ca/opioid/http://nationalpaincentre.mcmaster.ca/opioid/,

4. 4  Available at: http://nationalpaincentre.mcmaster.ca/opioid/ The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

5. 5 CNCP = Chronic Non-Cancer Pain *Courtesy of: “Toronto Rehabilitation Institute” Available at: http://nationalpaincentre.mcmaster.ca/opioid/ The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

6. 6 Moods Depression Anxiety Anger Irritability Social Functioning Diminished social relationships (family/friends) Decreased sexual function/intimacy Decreased recreational and social activities Societal Consequences Health care utilization Disability Loss of work days or employment Substance abuse Physical Functioning Mobility Impaired Immununity Sleep disturbances Fatigue Loss of appetite Ashburn MA, et al. Lancet. 1999;353:1865-1869. Harden RN. Clin J Pain. 2000;16:S26-S32. Agency for Health Care Policy and Research. Clinical Practice Guideline No. 9. 1994. Meyer-Rosberg, K et al. Eur J Pain. 2001;5:379-389. Zelman D, et al. J Pain. 2004;5:114. Manchikanti L, et al. J Ky Med Assoc. 2005;103:55-62. Hoffman NG, et al. Int J Addict. 1995;30:919-927. Effects of Chronic Pain on the Patient

7. 7  Pain is moderate to severe  Pain has significant impact on function and QOL  Non-opioid pharmacotherapy has been tried and failed  Opioids indicated for specific pain condition  Opioid risk assessment has been done & documented  Informed consent (goals, risks, benefits, AEs, complications …)  Patient agreeable to have opioid use closely monitored (UDS, treatment agreement, freedom of information …)  Responsible prescribing of opioids Deciding to Initiate Opioid Therapy – Cluster 1

8. 8 Opioid Risk Tool & Checklist

9. 9 1. Diagnosis with appropriate differential 2. Psychological assessment › Including risk of addictive disorders 3. Informed consent › Verbal v. written/signed 4. Treatment agreement › Verbal v. written/signed 5. Pre trial assessment of pain/function and goals Universal Precautions in Pain Medicine

10. 10  One prescriber (include name)  One dispensing pharmacy (include name)  Will comply with safe/secured storage of opioid; Will comply with no driving while titrating  No sharing/selling of opioid; No accepting of any opioid medications from anyone else  Will not change the dose or frequency of taking the medication without consulting the doctor  Strict rules with respect to medication loss, early refills, possible abuse or diversion (e.g. Dr._________ will not prescribe extra medication for me. I will have to wait until the next prescription is due.)  Strict rules with respect to concomitant usage of other sedating medications, OTC/prescription opioids, recreational drugs (e.g. 222’s, Tylenol® #1 …)  Will comply with scheduled office visits and consultations  Will comply with pill/patch counts and random UDS when requested, and with limited quantity of opioid dispensed per prescription  Adverse effects, medical complications and risks (including addiction) of opioids understood  Freedom of information permitted  Understanding and agreement that if there is no demonstrable improvement in functionality, the physician reserves the right to wean patient off his/her opioid medications.  Understanding that if these conditions are broken, Dr. _______ may choose to cease writing opioid prescriptions for me Patient’s SignatureDate Physician’s SignatureDate Content of a Treatment Agreement

11. 11 (Passik 2000) 6.Appropriate trial of opioid therapy › +/- adjuvants › Replace short-acting opioid with long-acting opioid at equivalent dose › Limit the number of pills/patches that a patient may have at one time 7.Reassessment of pain score and level of function 8.Regular assess the “Six A’s” of pain medicine › Analgesia › Activities › Adverse effects › Ambiguous drug taking behaviur › Accurate medication record › Affect 9.Periodically review Pain Diagnosis and co morbid conditions including addictive disorders 10.DOCUMENT, DOCUMENT, DOCUMENT Universal Precautions in Pain Medicine

12. 12  Start low, go slow › Titrate to “optimal dose” › Remember safety issues when selecting opioids, including altered pharmacokinetics (e.g. liver/kidney) &/or drug interactions › Comprehensive review before nearing the “watchful dose”  Document progress / opioid effectiveness  Monitor adverse effects, medical complications, risks › Opioid Manager* › 6 A’s  If risks outweigh benefits, then: switch, taper ± discontinue *Courtesy of: “Toronto Rehabilitation Institute” Available at: http://nationalpaincentre.mcmaster.ca/opioid/. Conducting an Opioid Trial Summary – Cluster 2

13. 13 Opioid Manager

14. 14 Physical / RehabilitativePsychological Medical Pharmacological Interventional Goals Adapted from Jovey RD, 2008 Complementary and Alternative Medicine Chronic pain self-management programs Goals Guide Treatment Options

15. 15 The Analgesic Toolbox Non- opioid Acetaminophen, ASA, COXIB, NSAID OpioidBuprenorphine transdermal system, codeine, fentanyl transdermal system, hydromorphone, morphine, oxycodone, tramadol Choice exists between IR (immediate release) and CR (controlled release) formulations for many agents

16. 16 Basis for Opioid Selection Selection Criteria: Current /past efficacy and side effect profile of short-acting opioid Convenience and compliance potential Cost (coverage by drug plan or ability to pay) Patient preference History of abuse/misuse/diversion (screen) Concomitant health conditions necessitating adjustments in dosage and/or dosing interval of some opioids (e.g., morphine or codeine in renal failure) Compromised oral route Evidence of molecule efficacy for different pain characteristics Chou R et al, 2009; Gardiner-Nix; Wisconsin Medical Journal, 2004 ; Jovey RD et al, 2002

17. 17 Opioids: Initial Dose and Titration

18. 18 Maalis-Gagnon, Elafi Altlas 2010 Opioids: Initial Dose and Titration

19. 19 Morphine 10mg Codeine 60mg Oxycodone 7.5mg (O:M= 2:1 acute 1.5:1 chronic) Hydromorphone 2mg(H:M=5:1) Meperidine 100mg Methadone Variable Transdermal fentanyl 25ug/h = 60-134 mg 37ug/h = 135-179mg 50ug/h = 180-224mg 62ug/h = 225-269mg 75ug/h = 270-314mg 100ug/h = 360-404mg PO Opioid Analgesic Equivalence table

20. 20 When patient:  Does not realize meaningful pain relief from therapy  Has adverse reactions to opioids, such as depression or respiratory depression  Does not achieve reasonable therapeutic goals such as improved physical or social functioning, even with effective pain relief When to Stop Opioid Therapy Ballantyne JC et al, 2003; Benyamin R et al, 2008; Chou R et al, 2009; Porreca F et al,2009; Slatkin NE, 2009

21. 21  Discuss with the patient and other responsible persons who may be helpful. Patients with aberrant behaviour or addiction may refuse to comply and leave treatment, seeking opioids elsewhere. › Controlled withdrawal from opioids is not dangerous › May experience discomfort, anxiety, restlessness, nausea, sweating, etc.  Reassure patient of alternative plan for pain control.  Document discussions and provide a written treatment plan  If the patient is taking a sedative or benzodiazepine, these should be maintained Tapering Opioid Therapy Ballantyne JC et al, 2003; Chou R et al, 2009

22. 22  2010 National Opioid Use Guidelines (NOUG) serve to improve the responsible use of opioids in Canada  When considering the use of long-term opioid therapy, screening for addiction risk must be a part of the assessment process  Improvement in function as measured with the BPI is a key factor supporting the continuation of CR opioids in CNCP  Management of CNCP is multi-modal using non-opioid medications, interventional techniques and self-management strategies. Key Learning Points

23. Thank You Questions?