How to Use Pain Medicine Safely: Tips for Seniors

1. How to Use Pain Medicine Safely: Tips for Seniors Tatyana Gurvich, Pharm.D., BCGP Assistant Professor of Clinical Pharmacy USC School of Pharmacy UCI Department of Geriatrics

2. Historical Perspective • John Bonica, MD • Hospital- and clinic-based programs with physicians, psychologists, PT/OT. • Narcotics were used sparingly • Problems with insurance coverage emerge… • “Pain is whatever the patient says it is” • “Treatment of Pain is a Universal Right” - WHO • Cancer pain/terminal care pain management guidelines • Long-acting medicines like Oxycontin emerge… • JCAHO (accredits and certifies health care facilities) mandates pain assessment and treatment JG, Compton P. Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug Alcohol Depend. 2017 Apr 1;173 Suppl 1:S11-S21.

3. The Numbers behind the Opioid Crisis • 20% of patients with chronic pain receive an opioid prescription • >420,000 emergency department visits related to the misuse or abuse of opioids in 2011 • 259 million prescriptions written for opioids in 2012 * Updated CDC guidelines for prescribing opioids Enough for every adult in the United States to have a bottle of pills

4. The Opioid Crisis and Seniors • Opioid misuse among older Americans is also on the rise • Older adults who misuse opioids is expected to double by 2020 • In 2016, more than 500,000 Seniors received opioids in doses higher than recommended by the manufacturer *SAMHSA: State Technical Assistance Contract

5. Pain is a common medical problem 50% of older Americans suffer from chronic pain • Arthritis • Fibromyalgia • Nerve pain • Chronic back pain • Other chronic musculoskeletal conditions *SAMHSA: State Technical Assistance Contract

6. Strong Pain Medicines related to Morphine All work on the same receptors in the brain to relieve pain • Tramadol • Tylenol with Codeine • Norco/Vicodin • Percocet • Morphine/MS Contin • Oxycodone/Oxycontin • Dilaudid • Fentanyl Patch

7. All Opioids are NOT the SAME • Short acting (4-6hrs) • Long acting (12-72hrs) • Combinations with Tylenol • Norco, Percocet, Tylenol w/Codeine (Tylenol #3) All Have Different Potencies If Dilaudid were a Hamburger.... 5 to 7mg of Morphine equals 1mg Dilaudid Tramadol & Codeine < Hydrocodone & Morphine < Oxycodone < Dilaudid < Fentanyl (LEAST) (MOST)

8. Side Effects & How to Mitigate

9. But, am I an Addict? • Tolerance: Need a higher dose to get the same pain relief • Dependence: Withdrawal symptoms if stopped abruptly • Addiction: Dependence with abusive pleasure-seeking behavior

10. Additional Risks Associated with Opioid Uses • Physical side effects : Mood changes, urination difficulties, depressed breathing, itching, osteoporosis, sexual dysfunction • Symptoms of withdrawal: Abdominal cramping, pain, diarrhea, sweating, irritability • Victimization: Risk of theft, deceit, assault, or abuse by persons seeking to obtain the patient’s opioids • Hyperalgesia: Increased sensitivity to and/or increasing experience of pain and may require change or discontinuation • Sleep apnea may be caused or worsened • Driving under the influence of drugs: Especially at initiation of therapy or with changes in doses opioids can impair ability to drive or operate machinery. It is against the law and unsafe to drive or operate machinery when impaired. • Life-threatening irregular heartbeat with methadone, EKG monitoring required • Overdose or using with alcohol or other drugs can result in slowed breathing, coma, brain damage, death

11. Factors that increase risk of dangerous side effects • History of substance abuse • History mental disease • High dose of Opioids:(>50 Mg Morphine/day) • First time opioid user • Anti-anxiety/ sleep medicine • Heart and lung disease • Kidney and liver disease • Sleep apnea

12. Seniors face additional risks • Reduced kidney function • Long history of lung disease • Increased risk of overdose • Increased confusion • Increased fall risk • Polypharmacy concerns • Increased risk of side effects and drug interactions • Medication errors

13. Recognizing Emergencies Seek Medical Attention Urgently: CALL 911! Slow or no heartbeat Aren’t breathing Others can’t wake you up Lips are blue Can’t speak clearly While asleep making gasping, gurgling, or snorting sounds • Severe dizziness • Inability to stay awake • Hallucinations • Heavy or unusual snoring • Slow breathing

14. How to Use Opioids Safely DO: FOLLOW SAFE PRACTICES DO NOT USE WITH OPIOIDS! Alcohol Anti-Anxiety medicines: Xanax, Ativan, Klonopin, Valium Sleep Aids: Ambien, Lunesta, Sonata, Restoril, Halcion Muscle Relaxants: Soma, Flexeril, Robaxin Other Opioids • Use: • As needed only • For as short a time as possible • Don’t: • Drive or operate machinery until you know how the medication affects you • Never: • Take more than prescribed • Take someone else’s medicine • Share your medicine

15. Talk to Your Doctor! • Establish treatment goals for pain relief and function • A plan should be in place for stopping opioids if treatment is unsuccessful • Continue opioids only if meaningful improvement in pain AND function is observed by you and your doctor • Discuss any side effects you have promptly

16. It is now harder to get Opioid prescriptions Physician’s offices • Have protocols in place • May require more frequent appointments • Reluctant to prescribe for prolonged period of time • Stay away from long acting opioids: Oxycontin/MS Contin/Fentanyl Pharmacies • Reluctant to refill opioids long term • Insurance companies may only pay for a 7 day supply • Extra authorization is needed • Delays in getting your medicine

17. Tools your doctor may use when prescribing Opioids • A pain contract between you and your doctor • Risks and realistic benefits of opioid therapy • Patient AND Provider responsibilities for managing this therapy • A pain diary to document when you use medicines • Is your pain relieved? • Are you better able to move about and do your activities? • 24-hour recall of medication use • Adjuvant Pain Medications • A CURES report is now a requirement • Urine drug testing • Naloxone to keep you safe

18. Naloxone (Narcan) • It is a medication which quickly reverses the effect of an opioid medication • It should ONLY be used when overdose is suspected • Comes as an Injection, Spray or an Auto-Injector • IF Naloxone is used you must call 911 immediately

19. Who will get a Prescription for Naloxone (Narcan) • Higher-dose opioid prescription • Receiving ANY opioid prescription PLUS anti-anxiety or insomnia medicine • Voluntary request from patient or caregiver • Patients who may have difficulty accessing emergency medical services (distance, remoteness) • If you have been in an overdose situation before • Suspected history of substance abuse • Starting a treatment program for addiction

20. Safer Alternatives

21. Non-Opioid Pain Medicines

22. Selected Topical Medicines

23. Medicines which Prevent Pain Dosages start low and increase slowly

24. Where does this leave us? • Opioid use can be a problem, especially for older adults • If they are necessary, they should be used with extra caution for as short a time as possible • Adjuvants medications must be tried • They are effective • They should reduce the amount of opioids you take, and in some cases,can completely eliminate them

25. Contributors to this Lecture Presentation • Ana Barron, Pharm. D. Candidate 2019 • Amy Nham, Pharm.D. Candidate 2019 • Liana So, Pharm.D. Candidate 2019 • Katelyn Swafford, Pharm.D. Candidate 2019 • USC School of Pharmacy