All Aboard: Pain Management: CDC Guidelines and Appropriate Use of Opioids

1. All Aboard: Pain Management: CDC Guidelines and Appropriate Use of Opioids Fatima Sheikh, MD, MPH, CMD Alva S. Baker, MD, CMDR, HMDC November 10, 2018

2. Speaker Disclosures Dr. Sheikh has disclosed that she has no relevant financial relationship(s). Dr. Baker has disclosed that he has no relevant financial relationship(s).

3. Learning Objectives • Describe the opioid crisis in United States • Discuss different options for pain control in skilled nursing facilities and long-term care • Describe challenges in the SNF and LTC settings • Understand Centers for Disease Control guidelines for appropriate and effective prescribing • Discuss pain management in the context of patient assessment

4. All Aboard: Pain Management Prescription Opioid Abuse Crisis • Approximately 12.5 million of Americans reported misusing or abusing prescription opioids (2014-2015) • Doubled since 2001-2002 • Diversion of prescription pain medications remains a concern Hughes A, Williams MR, Lipari RN, et al. Substance Abuse and Mental Health Services Administration. Prescription drug use and misuse in the United States: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review; September 2016

5. All Aboard: Pain Management • 2015 national survey- 54% of prescription pain medication abusers got access to it for- • Free (41%) or • Purchased them (13%) Hughes A, Williams MR, Lipari RN, et al. Substance Abuse and Mental Health Services Administration. Prescription drug use and misuse in the United States: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review; September 2016

6. All Aboard: Pain Management Pain increases in intensity in older adults and can interfere with activities of daily living Untreated pain is associated with • Increased disability • Worsening of depression and anxiety • Increased health care utilization • Decreased quality of life Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011 Simsek et al, The effects of pain on health-related quality of life and satisfaction with life in older adults. Top Geriatr Rehabil 2010;26:361-7

7. All Aboard: Pain Management • Pain is more likely, more frequent, and more severe in subjects with • lower income • lower education • With a broad plateau between the ages of 45 and 75, pain worsens with age

8. Pain in older adults Physiological changes in the elderly • Decrease in neurotransmitters (GABA, serotonin, noradrenaline, and acetylcholine) • Decrease in the number of peripheral nociceptive neurons • Increase in pain thresholds • Reduced endogenous analgesic responses resulting in a paradoxical increase in the pain • Loss of homeostatic reserve of various organ systems https://www.cureus.com/articles/14819-managing-chronic-pain-in-the-elderly-an-overview-of-the-recent-therapeutic-advancements

9. Pain in older adults

10. Conclusion: In nursing home residents with moderate-to-severe dementia, systematic use of analgesics reduced agitation during treatment but not after treatment was stopped.

11. JulY 18, 2017

12. All Aboard: Pain Management • Case study: • Ms. AB is a 89 year old female who was admitted to the SNF • She had a fall with resultant right hip fracture. During her hospitalization, she received hip replacement and was sent to the SNF for rehabilitation. • Medications: • Tylenol 650mg Q6 prn for pain • You see her the next day and she complains of pain in her right hip and does not want to do therapy!

13. CASE STUDY 1 Past Medical History Medications • Arthritis (generalized) • Asthma • HTN • Anemia • Albuterol prn • Tylenol prn • Amlodipine 5mg Q24

14. Choice of pain medication for older adults First-line treatment: Acetaminophen • Doses range 650 -1000mg every 6 hours • Maximum daily dose • Healthy elderly patients should not exceed 4 gm • Frail, older, especially low-weight elders-3 gm max dose daily dose. • Liver disease-1-2 gm max daily dose (careful surveillance for worsening liver disease and counsel about risks) • Combination medications that contain additional acetaminophen should be considered in daily max dose Horton CE, Horton JR. Managing Pain in the Elderly Population: Pearls and Pitfalls. Curr Pain Headache Rep 2010;14:409-417 American Geriatrics Society. AGS Clinical practice guideline: Pharmacological management of persistent pain in older persons (2009). J Am Geriatr Soc 2009 Aug;57(8):1331-46

15. Choice of pain medication for older adults Non-steroidal anti-inflammatory drugs (NSAIDS) • Should be used with extreme caution • Recommended for short-term flares • Inflammatory conditions, such as rheumatoid arthritis • Non-inflammatory (degenerative joint disease, low back pain) • These drugs have considerable toxicity- • Renal injury, gastropathy, cardiovascular disease and congestive heart failure, and are a common cause of hospitalization in older adults • Black box warning about gastrointestinal bleeding for Cyclooxygenase-2-selective NSAIDs such as celecoxib as for traditional NSAIDS • Topical NSAIDS are safe but should be used short term (<4weeks) to be effective Wienecke et al, Cochrane Database Syst Rev 2004  Lee et al, Arthritis Rheum 2004 Roelofs et al, Cochrane Database Syst Rev, 2008

16. Adjuvants to pain medication Topical agents/Patches Heat and ice therapy Diathermy Acupuncture Antidepressants

17. Case study 1 • Ms. AB is a 89 year old female who was admitted to the SNF • She had a fall with resultant right hip fracture. During her hospitalization, she received hip replacement and was sent to the SNF for rehabilitation. • Medications: Acetaminophen 650mg Q6 prn for pain You changed the acetaminophen to 1gm TID and next day the nurse calls you and tells you that Ms. AB has 8/10 pain in right hip.

18. Choice of pain medication for older adults Second-line treatment Opioids should be started for- • Moderate to severe pain • On trial basis in small doses • Up-titrated gradually • If the therapeutic goals of the opioid treatment trial are not met, then the opioids should be stopped and other treatment options should be sought

19. Choice of pain medication for older adults • Non-cancer pain: • Musculoskeletal disorders like OA and low back pain • Neuropathic pain including diabetic neuropathy and post-herpetic neuralgia • Cancer related pain Morphine, oxycodone, hydromorphone and fentanyl are commonly used opioids to treat moderate to severe pain • In younger patients Morphine =Oxycodone=Hydromorphone • Elderly patient ??

20. Choice of pain medication for older adults Older patients who are opioid naïve- • Intermittent moderate-to-severe pain-small doses of short-acting opioids as prn • Mild persistent pain, scheduled doses with rescue doses for breakthrough pain • For moderate pain-uptitrate at least every 24 hours with dose increases of 25-50% • For severe pain-uptitrate more frequently with dose increase by 50-100% in 24 hours

21. CASE STUDY 2 • Ms. AB is a 89 year old female who was admitted to the SNF • She had a fall with resultant right hip fracture. During her hospitalization, she received hip replacement and was sent to the SNF for rehabilitation. • Medications: Acetaminophen 650mg Q6 prn for pain You changed the acetaminophen to 1gm TIDandstarted her on low dose Oxycodonefew days ago. Nurse calls you that Ms. AB has 8/10 pain in right hip.

22. CASE STUDY 2 Past Medical History Medications • Arthritis (generalized) • COPD (hx of intubation, on 2 L of O2) • Anxiety • Depression • Asthma • Rt shoulder dislocation x 3 • History of E.coli bacteremia • Seizures • HTN • DM2 with neuropathy • Tylenol 1gm TID • Buspirone5mg BID • Sertraline 50mg Q24 • Advair/Spiriva/Duonebs • Amlodipine 5mg q24 • Gabapentin 400mg TID • Keppra 500mg BID

23. Tramadol Tramadol is a weak opioid analgesic that also releases serotonin and inhibits reuptake of norepinephrine. • Side effects: • Drowsiness, nausea and constipation • Potential to cause seizures

24. Tramadol • Adverse effects are about twice as common among elderly patients • Dependence, both psychological and physical • No reason to use tramadol in preference to other narcotics • Small initial dose should be used • Drug interactions should be considered • Extended release formulations should be avoided

25. Fentanyl Patches Should be considered for moderate to severe chronic pain • Patients who have dexterity to apply them properly • Who cannot take oral medication or cannot take scheduled medications • Therapeutic window may be very narrow in patients with hepatic or renal impairment.

26. Methadone • Methadone dosing and titration is complex due to its long and variable half-life (24-36 hours) • There are few data in the elderly • It interacts dangerously with several other drugs • More commonly used for chronic pain

27. CASE STUDY 3 • Mr. G is a 90 y/o male who was admitted to hospital for AMS and was found to have Afib with RVR with severe abdominal pain 2/2 distended bladder which resolved with Foley catheter placement. • He was also dxed with UTI and was started on Amoxicillin • He is now transferred to your facility and during your initial evaluation he complains of Rt leg sciatica pain

28. CASE STUDY 3 Past Medical History Medications Urinary retention with Foley placement and delirium New onset Afib (CHADS2-VASc score of 3 with 3.3 % risk of stroke/year) HTN Erosive Rtsacroiliitis with erosive changes AKI during hospitalization Depression Hx of multiple rib fractures Constipation OA Rt sided sciatica Hx skin cancer B/L SN hearing loss, cochlear implant on Rt Rt eye retinal hemorrhage Pseudophakia Venous insufficiency GERD Insomnia • Lasix 40mg BID • ASA 81mg q24 • Apixaban 5mg BID • Metoprolol to 50mgQ24 • Verapamil • Omeprazole • Flomax 0.4mg qday • Tylenol 650mg BID

29. Neuropathic Pain Tricyclic antidepressants Adverse effects in the elderly include • Anticholinergic • Cardiac side effects • Interactions with other medications Antiepileptics • Pregabalin is FDA approved for neuropathic pain. • Gabapentin is only approved for post-herpetic neuralgia and for adjunctive therapy in the treatment of partial seizures Opioids • Only effective for neuropathic pain • Acute • Breakthrough pain • Bridge therapy when starting tricyclic antidepressants

30. CASE STUDY 4 • Ms. T is a 65 y/o F who was admitted to the hospital for lumbar discectomy with interbody fusion of L4, pedicle fixation of L4-L5 • She is sent to your facility for rehabilitation. • On disability for last few years due to chronic back pain • Used to smoke 1 pack/day from age 16 yrs till 55yrs of age, no hx of drinking, used to inject cocaine and heroin-quit 21 yrs ago • Does not drive due to back pain and paresthesias • Independent in ADLS and iADLS except grocery shopping

31. CASE STUDY 4 Past Medical History Medications • Hx of chronic back pain 2/2 Spinal stenosis • Seizure d/o • LE edema • HTN • CKD stage 3 • HLD • Depression • OSA • Supraventricular tachycardia • Myalgias • Neuropathy • Obesity • Morphine ER 15mg BID • Oxycodone/Tylenol 2.5/325mg 1 tab Q6 prn • Lamictal • Lasix 20mgq24 • Verapamil • Metoprolol 50mgq24 • Venlafaxine • Crestor • Omeprazole • Senna prn

32. CASE STUDY 4 • How to treat new pain with history of chronic pain? • Is this drug seeking behavior?

33. Acute on Chronic Pain • Patients already receiving opioids for chronic pain often need higher doses to treat new or worsening pain • If the patient is already taking a long-acting opioid, short acting opioids can be used and uptitrated carefully • Methadone? • Fentanyl patch?

34. Acute on Chronic Pain • Progression of the primary disease? Complication of the procedure? • New pathology? • Changes in administration or absorption of drug? Timing of the administration? • Psychosocial issues?

35. Drug Seeking Behavior • “Drug-seeking behavior” is a term used to imply that the patient is displaying pain behavior in order to obtain opioids for reasons other than pain relief, such as recreational use, drug addiction or (especially among outpatients) later resale of the drug for profit • A person in severe pain will demonstrate “drug-seeking” behavior until the pain is controlled • The absence of pain behaviors is non-diagnostic especially when pain is chronic.

36. Drug Seeking Behavior Addiction or drug dealing may be suspected if there is- • History of forged or lost prescriptions • Frequent unprescribed dose escalations, stealing or borrowing narcotics • Buying them “on the street,” • Taking other “street drugs” • Parenteral (e.g. intravenous, subcutaneous, intranasal) administration of drugs prescribed as PO meds • History of mental disorder in elderly patients • Individuals with alcohol-use disorders

37. Drug Seeking Behavior-Monitoring • Written controlled-substance agreement • Urine drug testing • There are no validated screening or assessment tools available for identifying or diagnosing drug abuse in older adults • Written agreements and urine drug screening are not always feasible in SNF/LTC Berland D, Rodgers P.Rational use of opioids for management of chronic non-terminal pain. Amer Fam Phys 2012;86(3)

38. Drug Seeking Behavior • Patient satisfaction • Fear of treating a patient with possible “drug seeking behavior” • Fear of drug monitoring program

39. Prescription Drug Monitoring Program (PDMP) • CRISP User, • Effective July 1, 2018, Maryland law requires CDS prescribers and pharmacists to request and assess data from the Prescription Drug Monitoring Program (PDMP) in certain prescribing and dispensing situations.   • The materials below were sent from the Maryland Department of Health (MDH), to the email address of record linked to your PDMP account, and mailed to you by USPS. These documents detail when you are required to check the PDMP, where exceptions exist – both clinical and technological – and how to appropriately document your actions: • Pharmacists • Letter from Maryland Department of Health (MDH) Secretary Neall • Fact sheet explaining the PDMP Use Mandate for pharmacists • Providers • Letter from Maryland Department of Health (MDH) Secretary Neall • Fact sheet explaining the PDMP Use Mandate for prescribers • Center for Disease Control (CDC) guidelines for prescribing opioids • Suicide risk assessment billing code fact sheet

40. Prescription Drug Monitoring Program (PDMP)

41. CASE STUDY 5 • Mr. M is a 54 y/o male who is a LTC resident has history of generalized pain 2/2 OA • Pain control: • Tylenol 650mg Q6 prn • Oxycodone 10mg Q4prn • Fentanyl patch 37.5 mcg/72hrs • Lidoderm patch • Diathermy

42. CASE STUDY 5 • He is flagging on the CASPER report for uncontrolled pain. • DON asks you to start long acting pain medication • What do you do?

44. Pain Control-Quality Measures • The current nursing home quality measures are: • Short Stay Quality Measures • Percent of Residents who Self-Report Moderate to Severe Pain (Short Stay) • Percent of Residents with Pressure Ulcers that are New or Worsened (Short Stay) • Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) • Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (Short Stay) • Percent of Short-Stay Residents Who Newly Received an Antipsychotic Medication • Long Stay Quality Measures • Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) • Percent of Residents who Self-Report Moderate to Severe Pain (Long Stay) • Percent of High-Risk Residents with Pressure Ulcers (Long Stay) • Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (Long Stay) • Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (Long Stay) • Percent of Residents with a Urinary Tract Infection (Long Stay) • Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder (Long Stay) • Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay) • Percent of Residents Who Were Physically Restrained (Long Stay) • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay) • Percent of Residents Who Lose Too Much Weight (Long Stay) • Percent of Residents Who Have Depressive Symptoms (Long Stay) • Percent of Long-Stay Residents Who Received An Antipsychotic Medication

46. Pain Control-Quality Measures • Why is the pain is not controlled? • Any new causes for uncontrolled pain? Anxiety? Postural? • Can any of the non-pharmacological modalities be tried? • What changes in his meds will you recommend?

47. Special Considerations Liver Disease: Fentanyl is the only opioid whose pharmacokinetics are unchanged For all others, increased bioavailability (due to decreased first-pass metabolism) and/or accumulation of drug and active metabolites (due to decreased clearance) increase the risk of harm Renal Failure: Hydromorphone, fentanyl, and perhaps methadone are the least affected Renal and hepatic insufficiency: Initial doses of opioids and the frequency of administration should be decreased Horton CE, Horton JR. Managing Pain in the Elderly Population: Pearls and Pitfalls. Curr Pain Headache Rep 2010;14:409-417 Bosilkovska et al, Analgesics in patients with hepatic impairment: pharmacology and clinical implications. Drugs 2012 Aug 20;72(12):1645-69 Tegedar et al, Pharmacokinetics of opioids in liver disease. Clin Pharmacokinet,1999 Jul;37(1):17-40

48. Cognitive Behavioral Therapy • Can be considered for cognitively intact patients who have- • Poor coping skills • Psychosocial factors may be contributing prominently to pain Limitations on CBT: • Patient lack of faith in this therapy • Physician reluctance to offer it • Data is scarce about use of CBT in older patients • CBT can help chronic widespread pain like fibromyalgia

49. Pain and Delirium • Uncontrolled pain can cause delirium: up-titration should be considered in patients who remain in pain • Too much of pain meds can cause delirium  (suspect if pain meds have recently been up-titrated and the delirium is hypoactive) • Too rapid a dose reduction can cause or worsen delirium, Because under-treatment of pain can also cause delirium • Both pre-operative and postoperative pain are associated with delirium and the association is strongest for severe pain Morrison et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003 Jan;58(1):76-81  Vaurio et al. Postoperative delirium: The importance of pain and pain management. Anesth Analg.2006 Apr;102(4):1267-73

50. Pain and Cannabis Conclusion: Limited evidence suggests that cannabis may alleviate neuropathic pain in some patients, but insufficient evidence exists for other types of chronic pain. Among general populations, limited evidence suggests that cannabis is associated with an increased risk for adverse mental health effects. Common AEs included dizziness, dry mouth, nausea, fatigue, somnolence, euphoria, vomiting, disorientation, drowsiness, confusion, loss of balance, and hallucination JAMA 2015 Jun 23-30;313(24):2456-73. doi: 10.1001/jama.2015.6358. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis.