The Role of Opioid Medication in Chronic Pain Management

1. The Role of Opioid Medication in Chronic Pain Management Lorraine Widdall, MS APRN BC Interventional Spine and Pain Center

2. Indiana Prescribing Guidelines • Effective December 15, 2013 • Emergency rule that temporarily adds provisions under P.L. 185-2013 (SEA246) regarding physicians prescribing opioids for chronic pain. • Under Title 844 Medical Licensing Board of Indiana

3. Included: • Patients with chronic pain. • Chronic Pain is defined in this document as: A state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.

4. Excluded: • Patients with a terminal condition • Residents of a healthcare facility • Patients enrolled in a hospice program • Patients enrolled in an inpatient or outpatient palliative care program of a hospital

5. Guidelines apply when: Patient has been prescribed: • More than 60 opioid containing pills a month; or • A morphine equivalent dose of more than 15 mg per day; for more than 3 consecutive months

6. Also included • Evaluation and Risk stratification • Education of the patient as to risks and benefits of opioid therapy as well as expectations related to prescription requests and proper medication use • Continual monitoring and evaluation of therapy • DOCUMENTATION

7. Why? • Indiana legislature passed a law, in compliance with a federal mandate for states, requiring the Indiana Medical Licensing Board to develop an emergency opioid prescribing rule. • Proliferation of “pill mills” • Prescription drug abuse has become a bigger problem than all other illicit street drugs • Pain has been treated as “5th Vital Sign”

8. Is there a problem? The US comprises 4% of the world’s population yet consumes 85% of the opioid medication. CDC

9. Lake County, IN • Detox in Lake County Jail exploding from prescription drugs (10:1 RX to heroin) • Sheriff has established the High Intensity Drug Trafficking Task Force (Seized over $7M in RX drugs in 2013, already over that for 2014) • New trend: heroin cut with BZA • Wellbutrin and Gabapentin snorted together mimic heroin.

10. Indiana • 17th in US for RX drug deaths • Porter county #1 in IN for heroin deaths • In 2013, the OAG filed disciplinary complaints against 15 physicians for overprescribing pain medication; so far in 2014 they have already surpassed that number

11. Opioid Free Treatment • Procedures • Physical therapy/Aquatic therapy • Lifestyle changes • NSAID • Adjuvant medications • Psychological counseling • Alternative treatments

12. Procedures • Epidural Steroid Injections • Joint injections Steroid/Hyaluronate(Synvisc or Hyalgan) • Trigger Point Injections • Scar Neuroma Injections • Nerve Blocks (Chemical/Thermal) • Chemodenervation (Botox)

13. Physical Therapy • Aquatic Therapy • Land Based • Home exercise program

14. Lifestyle Changes • Weight loss • Smoking Cessation • Activity pacing • Back to work (work hardening/conditioning/restrictions) • Exercise

15. NSAID’s • OTC ibuprofen and naproxen • Prescription Mobic, Celebrex, Motrin, Diclofenac • Tylenol • Topical preparations Pennsaid, Voltaren Gel, Flector patches

16. Adjuvant Medications • Antidepressants: Nortriptyline, Amitriptyline, Effexor, Cymbalta, Savella • Antiseizures: Gabapentin, Lyrica, Topamax, Lamitcal, Tegretol, Gralise • Muscle Relaxants: Baclofen, Tizanadine, Flexeril, Zanaflex, Robaxin, Skelaxin, (Exclude Soma) • Sedative/Antianxiety: Valium, Xanax, Klonopin • Topical: Lidoderm

17. Psychological Counseling • Evaluation is ALWAYS appropriate • Treat underlying issues that are closely related to pain such as depression and sexual abuse • Biofeedback • Relaxation/meditation • Imagery • Music therapy

18. Alternative Treatments • Acupuncture • Acupressure • Massage • Hypnosis

19. Managing Opioid Therapy • Evaluation and risk stratification History and physical Obtain and review records from other providers Objective pain assessment tool Risk for substance abuse tool (SOAPP) Establish working diagnosis and tailor a treatment plan

20. Managing Opioid Therapy • Risks/benefits and expectations Discuss alternative modalities to opioids Simple and clear explanation to help patient understand the key elements of their treatment plan Discuss with females ages 14-55 with childbearing potential possible risks to the fetus

21. Managing Opioid Therapy • Review and sign a treatment agreement which shall include at least the following: 1. Goals of treatment 2. Consent to drug testing*****(delayed until 1/1/15 due to ACLU lawsuit filed 1/8) 3. Physician prescribing policies which must include (at least) that the medication be taken as prescribed and not shared with anyone else.

22. 4. A requirement that the patient inform the physician about any other controlled substances prescribed or taken. 5. Permission for random pill counts 6. Reasons that the opioid therapy may be discontinued or changed by the physician. *A copy of this agreement is to be retained in the patient’s chart.

23. Managing Opioid Therapy • Periodic scheduled face to face visits Stable medication regime: at least every 4 months Changed medication regime: at least every 2 months During the visit, evaluate progress and compliance and set clear expectations along the way (such as participation in physical therapy)

24. Managing Opioid Therapy • INSPECT At the outset of an opioid treatment plan and at least annually thereafter. Document in chart the consistency with physician’s knowledge of patient’s controlled substance history

25. Managing Opioid Therapy • Drug Testing At the outset of opioid treatment plan and at least annually thereafter. Doesn’t specify serum, urine or saliva Must include confirmatory test results Inconsistencies or presence of illicits require review of treatment plan. Documentation of revised plan and discussion with patient must be recorded in chart.

26. Managing Opioid Therapy • When a patient’s opioid dose reaches a morphine equivalent of 60 mg/day: Face to face review of treatment plan Consideration of referral to specialist If continuing therapy, there must be a revised assessment and plan for therapy Documented assessment of increased risk for adverse outcomes, including death.

27. Appropriate Use of Opioids • Short acting: Tylenol with codeine, Tramadol, hydrocodone, oxycodone, hydromorphone, Nucynta • Long acting: MS Contin, Fentanyl, Opana, Oxycontin, (Zohydro) • Methadone • Demerol • Intrathecal opioid therapy

28. Appropriate Use of Opioids • THE HOLY TRINITY Hydrocodone Muscle Relaxant (Soma) Benzodiazepine Red flag for DEA

29. Appropriate Use of Opioids • PRN vs. Scheduled • Treat flares and return to baseline • It’s OK to say “no.” • Be aware of trends and fads (Adderall) • Stay informed and aware www.opiophile.org

30. Resources • Lake County Drug Task Force 219-755-3822 • www.deadiversion.udsoj.gov • Scott Nowland (219) 681-7000 x128 • www.cdc.gov • www.bitterpill.IN.gov (Indiana AG office) • www.supportprop.org (Physicians for Responsible Opioid Prescribing)