The Opioid Crisis:Safe Prescribing &Pain ManagementLee T. Snook, Jr., MDABIM, ABA, ABPM, ABAM, MROSacramento County OpioidAwareness SummitSeptember 12, 20181
Pain Management ExperiencesPain Medicine since 1987Patients who “fall through the cracks”Multidisciplinary pain managementCancer Related PainPain Kills2
3Opioid Crisis:What We Have LearnedOxyContin introduced 1995, a sentinel event.Prompted by several factors that led to anincrease in opioid prescribingA belief that addiction was rareAssessment of pain “as the fifth vital sign” 1996Aggressive marketing campaigns by PharmaUnder treatment of pain is was so common. AB 487 – Mandatory 12 CME on pain.The sale of prescription opioids tripled between 1999 and 2011, paralleled by 4x increase in admissionsfor SUD treatment and 4x increase in OD deathsMisuse of Prescription Rx is a significant risk factorfor heroin use80% of heroin users began with misuse of prescription Rx4% of those who misuse prescription Rx go on to initiate heroin use within 5years.
4Opioid Crisis:What We Have LearnedOxyContin introduced 1995, a sentinel event.Prompted by several factors that led to anincrease in opioid prescribingA belief that addiction was rareAssessment of pain “as the fifth vital sign” 1996Aggressive marketing campaigns by PharmaUnder treatment of pain is was so common. AB 487 – Mandatory 12 CME on pain.The sale of prescription opioids tripled between 1999 and 2011, paralleled by 4x increase in admissionsfor SUD treatment and 4x increase in OD deathsMisuse of Prescription Rx is a significant risk factorfor heroin use80% of heroin users began with misuse of prescription Rx4% of those who misuse prescription Rx go on to initiate heroin use within 5years.
What are opioids?An opium-like compound that binds to one or more opioid receptors. Poppy pods used asearly as 4000 B.C.Opioid receptors in the brain, spinal cord and nervous systemThey affect the intensity of pain-signal perceptionThey affect brain areas that control emotionAffect reward centers of the brain causing euphoria.Have been used for centuries to treat pain, cough, and diarrhea.Can cause a worsening of pain when used long term ( hyperalgesia)5
6What areOpioids?TheEndogenousOpioid System
7What areOpioids?The RewardCircuit
Action ofOpiate AgonistBinding to endorphinreceptors in painpathway analgesiaBinding to receptors inreward pathway dopamine released person feels good.8
10Opioid TypesOpiates Opium Morphine CodeineSemi - SyntheticSynthetic Heroin Hydrocodone Hydromorphone Oxycodone Oxymorphone Buprenorphine Fentanyl Methadone Tramadol
Guidelines for Prescribing ControlledSubstances for PainThe Medical Board of California (MBC), in collaboration withCMA, published updated treatment guidelines for safeprescribing.Widely accepted as best practices for safe prescribing.Premised that quality medical care supports that thepeople of California have access to appropriate, safe andeffective pain management.13
Summary of Key Points14All biologically active drugs pose risks if they are not used appropriately.Opioid analgesics are widely accepted as appropriate and effective for alleviating moderateto-severe acute pain, pain associated with cancer and persistent end-of-life pain.Opioids may be appropriate for certain patients with chronic pain, provided they are prescribedcautiously and in a manner consistent with approved clinical practice guidelines.Opioids should be used for chronic pain only when safer options have been deemed ineffectiveand continued treatment should be based on maintenance of clinical and functional goals.
Summary of Key PointsInformedconsent foropioid use forchronic painincludespatientknowledge ofandacceptance ofthe following:15The potential benefits and/or safety of opioids are not proven by high-quality evidence, such asrandomized controlled clinical trials;Risks, including risk of abuse and overdose, tend to increase with dose;Addiction, abuse, clinical coping and other problems associated with opioids are not uncommon;Some patients have difficulty discontinuing opioid therapy;Taking other substances/drugs with opioids (e.g. alcohol) or having certain conditions (e.g. sleepapnea, mental illness) can increase the risk and cause serious adverse effects; andOpioids should be used only as prescribed, should be stored securely and when a course oftreatment is altered, discontinued or stopped, any unused opioids should be disposed of properly.
Implementation in California from 2014-2016:Demonstrated:1. A 17% decrease in opioid prescriptions2. A 14% increasing buprenorphineprescriptions3. One of only 5 states with multilayereddecrease in prescription opioid overdoses4. California now tied for the lowest per capitaopioid prescription rate in the country16
CDC Guidelines for Prescribing Opioids forChronic Pain – Published March 15, 2016Improve communication between clinicians and patientsabout the risks and benefits of opioid therapy for chronicpain.Improve patient outcomes such as reduced pain andimproved function.Improve the safety and effectiveness of pain treatment.Reduce the risks associated with long-term opioid therapy,including opioid use disorder, overuse, and other adverseevents related to opioid use.17
Pain and AddictionAmerican Society of Addiction Medicine 201818Prevalence of Opioid use Disorder is estimated to be 20-25% in long term use of opioids to treat chronic pain.Prevalence indicates the proportion of a population that is diagnosed at a specified point in time.Heroin abuse increase by 63% from 2002 through 2013. Deaths increased by 286% from 0.7 to 2.7 per 100,000 peopleRate of heroin initiation is 19 times higher if used Rx nonmedically.80% of heroin users begin with misuse of prescription opioids.Oxycodone is particularly popular for non medical useFentanyl and other Synthetic Opioids represent an escalation of the opioid epidemic.Fentanyl is 80 times more potent that morphine in vivo.Illicit Fentanyl is largely responsible for OD deaths from 3,105 in 2013 to 9,580 in 2015
Biopsychosocial Model of Health19MultidisciplinaryApproach to PainManagement
20Multidisciplinary Approach to Pain ManagementLivingwithpain canimpactpeople’slives:Decreased activity levelsDisturbed sleep,Loss of appetitePsychological and emotional strainPhysical exhaustionLoss of joy of living.Each patient is unique and benefits from anindividual treatment planEducation tidisciplinaryApproach toCareSurgicalInterventionExercise, Diet,Physical Therapy
ReflectionsThe opioid crisis is real and must be addressedWhat about the 75-80% of patients who DO NOTdevelop an opioid use disorder?Those who suffer from chronic pain that has notresponded to other methods or modalities21
Guiding Principles22Physician’s professional obligation and ethical duty is to provide appropriatemedical care and treatment for the patient based on the physician’s training,experience and clinical judgement.Recommend well-balanced approach to opioid prescribing and treatmentthat considers the unique needs of the patient.With education and implementation of treatment guidelines, the currentepidemic of opioid use and abuse, in so far as physician prescribing practicesare involved, will be radically reduced.
The Opioid Crisis: Safe Prescribing & Pain Management Lee T. Snook, Jr., MD ABIM, ABA, ABPM, ABAM, MRO Sacramento County Opioid Awareness Summit September 12, 2018 1. Pain Management Experiences Pain Medicine since 1987 . safe and effective pain management. 13. Summary of Key Points.