1 / 29

Evidence-Based Chronic Pain Management: How Well Do Physicians Do It?

Evidence-Based Chronic Pain Management: How Well Do Physicians Do It?. Barbara J Turner MD, MSED Mahlon H. Delp Lecture September 11, 2009 . Chronic Non-Cancer Pain Management. Pain in community and primary care settings Efficacy of opioids for chronic non-cancer pain care

layne
Download Presentation

Evidence-Based Chronic Pain Management: How Well Do Physicians Do It?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Evidence-Based Chronic Pain Management: How Well Do Physicians Do It? Barbara J Turner MD, MSED Mahlon H. Delp Lecture September 11, 2009

  2. Chronic Non-Cancer Pain Management • Pain in community and primary care settings • Efficacy of opioids for chronic non-cancer pain care • Side effects of opioids • Misuse and death • Reducing misuse • Disparities in use of opioids for pain • Opportunities to improve our care

  3. Prevalence of Chronic Pain • Community-based and primary care population-based surveys • 10-15% of respondents report chronic pain Smith BH, Fam Pract,2001 Hardt J, Pain Med. 2008 • Four-year follow-up survey of 2,200 U.K. primary care patients with chronic pain at baseline • 79% still had constant or frequent pain Elliott AM, Pain, 2002

  4. Efficacy for Chronic Back Pain • Systematic review • 5 trials with different opioid regimens • Assess change in pain from baseline • Reduction in pain, P =0.055 • Limitations • <16 weeks duration • Disparate opioid regimens • Generally moderate opioid doses Martell B, Ann Intern Med, 2007 Deshpande A. Cochrane Database Syst Rev. 2007

  5. Efficacy for Neuropathic Pain • Meta-analysis of 8 studies of opioid therapy (all long-acting) versus placebo • Mean duration of therapy 28 d, range 8-56) • Pain intensity 14 units lower (scale 0-100) after opioids (P<.001) • Limted long-term studies Eisenberg E, JAMA. 2005

  6. Side Effects of Opioids • Number Needed to Harm (NNH) • Nausea (3.6; 95% CI, 2.9-4.8) or 21% in 34 trials • Constipation (4.6; 95% CI, 3.4-7.1) or 15% • Drowsiness (5.3; 95% CI, 3.7-8.3) • Vomiting (6.2; 95% CI, 4.6-11.1) • Dizziness (6.7; 95% CI, 4.8-10.0) • 34 arthritis clinical trials <4 weeks, 22% of subjects withdrew due to side effects Eisenberg, E. JAMA, 2005 Moore RA, McQuay HJ. Arthritis Res Ther, 2005

  7. Withdrawal Effects of Opioid Analgesics • Physical dependence expected • Anhedonia during early withdrawal (mesocorticolimbic system) • Withdrawal hyperalgesia (pain systems) • Physical effects of withdrawal (upregulation of cAMP in locus ceruleus and other locations) • Yawning, sweating, lacrimation, rhinorrhea, anxiety, restlessness, insomnia, dilated pupils, piloerection, chills, tachycardia, hypertension, nausea/vomiting, cramping abdominal pains, diarrhea, and muscle aches and pains

  8. Dilemma: Misuse • Systematic review of prevalence of current aberrant behaviors with chronic non-cancer pain (CNCP) treated with opioids • 5 to 24% in 5 studies in diverse settings • Study quality fair-poor • 900 primary care patients with CNCP, 80% admitted to ever using opioids aberrantly • ask for early refills (42%); • take more medication than prescribed (35.7%); and • feel intoxicated from opioids (32.2%) Fleming MF, Pain Med, 2008 Martell B, Ann Intern Med, 2007

  9. Annual Sales of Prescription Opioids and Unintentional Overdose Death1990 - 2006 Source: Paulozzi, CDC, Congressional testimony, 2007

  10. Dilemma: Overdose Deaths • Of drug overdose deaths in W VA in 2006 • Prescribed opioids contributed to >90% • 56% had no record of being prescribed opioids • 20% were doctor shopping for opioid prescriptions Hall AJ, JAMA, 2009 • Editorial recommends treating pain but monitoring • Urine drug screening • Prescription monitoring programs McLellan & Turner, JAMA, 2009

  11. Use of Methods to Monitor/ Reduce Misuse in Primary Care • Urine drug screen • Two studies, 2 to 18% of patients on chronic opioids • Six studies, 8 to 30% of MDs report ever ordering to monitor chronic opioid therapy • Opioid prescription agreement (contract) • Two studies, 27 to 39% of patients on opioids in academic practices Starrels J, SGIM Annual Meeting, 2009

  12. Evidence that These Methods Reduce Misuse • Systematic review of urine drug screens and opioid prescription agreements • Two good quality, prospective studies in VA primary care settings • Opioid agreements + other monitoring methods significantly reduced misuse by 40-50% • Two moderate quality, chart review studies in pain centers • Urine screen + opioid agreements had small but significant reductions in misuse Starrels J, SGIM Annual Meeting, 2009

  13. Set Up for Disparities in Care • Evidence of benefits not strong, controversy increases variations in care • Drugs have street value • Equi-analgesic doses of generic MS vs OxyContin • 30 day supply $42 vs $723 • Patients can become dependent or die • Physicians can go to jail • Understandably reluctant to take risks

  14. Disparity in Physicians’Management of Pain • Pain-related care accounted for 42% of US ED visits over a 13 year period, opioid Rx increased from 23% (1993) to 37% (2005) of these visits • White patients with pain more likely to receive an opioid (31%) than black (23%) (AOR 0.66; 95%CI, 0.62-0.70) • Physicians nearly twice as likely to underestimate pain in black than white patients (OR = 1.92; 95% CI: 1.31-2.81) Pletcher MJ, JAMA, 2008 Staton LJ, Natl Med Assoc, 2007

  15. Disparities in Primary Care Settings • 400 primary care patients with CNCP • Blacks higher on 10 point pain measure (6.7) than whites (5.6) (p<0.001) • White patients more likely to be prescribed opioid analgesics than blacks (45.7 vs 32.2%, P=0.006) • AOR = 2.67, 95%CI 1.71-4.15 • Adjusting for pain level & duration, age, gender, insurance, education, depression, work hours, disability, PT • Other aspects of pain care similar Chen I, JGIM, 2005

  16. Our Research Question • Are there racial differences in chronic opioid treatment management/ monitoring? • Urine drug screening • Limiting early refills (i.e. less 2 more than one week early) • Office visit monitoring (i.e. at least every 6 months) • New opioid or stronger dose followed by a visit within one month Becker W, SGIM Annual Meeting, 2009

  17. Study Data • Electronic medical records for 6 Penn primary care practices • 4 general medicine, 1 family medicine, 1 geriatrics • Timeframe: 1/1/2004 to 7/1/08 • Demographics, clinical data (recorded diagnoses), tobacco use, prescriptions • Linked administrative data on emergency room visits and hospitalizations

  18. Study Population • Patients aged 18+ • Opioid prescription and 3+ visits from 1/1/2004 to 12/31/074,217 • 3+ opioid Rxes 21d apart within 6 mos not Tramadol 2,153 • Musculoskeletal/neuropathic pain 1,944 • No cancer but can have skin or inactive prostate cancer 1,657 • Exclude race other than white or black 1,626

  19. Demographic and Clinical Conditions by Race

  20. More Clinical Conditions by Race

  21. Monitoring and Health Care Outcomes * P<0.001

  22. Opioid Treatment by Race

  23. Adjusted* Association of Black Race with Outcomes Opioid change – no visit No visit in 6 months Urine drug screen 2+ early refills 3.35 0.5 1 1.5 2.0 Adjusted Odds *Demographics, clinical, duration of opioid use, type of opioids

  24. Possible Physician-Related Reasons for Disparities • Distrust • But no adjusted association of race with misuse Turk DC Clin J Pain. 2008;Ives TJBMC Health Serv Res. 2006 • Fear of confrontation • National primary care MD survey (N=400) • Vignettes (w pictures) differed by race • Challenging patients (e.g., demands a specific narcotic, exhibits anger) vs. more stoic patients • Challenging blacks 2x more likely to receive opioids than whitesBurgess DJ, Soc Sci Med. 2008

  25. Universal Precautions in Pain Management • Diagnosis with appropriate differential • Assess risk of misuse (hx of alcohol or drug use, mental health disorder) • Risks and benefits of opioids, alternatives • Treatment agreement • Trial of opioid therapy (not alone) • Monitoring for misuse on a regular basis • Assess impact on pain and function Gourlay DL, Pain Med 2005;6:107-112.

  26. Goal-Directed Opioid Agreement • Agreement needs to define: • use/refill guidelines; • follow-up guidelines; • single prescriber/pharmacy; • no use of illicit drugs or diversion; • safe storage; • urine screen; • prescription monitoring program (some states) • Goal-directed: if pain/physical function/quality of life is still unchanged after a specified period of increasing dosage of opioids, consider stopping • Multi-modality treatment Hariharan J et al JGIM 2007;22:485–490 Von Korff M, Clin J Pain 2008;24:521–527

  27. Alternative/ Adjunctive Pain Management • Non-narcotic pain medication • Anti-spasmotics • Lidocaine patch • Anti-depressants • Anti-convulsant • Chiropractic care • Physical therapy • Steriod injections • Surgery

  28. Four ‘A’s of Pain Medicine • Analgesia • Activity (functional status) • Adverse reactions • Aberrant behaviors

  29. Summary • Chronic pain common, increasing use of opioid analgesics • Limited evidence for benefit of long-term opioid treatment • Risks – side effects, misuse, overdose, death • Disparities in monitoring practices • Need to adopt standards to monitor • Use multiple pain management strategies

More Related