Improving safety and efficacy of opioid prescribing for pain in primary care

1. Improving safety and efficacy of opioid prescribing for pain in primary care William C. Becker, MD, FASAM Instructor Section of General Internal Medicine Yale University School of Medicine Good Morning everyone. Nice to be here today. I�m Will Becker from the Section of General Medicine and the primary care residency program at Yale. I�m going to be talking today about Improving safety and efficacy of opioid prescribing in primary care. This is the first of a lecture series under the broad heading of �addiction� that is a partnership between our section and Griffin�s department of internal medicine. In the spirit of full disclosure, this talk is as much about what is not addiction as it is about what is addiction but nonetheless, it seems this particular topic is one that I hope you will find engaging. A bit about my background: I�m a general internist with additional training in addiction medicine. I got interested in quality improvement in the treatment of chronic pain during residency when I found myself seeing a tremendous number of patients in primary care with chronic pain and frankly not feeling very prepared to take care of them. I have developed a specific interest in improving efficacy and safety of opioids but I�m also interested in improving treatment of chronic pain in general, involving opioids or not. Good Morning everyone. Nice to be here today. I�m Will Becker from the Section of General Medicine and the primary care residency program at Yale. I�m going to be talking today about Improving safety and efficacy of opioid prescribing in primary care. This is the first of a lecture series under the broad heading of �addiction� that is a partnership between our section and Griffin�s department of internal medicine. In the spirit of full disclosure, this talk is as much about what is not addiction as it is about what is addiction but nonetheless, it seems this particular topic is one that I hope you will find engaging. A bit about my background: I�m a general internist with additional training in addiction medicine. I got interested in quality improvement in the treatment of chronic pain during residency when I found myself seeing a tremendous number of patients in primary care with chronic pain and frankly not feeling very prepared to take care of them. I have developed a specific interest in improving efficacy and safety of opioids but I�m also interested in improving treatment of chronic pain in general, involving opioids or not.

2. Disclosure I have no potential or actual conflict of interest related to this presentation. OK so first I would like to attest that I have no potential or actual conflict of interest related to this presentation. OK so first I would like to attest that I have no potential or actual conflict of interest related to this presentation.

3. Learning objectives To understand terminology related to use of opioids for chronic non-cancer pain To appreciate the prevalence of chronic non-cancer pain, opioid prescribing and adverse events related to opioids To review fundamental components of effective management of chronic non-cancer pain To understand practical techniques for improving safety and efficacy of opioid prescribing for pain Next, let�s briefly review the learning objectives for today�s talk which areTo understand terminology related to use of opioids for chronic non-cancer pain To appreciate the prevalence of chronic non-cancer pain, opioid prescribing and adverse events related to opioids To review fundamental components of effective management of chronic non-cancer pain To understand practical techniques for improving safety and efficacy of opioid prescribing for pain Next, let�s briefly review the learning objectives for today�s talk which areTo understand terminology related to use of opioids for chronic non-cancer pain To appreciate the prevalence of chronic non-cancer pain, opioid prescribing and adverse events related to opioids To review fundamental components of effective management of chronic non-cancer pain To understand practical techniques for improving safety and efficacy of opioid prescribing for pain

4. Chronic Pain Pain lasting most of the day during most days for > 3 months Point prevalence in U.S. adults: 15-20% Lifetime prevalence in U.S. adults: 50-75% Pain is most often-reported symptom in office visits after URI Multi-faceted disorder that, by definition, has bio- psycho- social components First, let�s start by defining some terms starting with Chronic pain, which, is defined many different ways but I like: pain lasting most of the day during most days for > 3 months If you�ve spent any time in primary care you know this is a widely prevalent condition with the point prevalence in U.S. adults at 15-20% And an astounding Lifetime prevalence in U.S. adults from 50-75% Indeed Pain is most often-reported symptom in office visits after upper respiratory infection symptoms. These three facts are meant to illustrate the fact that chronic pain is not something we can run away from if we aspire to patient-centered healthcare. It is also, like all chronic diseases, a Multi-faceted disorder that, by definition, has bio- psycho- social components, none of which can be treated in isolation of the other if we�re going to treat it appropriately.First, let�s start by defining some terms starting with Chronic pain, which, is defined many different ways but I like: pain lasting most of the day during most days for > 3 months If you�ve spent any time in primary care you know this is a widely prevalent condition with the point prevalence in U.S. adults at 15-20% And an astounding Lifetime prevalence in U.S. adults from 50-75% Indeed Pain is most often-reported symptom in office visits after upper respiratory infection symptoms. These three facts are meant to illustrate the fact that chronic pain is not something we can run away from if we aspire to patient-centered healthcare. It is also, like all chronic diseases, a Multi-faceted disorder that, by definition, has bio- psycho- social components, none of which can be treated in isolation of the other if we�re going to treat it appropriately.

5. Prescription opioids Full opioid receptor agonists used to treat pain (acute and chronic) e.g. morphine, oxycodone, hydrocodone, methadone, codeine, hydromorphone, fentanyl Next, let�s discuss Prescription opioids which are full opioid receptor agonists used to treat pain (both acute and chronic) Some of which you are no doubt familiar with include: morphine, oxycodone, hydrocodone, methadone, codeine, hydromorphone and fentanyl. And in general, these opioids, as a class, are exceptionally effective analgesics because of the ubiquity of mu opioid receptors in the central nervous system. The mu opioid receptors are located in the dorsal horn of the spinal cord and effectively interfere with afferent pain transmission to the brain. There are also mu receptors in the medulla and midbrain which affect general level of consciousness and pain transmission and finally there are mu receptors in the hypothalamus, thalamus and cortex that further alter our processing and sensation of painful stimuli. Next, let�s discuss Prescription opioids which are full opioid receptor agonists used to treat pain (both acute and chronic) Some of which you are no doubt familiar with include: morphine, oxycodone, hydrocodone, methadone, codeine, hydromorphone and fentanyl. And in general, these opioids, as a class, are exceptionally effective analgesics because of the ubiquity of mu opioid receptors in the central nervous system. The mu opioid receptors are located in the dorsal horn of the spinal cord and effectively interfere with afferent pain transmission to the brain. There are also mu receptors in the medulla and midbrain which affect general level of consciousness and pain transmission and finally there are mu receptors in the hypothalamus, thalamus and cortex that further alter our processing and sensation of painful stimuli.

6. Reward pathways The ubiquity of the mu opioid receptor in the central nervous system has a double-edged sword if you will because opioids agonists are not only potent analgesics but because of the mu receptor�s presence in the midbrain, opioids are very effective and efficient stimulators of reward pathways. What do I mean by reward pathways? Typically, endogenous opioids are released when we engage in pleasurable activities and these endogenous opioids stimulate the production of dopamine in the so-called reward center of the midbrain. Dopaminergic neurons project to the cortex to stimulate repeated behavior and then recurrent pleasurable feelings that the brain perceives as linked to and caused by the original activity. In the case of opioid analgesics, these medications directly agonize the mu receptors that cause the dopamine release that project to the cortex. So, the pleasurable activity that the brain begins to crave is taking the medication itself and this is how addiction arises. The seeking of and taking of opioids supercedes virtually every other activity for the patient including even eating. Now to be clear I am in no way saying that addiction is an inevitable consequence of opioid-taking. In fact, we know that it is a small minority of patients, probably with a genetic susceptibility related to mu receptor polymorphisms and other genetic variability that contributes to the risk of addiction. The ubiquity of the mu opioid receptor in the central nervous system has a double-edged sword if you will because opioids agonists are not only potent analgesics but because of the mu receptor�s presence in the midbrain, opioids are very effective and efficient stimulators of reward pathways. What do I mean by reward pathways? Typically, endogenous opioids are released when we engage in pleasurable activities and these endogenous opioids stimulate the production of dopamine in the so-called reward center of the midbrain. Dopaminergic neurons project to the cortex to stimulate repeated behavior and then recurrent pleasurable feelings that the brain perceives as linked to and caused by the original activity. In the case of opioid analgesics, these medications directly agonize the mu receptors that cause the dopamine release that project to the cortex. So, the pleasurable activity that the brain begins to crave is taking the medication itself and this is how addiction arises. The seeking of and taking of opioids supercedes virtually every other activity for the patient including even eating. Now to be clear I am in no way saying that addiction is an inevitable consequence of opioid-taking. In fact, we know that it is a small minority of patients, probably with a genetic susceptibility related to mu receptor polymorphisms and other genetic variability that contributes to the risk of addiction.

7. Adverse effects of opioids Addiction: compulsive substance use despite harm = DSM-IV dependence, at least 3 of the following: Tolerance Withdrawal Greater amounts/longer period than intended Persistent desire/unsuccessful efforts to cut down Inordinate amount of time obtaining, using, or recovering Important social, occupational or recreational activities given up or reduced due to substance use Use continued despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by substance Incidence in opioid treatment for pain: ~2% per year Contrast with: �Physiologic Dependence� So this leads us into a more detailed discussion of the potential adverse effects of opioids, the first of which we�re already discussing�. Addiction, which I think can simply be defined as compulsive substance use despite harm and is synonymous with the DSM-IV term �dependence,� which is, by definition, at least 3 of the following: Tolerance, defined by needed more of a substance to achieve the same effect, Withdrawal, defined a characteristic physiologic response with abrupt cessation of a substance Using Greater amounts or over a longer period than intended Persistent desire but unsuccessful efforts to cut down Inordinate amount of time obtaining, using, or recovering from use of a substance Important social, occupational or recreational activities given up or reduced due to substance use Use continued despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by the substance. So again, 3 of these in the space of a year�s time is the definition of dependence which is the same as addiction. The best available data tell us that opiate addiction in the setting of opioid treatment for chronic pain is actually fairly rare: about 2% per year of opioid treatment. Where we struggle I think most with our terminology and, perhaps our attitudes as well, is in patients who are taking long-term opioids safely and, in fact, the DSM-V, which is supposed to be coming out soon may formally adopt the term addiction and do away with �dependence� which is kind of a confusing term for the following reason. A person So this leads us into a more detailed discussion of the potential adverse effects of opioids, the first of which we�re already discussing�. Addiction, which I think can simply be defined as compulsive substance use despite harm and is synonymous with the DSM-IV term �dependence,� which is, by definition, at least 3 of the following: Tolerance, defined by needed more of a substance to achieve the same effect, Withdrawal, defined a characteristic physiologic response with abrupt cessation of a substance Using Greater amounts or over a longer period than intended Persistent desire but unsuccessful efforts to cut down Inordinate amount of time obtaining, using, or recovering from use of a substance Important social, occupational or recreational activities given up or reduced due to substance use Use continued despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by the substance. So again, 3 of these in the space of a year�s time is the definition of dependence which is the same as addiction. The best available data tell us that opiate addiction in the setting of opioid treatment for chronic pain is actually fairly rare: about 2% per year of opioid treatment. Where we struggle I think most with our terminology and, perhaps our attitudes as well, is in patients who are taking long-term opioids safely and, in fact, the DSM-V, which is supposed to be coming out soon may formally adopt the term addiction and do away with �dependence� which is kind of a confusing term for the following reason. A person

8. Adverse effects, continued Misuse ? Use other than how prescribed: To get high More than prescribed Selling, trading = �diversion�

9. Adverse effects, continued �Drug-seeking Behavior� ? requests for opioid medications for the purpose of getting high �Aberrant Behaviors� ? among patients on opioids for chronic pain, behaviors that may be indicative of misuse or addiction Early refills Frequent phone calls Doctor shopping Prescription forgery

10. Adverse effects, cont�d Constipation Nausea Itching Dizziness Clouded mentation Sedation Falls Overdose Death

11. Annual sales of Rx opioids and unintentional overdose death1990 - 2006  Sources: unintentional drug poisoning mortality is from the National Vital Statistics System.. The drug poisoning mortality category is defined by E850-E858 in 1990 through 1998 and by X40-X44 in 1999 through 2004. The rate for 2005 is estimated as 95% of the unintentional poisoning death rate. Total sales are from DEA ARCOS. Opioid sales are in total morphine equivalents for all major opioids combined except codeine. The conversions are the same as those used in Paulozzi and Budnitz, Pharmacoepidemiology and Drug Safety, 2006. Sales data for 2006 is estimated from the first 3 quarters of 2006. Sources: unintentional drug poisoning mortality is from the National Vital Statistics System.. The drug poisoning mortality category is defined by E850-E858 in 1990 through 1998 and by X40-X44 in 1999 through 2004. The rate for 2005 is estimated as 95% of the unintentional poisoning death rate. Total sales are from DEA ARCOS. Opioid sales are in total morphine equivalents for all major opioids combined except codeine. The conversions are the same as those used in Paulozzi and Budnitz, Pharmacoepidemiology and Drug Safety, 2006. Sales data for 2006 is estimated from the first 3 quarters of 2006.

12. How did we get here? 1990s Under-treatment of pain Pain as the 5th vital sign Pain as a human rights issue Early data that opioid risks were low, some of which intentionally minimized Interwined cultural and medical trend towards �a pill for what ails ya�� In 1999, the VA launched an initiative called �Pain as the 5th vital sign,� where nurses started asking about and documenting pain scores for all patients. The following year, JCAHO followed suit in requiring routine pain assessment. In this setting, more physicians began paying more attention to pain and treating pain more aggressivelyIn 1999, the VA launched an initiative called �Pain as the 5th vital sign,� where nurses started asking about and documenting pain scores for all patients. The following year, JCAHO followed suit in requiring routine pain assessment. In this setting, more physicians began paying more attention to pain and treating pain more aggressively

13. Juggling? So, what�s a physician to do? Many of us feel like we are juggling� trying to keep several thorny issues in mind. For those of us who aren�t skilled jugglers, it may feel chaotic and out of control. However, I want to introduce to you a model for addressing opioid management that will feel more deliberate and controlled.So, what�s a physician to do? Many of us feel like we are juggling� trying to keep several thorny issues in mind. For those of us who aren�t skilled jugglers, it may feel chaotic and out of control. However, I want to introduce to you a model for addressing opioid management that will feel more deliberate and controlled.

14. Case 57 M w/ chronic low back pain for 15 years after being thrown out of a jeep Worked as officer in NHPD until 50 Lives with wife and 3 daughters, active in community Admits to cocaine and speed for 1-2 years 25 years ago Pain has been worsening and interferes with functioning Dx based on hx/PE/MRI: spinal stenosis You prescribe NSAIDS, capsaicin, physical therapy After 8 weeks pt still experiencing significant pain that is negatively affecting function; you start opioids (MSContin 15 mg TID titrated to 30 mg TID) to good effect: improved pain and function One month later, routine UDT positive for cocaine

15. What do you do now? We�ll get to that discussion but also� What should you have done in the first place?

16. Practical techniques for improving efficacy and safety of opioid prescribing

17. Where it all begins Comprehensive approach to high-quality management of chronic pain Empathize, partner with the patient Perform a complete history and physical Set functional goals Utilize shared decision-making Employ multi-modal treatment plan Employ rational polypharmacy When using opioids: Follow the harm/benefit paradigm Perform frequent monitoring, reassessment and DOCUMENTATION

18. Empathize/Partner with your patient �Identification with and understanding of another person's situation or feelings�

19. Breaking the cycle �You�ve been through a lot.� �My goal is help *you* manage this better� � EMPOWER the patient to be the locus of control/change �Your pain will not go away entirely. Our goal is to get better control of it.� �Moving, stretching, activity will help you reach your goal.� �Uncontrolled pain makes mood worse, bad mood makes pain worse � have to work on both.�

20. Complete history and physical Region/systems involved Quality of pain Temporal characteristics Degree of intensity Time since onset This is the biological approach�. necessary but not sufficient

22. Tumors Fractures Infection Cauda Equina Syndrome Addiction Suicidality

23. Complete history and physical, cont�d Full standard exam plus: Focus on function � Watch the patient walk Ask the patient to transition from seated to standing position Ask the patient to stand on the floor, flex the back, extend the back

24. Set Functional Goals Functional Status: What�s a typical day like? What�s the most active thing you do? Do you ever stay in bed all day? Do you get any exercise? How have these things changed over the past weeks/months/years? What would you (realistically) like to be able to do?

25. Utilize Shared-Decision Making Uncontrolled chronic pain is found more often in patients who Are passive Catastrophize Perceive an external locus of control Counteract these by requiring the patient to make decisions and set goals with you.

26. Employ multi-modal approach

27. Employ Rational Polypharmacy Anti-nociceptive agents NSAIDs Acetaminophen Opioids Anti-neuropathic agents Anti-convulsants Tricyclics Anti-depressants

28. When Using Opioids, Follow the Harm/Benefit Paradigm

29. Initiating opioid treatment: When? When functional goals have not been achieved with non-opioid therapies (acetaminophen, ibuprofen, lidocaine, capsaicin, TCAs, gabapentin, physical therapy) New patient already on opioids

30. Initiating opioid treatment: Who? Active addiction (alcohol, illicit drugs, prescription medications) is a contraindication Risk factors for misuse that should prompt closer follow up but do not necessarily preclude opioid therapy Younger age Personal history of substance abuse Illicit, prescription, alcohol, smoking Family history of substance abuse Legal history (DUI, time in jail) Mental health disorders Patient who is showing engagement with process

31. Initiating opioid treatment: How? Therapeutic trial in the harm/benefit paradigm Set specific, functional goals Refer back to those goals to assess benefit Which medication? Long/short acting Strength Formulation Abuse potential

32. Informed consent Communication of risks, potential benefits, goals/expectations, and treatment and monitoring plans Written agreements or �contracts� Educate patient about safe opioid use Clearly define acceptable behavior

33. Opioid treatment agreements Tone is important: �This is so you know what to expect from us and what we expect from you� �This is about keeping you safe� �We do this for all patients�

34. What should be in your OTA? What patient can expect of the practice: A good faith effort to manage patient�s pain What practice can expect of patient: No unsanctioned dose escalation No early refills No replacement for lost or stolen prescriptions Single prescriber Safeguard meds and no sharing Keep regular appointments Follow-through with referrals and adjuvant treatment No use of illicit drugs or non-prescribed controlled substances Urine drug testing Whom/When to call for refill If agreement not followed, may taper opioids off and/or refer to addiction treatment

35. Monitoring: the 5 A�s Analgesia � 11- pt Numeric Rating Scale Activities of daily living (function) � �Your goal was to get back in your walking routine. How is it going?� Adverse effects: constipation, sedation, etc � ASK! Addiction/overuse � Is the patient oversedated? Does pt think he is addicted? Does the patient use other illicit drugs? Adhering to the treatment agreement

36. CT prescription monitoring program www.ctpmp.com Log of every scheduled medication filled in any Connecticut pharmacy Sortable by patient 1-2 week lag time

37. Urine drug testing Identifies more misuse than self-report or physician impression Which test to order? Immunoassay is screen Gas chromotography/mass spectroscopy for confirmation � would recommend doing this any time you get an unexpected result Always ask and document recent intake before sending test 84/185 (46%) with positive UDT denied illicit drug use during research interview, even when they were guaranteed anonymity (Fleming 2007) 84/185 (46%) with positive UDT denied illicit drug use during research interview, even when they were guaranteed anonymity (Fleming 2007)

38. How to discuss UDT �This is our routine practice.� �We want to ensure your safety.�

39. UTox8

40. Interpreting UDT Common errors: Standard Utox8 does not include oxycodone or fentanyl: you must include tests of medications patient is prescribed In most cases, oxycodone will NOT cause opiate assay to be positive; however, it can in high doses. Therefore, you MUST do confirmatory testing Hydrocodone metabolizes to hydromorphone so pt who takes hydrocodone may frequently have + hydromorphone on opiate GC/MS.

41. Responding to problems Reassess Document findings and plan Structured risk management Short courses and follow-up Frequent UDT and/or pill counts Referral to pain or addiction specialist Taper off opioids

42. Stay in the harm/benefit paradigm Explain how patient�s behavior or the outcome of the treatment is not in line with the treatment agreement. Firm but empathic -- you will still work with pt on pain treatment and primary care Pt is not bad; treatment is not effective, not safe, not appropriate. Benefits no longer outweighing harms. �Cannot responsibly continue prescribing opioids as I feel it would cause you more harm than good.�

43. Case 57 M w/ chronic low back pain for 15 years after being thrown out of a jeep After 8 weeks pt still experiencing significant pain that is negatively affecting function; you start opioids (MSContin 15 mg TID titrated to 30 mg TID) to good effect: improved pain and function One month later, routine UDT positive for cocaine

44. What was done/should have been done in advance Comprehensive approach to high-quality management of chronic pain Treatment agreement: discussion with pt about risk and benefits �Fair warning� that UDTs would be done �Fair warning� that + UDT might mean discontinuing opioids Practice-wide decision about how treatment agreement violations handled

45. What to do now? Get GC/MS confirmation of any unexpected result (if confirmed) Talk to patient, reveal result of test, ask him why he used Show empathy but do not allow patient to dispute results Show empathy but do not allow patient to shift blame: �I did it because my pain was out of control/you are not treating my pain� Based on practice policy, either begin opioid taper or �second chance� with close monitoring (1-2 week follow up with UDT) Consider addiction referral based on your assessment

46. Opioid Management: Summary If prescribed, opioids for chronic pain must be part of a comprehensive pain management plan Treatment agreements are useful to keep everyone on the same page Patients must be monitored for the 5 As Know the tools available to you for monitoring and how to use them Opioids should be continued when effective and safe, discontinued if ineffective or unsafe Use this harm/benefit paradigm to help you communicate with patient Document Several experts, professional societies, and regulatory agencies have published guidelines for opioid management. I�ve distilled their key recommendations here, and will discuss them in more detail in the coming slides. Initial assessment includes RISK of opioid misuse, appropriateness of opioids (pt has tried non-opioid pharmacologic and nonpharmacologic therapies). Monitoring includes assessing responsiveness to opiods (pain and function), but also adverse effects and aberrent medication taking behaviors. Need to consider adjuvant therapies such as PT, possibly counseling, biofeedback, acupuncture, as well as pharmalogic adjunts such as NSAIDS, TCAs� It has been recommended that PCPs refer all patients with any risk factors for misuse, or for whom problems arise, to pain or addiction specialists. Unfortunately, they are not always accessible. Still, we need to refer when we are out of our comfort level or to SA tx if patient is exhibiting signs of addiction.Several experts, professional societies, and regulatory agencies have published guidelines for opioid management. I�ve distilled their key recommendations here, and will discuss them in more detail in the coming slides. Initial assessment includes RISK of opioid misuse, appropriateness of opioids (pt has tried non-opioid pharmacologic and nonpharmacologic therapies). Monitoring includes assessing responsiveness to opiods (pain and function), but also adverse effects and aberrent medication taking behaviors. Need to consider adjuvant therapies such as PT, possibly counseling, biofeedback, acupuncture, as well as pharmalogic adjunts such as NSAIDS, TCAs� It has been recommended that PCPs refer all patients with any risk factors for misuse, or for whom problems arise, to pain or addiction specialists. Unfortunately, they are not always accessible. Still, we need to refer when we are out of our comfort level or to SA tx if patient is exhibiting signs of addiction.

47. Thank you

49. Bibliography Caudill-Slosberg et al. Pain (2004) Davis WR, Johnson DB. Prescription opioid use, misuse, and diversion among street drug users in New York City. Drug and Alc Dep. 2008;92:267-276. Fleming MF et al. J Pain. 2007 Katz NP. Patient Level Opioid Risk Management. PainEDU.org Manual. 2007 Olsen Y et al. J of Pain (2006); Passik J Opi Manage 2005 R.K. Portenoy, �Opioid Therapy for Chronic Nonmalignant Pain: Current Status,� in H.L. Fields and J.C. Liebeskind, eds., Progress in Pain Research and Management (Seattle: IASP Press, Vol. 1, 1994): at 267. Monitoring the Future National Survey of Drug Use and Health Drug Abuse Warning Network TEDS Zacny JP, Galinkin JL. Psychotropic drugs used in Anesthesia Practice: Abuse Liability and Epidemiology of Abuse. Anesthesiology. 1999;90(1):269-288.

50. Recall that not all AMTB are misuse! In fact, despite the term, some may be normal behavior (passik found 45% with ADRB in 6 mos) Recall that not all AMTB are misuse! In fact, despite the term, some may be normal behavior (passik found 45% with ADRB in 6 mos)

51. Outline Case Context Achieving balance Initiating opioid treatment Informed consent and agreements Monitoring and documentation (the 4 As) Responding to problems First we�ll discuss pain and opioid use in historical and societal context Then I will introduce a model of opioid management based on balancing risks and benefits I will discuss how to initiate opioid treatment, including selecting medications and defining a treatment plan, Using informed consents and/or opioid treatment agreements (OTAs), How to monitor patients on long-term opioids, and document it, And finally, provide some strategies for responding to inevitable problems First we�ll discuss pain and opioid use in historical and societal context Then I will introduce a model of opioid management based on balancing risks and benefits I will discuss how to initiate opioid treatment, including selecting medications and defining a treatment plan, Using informed consents and/or opioid treatment agreements (OTAs), How to monitor patients on long-term opioids, and document it, And finally, provide some strategies for responding to inevitable problems

52. Opioids for chronic pain Increasing use for musculoskeletal pain: 1980 to 20001 6% of all primary care visits in 20012 Between 1980 and 2000, opioid prescription increased from 8% to 16% of outpatient visits for chronic musculoskeletal pain (NAMC data). Half of all chronic pain is managed by primary care docs (also Caudill-Slosberg NAMC data). Use in opioids in PC is now extremely prevalent, with a prescription for opioids being written at over 6% of all PC visits. Between 1980 and 2000, opioid prescription increased from 8% to 16% of outpatient visits for chronic musculoskeletal pain (NAMC data). Half of all chronic pain is managed by primary care docs (also Caudill-Slosberg NAMC data). Use in opioids in PC is now extremely prevalent, with a prescription for opioids being written at over 6% of all PC visits.

53. Sources of misused opioids 19% directly from a doctor 56% given for free by a friend or relative 81% of those friends/relatives received them from a doctor 9% bought from a friend or relative 4% from a drug dealer or stranger When asked where they obtained the last opioids they misused, the majority of adults (>12 yo) reported getting them from a doctor or from a friend/relative who got them from his/her doctor. <1% from internet. According to data from the 2006 NSDUH, the majority of misused opioid analgesics are supplied by physicians (directly or indirectly). When asked where they obtained the last opioids they misused, the majority of adults (>12 yo) reported getting them from a doctor or from a friend/relative who got them from his/her doctor. <1% from internet. According to data from the 2006 NSDUH, the majority of misused opioid analgesics are supplied by physicians (directly or indirectly).

54. Increasing opioid misuse, morbidity, mortality incidence misuse1,2 admissions for addiction treatment3 ED visits4 overdose deaths5 In the 2006 NSDUH, 5% of Americans >12 reported abusing opioid analgesics in the prior year. Of all abusable drugs, opioid painkillers were the most frequently newly initiated in 2006, finally overtaking marijuana. TEDS: 4-fold increase in mentions of opioid analgesics 96 to 06) DAWN: ED visits increased 24-33% (24 overall, 29 methadone, 33 other opioids) from 2004 to 2005 while overall drug abuse mentions remained flat NCHS: 4x inc methadone deaths 99-04 (fingerhut study) In the 2006 NSDUH, 5% of Americans >12 reported abusing opioid analgesics in the prior year. Of all abusable drugs, opioid painkillers were the most frequently newly initiated in 2006, finally overtaking marijuana. TEDS: 4-fold increase in mentions of opioid analgesics 96 to 06) DAWN: ED visits increased 24-33% (24 overall, 29 methadone, 33 other opioids) from 2004 to 2005 while overall drug abuse mentions remained flat NCHS: 4x inc methadone deaths 99-04 (fingerhut study)