Spotlight Case

1. Spotlight Case The Pains of Chronic Opioid Usage

2. Source and Credits • This presentation is based on the September 2013 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Laxmaiah Manchikanti, MD, University of Louisville, and Joshua A. Hirsch, MD, Harvard Medical School • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Describe the appropriate initial assessment of patients with chronic non-cancer pain • List the most common errors made in prescribing opioids for non-cancer pain • Outline appropriate monitoring for patients prescribed opioids for non-cancer pain • Appreciate the need to risk-stratify patients taking opioids for non-cancer pain

4. Case: Pains of Chronic Opioids A 42-year-old man with a history of asthma and chronic lower back pain was admitted to the hospital with community-acquired pneumonia and an asthma exacerbation. His primary care physician (PCP) had been prescribing high doses of long-acting morphine (MS Contin), oxycodone, and gabapentin for his low back pain. He was marginally housed and often slept in shelters.

5. Case: Pains of Chronic Opioids (2) On admission to the hospital, he was treated with nebulizers, antibiotics, and prednisone. Due to some odd behavior and suspicion for substance abuse, a urine toxicology test was sent and results were positive for benzodiazepines, methadone, and opiates. As neither benzodiazepines nor methadone were prescribed medications, the hospitalist confronted the patient who admitted selling his prescribed opiates and buying diazepam and methadone on the street. He stated that these could "control [my] pain better."

6. Background • Opioids frequently used in chronic non-cancer pain • In US, enough opioids are prescribed to supply every adult American with 5 mg of hydrocodone 3 times daily for more than 45 days • Opioid prescribing for chronic pain in ambulatory setting doubled from 8% in 1980 to 16% in 2000 • Approximately 20% of patients in primary care were longtime opioid users, and nearly 2/3 had received at least one course of opioids • Increasing use is not based on evidence of efficacy or supported by safety data

7. Nonmedical Use of Opioids How often patients use opioids without a prescription or outside limits of prescription is unclear It may be as much as 5% to 41% of patients prescribed opioids The use and abuse of opioids can result in injury and death

8. Overdose on Prescription Medications • A Centers for Disease Control and Prevention (CDC) study characterized patients who had overdosed on prescription medications: • Approximately 80% of patients prescribed low doses (defined as <100 mg of morphine equivalent dose/day) accounted for only 20% of all prescription overdoses • The 10% prescribed high doses accounted for an estimated 40% of prescription opioid overdoses

9. Errors in Opioid Prescribing • Providers may make multiple errors when prescribing opioids for non-cancer pain • It is useful to classify opioid prescribing errors into four categories: • Inadequate screening for safe and effective opioid use • Inability to monitor adherence • Improper selection of opioids • Insufficient consideration of comorbid conditions

10. Prescribing in This Case • For this patient, there may have been inadequate screening for safe use, potentially improper selection of opioids, and possibly insufficient consideration of his asthma • The patient was also receiving both long-acting and short-acting opioids • This can be a setup for fatalities and deaths, particularly when comorbid factors are considered

11. Case: Pains of Chronic Opioids (3) Given complexity of the pain regimen and the drug diversion, the hospital's pain service was consulted. They changed the patient's medications to methadone, hydromorphone, clonazepam, and venlafaxine. The morphine and oxycodone were discontinued. With this regimen, the patient had reasonable pain relief at discharge. He was discharged with a prescription for a 2-week supply of medications and had a follow-up appointment with his PCP 10 days later. As it was a weekend, the discharging hospitalist was not able to speak directly with the PCP but sent her an e-mail with the medication changes.

12. Case: Pains of Chronic Opioids (4) Five days after discharge, the patient was found unconscious at a subway station and pronounced dead at a local hospital following unsuccessful resuscitation. Based on the clinical presentation, the cause of death was likely from unintentional opiate/benzodiazepine overdose. In reviewing his medications, the patient had refilled his MS Contin and oxycodone one day prior to admission. Unfortunately, this information was not available to the hospitalist, and the patient stated that he had not recently refilled his opiates. The patient filled the new prescriptions for methadone, hydromorphone, and clonazepam on the day of discharge.

13. Reflections on Case Unclear from case details whether patient's unexpected death could have been prevented This scenario acts as a powerful reminder of the risks of opioid prescribing It would seem much can be done to prevent such events in the future

14. Preventing Errors in Opioid Prescribing All providers should follow appropriate guidelines to provide proper prescriptions Enhancing and updating clinical teaching and training is crucial for all providers, especially those involved in pain management A more comprehensive and contemporary curriculum for prescribers seems warranted

15. Best Practices for Preventing Errors • A 10-step algorithm can be used to optimally prescribe opioids for non-cancer pain • The algorithm describes the following steps: • Diagnosis • Determination of medical necessity • Establishment of treatment goals • Informed consent • Adherence monitoring • Addressing adverse effects

16. Errors in This Case • In the present case, appropriate prescription practices were not followed • First error was prescribing both long-acting morphine and oxycodone in a patient with asthma, who lacked support systems or stable housing • May have been more appropriate to start with a single short-acting agent

17. Errors in This Case (2) Second error was decision to switch patient to methadone, even though he admitted to selling opioids and purchasing diazepam and methadone Hospitalist likely should have tried to manage patient's pain with short-acting oxycodone (given adverse effects of methadone)

18. Screening for Abuse Limited evidence for reliability and accuracy of available screening instruments The evidence is also limited that screening will reduce abuse Prescription drug monitoring programs (large databases that collect prescription data) may help reduce risks in opioid prescribing

19. Screening for Abuse (2) Good evidence that prescription drug monitoring programs provide data on patterns of prescription drug usage, which may lead to earlier recognition of abuse Fair evidence that prescription drug monitoring programs may reduce prescription drug abuse or doctor shopping However, only limited evidence that prescription drug monitoring programs reduce emergency room visits, drug overdoses, or deaths

20. Adherence Monitoring Urine drug testing, as part of compliance monitoring, is crucial in managing opioid therapy While patients may balk at this testing, urine drug screening should be used as an exercise to strengthen the patient–physician relationship Urine drug testing may identify patients who are noncompliant and may decrease prescription drug abuse or illicit drug use

21. Pain Contracts Providers may choose to engage patients in formal treatment agreement (i.e., pain contract) Informed consent essential Consequences of violating contract should be clear

22. Risk Stratification • Stratification of risk for patients initiated or maintained on chronic opioid therapy is crucial to prevent misuse and abuse • Can be classified into low, medium, and high risk • Patients with concurrent substance abuse and high risk for abusing prescription opiates fall under the category of high risk • High-risk patients need more monitoring and repeat assessments • High-risk patients should be on low-dose opioids (not combination therapy) and weaned off if they have aberrant behaviors

23. This Case This patient had significant abuse patterns and should have been considered high risk He likely never should have been initiated on high-dose opioid therapy He should have been appropriately monitored and potentially weaned off his opiates, or referred to addiction management

24. Take-Home Points The initial assessment in managing patients with chronic non-cancer pain should involve establishing the diagnosis, medical necessity, and treatment goals The most common errors associated with opioid prescribing for non-cancer pain include: inadequate screening for safe and effective opioid use, inability to monitor adherence, improper selection of opioids, and insufficient consideration of comorbid conditions

25. Take-Home Points (2) • Providers should obtain full informed consent before prescribing opioids and determine methods to monitor adherence • Patients who are prescribed opioids should be monitored continuously for adherence and adverse effects as well as screened for abuse; urine drug testing may be effective • Stratifying patients into low, medium, and high risk is essential prior to embarking on initial treatment