Substance Use Disorder Series

MODULE 8

Managing Pain in Patients with Substance Use Disorder

Casey Fitzpatrick, PharmD, BCPS Advisory Board

• Casey Fitzpatrick, PharmD, BCPS • Brittany Riley, PharmD, BCPS, MS • Charles “CK” Babcock, PharmD, CDE, BCACP • Kimberly Broedel-Zaugg, RPh, MBA, PhD Disclosures

• Authors of this presentation have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation Objectives

1. Recommend non-pharmacologic treatment options for the management of pain in patients with a history of substance use disorder (SUD) 2. Recommend non-opioid pharmacologic treatment options for the management of pain in patients with a history of SUD 3. Understand the utilization of opioids for the management of pain in patients with a history of SUD 4. Develop a treatment plan for patients receiving medication assisted treatment (MAT) who experience severe pain or are undergoing surgery Definition of Pain

• International Association for the Study of Pain (IASP) • An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage • Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors. • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons. • Through their life experiences, individuals learn the concept of pain. • A person’s report of an experience as pain should be respected. • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being. • Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

“IASP Terminology.” International Association for the Study of Pain. https://www.iasp- pain.org/Education/Content.aspx?ItemNumber=1698#Pain Accessed November 29, 2020 Types of Pain

• Acute – usually results from injury or surgery, has a limited duration, and associated with objective findings (tachycardia, anxiety, sweating) • Typically, lasts less than three months • Chronic pain – pain that persists beyond 12 weeks, often objective • Examples include arthritis, cancers, and fibromyalgia Types of Pain continued

• Neuropathic pain • Nociceptive pain • Nociplastic pain

“IASP Terminology.” International Association for the Study of Pain. https://www.iasp- pain.org/Education/Content.aspx?ItemNumber=1698#Pain Accessed November 29, 2020 Neuropathic Pain

• Pain caused by a lesion or disease of the somatosensory nervous system • Examples include diabetic neuropathy, carpal tunnel syndrome, trigeminal neuralgia and complex regional pain syndrome • Often described as tingling, burning, shooting or shock-like pain

“IASP Terminology.” International Association for the Study of Pain. https://www.iasp- pain.org/Education/Content.aspx?ItemNumber=1698#Pain Accessed November 29, 2020 Nociceptive Pain Terms

• Noxious stimuli – an actually or potentially tissue damaging event • Nociceptors – a high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli • Nociception – the neural process of encoding noxious stimuli

“IASP Terminology.” International Association for the Study of Pain. https://www.iasp- pain.org/Education/Content.aspx?ItemNumber=1698#Pain Accessed November 29, 2020 Nociceptive Pain

• Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors • Fundamentally, damage to body tissue • Visceral – stimulation of internal organ pain receptors (pancreatitis, irritable bowel syndrome) • Somatic – irritation of pain fibers of the skin or deep tissues (muscle sprain, bone fracture)

“IASP Terminology.” International Association for the Study of Pain. https://www.iasp- pain.org/Education/Content.aspx?ItemNumber=1698#Pain Accessed November 29, 2020 Nociplastic Pain

• Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of somatosensory system causing the pain • Includes fibromyalgia, arthritis and non-specific low back pain • Note: Patients can have a combination of nociceptive and nociplastic pain

“IASP Terminology.” International Association for the Study of Pain. https://www.iasp- pain.org/Education/Content.aspx?ItemNumber=1698#Pain Accessed November 29, 2020 Assessment of Pain

Medical Physical Assessment History Examination Tools

Surgery/trauma Visual scales Signs/symptoms

Pain Comorbidities quality/description Location Exacerbating/relieving Questionnaires factors

Type of pain Previous treatments Drawings/location Assessment Tools

Wong-Baker Faces Pain Rating Scale: tool based on faces (happy at 0, crying at 10), that patients can use to best describe their level of pain Assessment Tools continued

• Numerical rating scale: individual rates pain on 0 to 10 scale

• Verbal descriptor scale: pain described in descriptive terms

Suresh S, Soniya S, Ranejdran G. J Indian Assoc Public Health Dent. 2015;13:486-91 Assessment Tools continued

Visual analog scale (VAS): individual points to or mark a spot on the line where they feel indicates their current level of pain

Suresh S, Soniya S, Ranejdran G. J Indian Assoc Public Health Dent. 2015;13:486-91 PQRST Pain Assessment Method

Characteristics Questions to Ask P Palliative factors What makes the pain better? Provocative factors What makes the pain worse? Q Quality Describe the pain. What does it feel like? R Radiation/Region Where is the pain? What area of the body is affected? S Severity How severe is the pain on a scale of 1-10? T Temporal factors When did it begin? Does the intensity of the pain change with time?

Phillips SE. US Pharm. 2007;32(5):37-52 Pain Management Considerations

• 80% of primary care providers reported significant stress when managing pain in patients with a history of substance use • Pain in SUD patients is often undertreated by physicians • Stigma surrounding SUD patients (e.g., drug seeking) • Fear of relapse • May require greater amounts of pain medications (hyperalgesia/tolerance)

Jamison RN, et al. J. Opioid Manag. 2014;10(6):375-82. Goals of Pain Management

• Improve or maintain activity level and quality of life • Prevent withdrawal and/or relapse to addiction • Involve patient in decision making process and agree on realistic treatment goals • Minimize pain and avoid triggers of pain Non-Pharmacologic Treatment Options Non-Pharmacologic Treatment Options • Pain education • Complementary and alternative medicine (CAM) • Cognitive behavioral therapy • Physical therapy • Electrotherapy • Manipulative therapy • Support groups Pain Education

• Providing education about pain and therapies is extremely important so that patients can make educated decisions about their treatment • Has been shown to: • Improve adherence • Improve health, well-being, and outcomes • Increase satisfaction with treatment by promoting realistic expectations • Provide an opportunity to discuss concerns • Alleviate fears about treatments or medications

• Used in conjunction with standard medical treatments • Examples include acupuncture, needling, yoga, and optimal healing environment • May provide symptomatic relief for some individuals • Little to no evidence supporting its use for pain management in patients with a history of SUD

Cheatle M, et al. Popul Health Manag. 2014;17(2):78-79. Cognitive Behavioral Therapy

• Involves specific skill acquisition to help patients manage their pain • Skills include relaxation therapy and stress management • Supporting evidence exists regarding its efficacy in treating patients with various pain disorders and in patients with a history of SUD

Cheatle M, et al. Popul Health Manag. 2014;17(2):78-79. Physical Therapy

• Physical exercises have been shown to improve both pain and mood as well as increase functionality • Individualized based on source of pain • Physical therapists can create plans for acute pain and different plans to address chronic pain • Important to set functional goals and educate patients that they may initially have increased pain

Cheatle M, et al. Popul Health Manag. 2014;17(2):78-79. Physical Therapy continued

• A variety of techniques can be implemented to address various pain types. May include: • Therapeutic exercise • Joint mobilization • Aerobic exercise • Aquatics • Manipulation • Massage • Myofascial release • Compression wrapping • Therapeutic taping Electrotherapy

• Often prescribed by physical therapists • Includes wide range of treatments using mechanical and electrical impulses to reduce pain, promote circulation, and repair tissue • Provides targeted pain relief for joint, neck, or other acute pain and can be used as needed • Example: transcutaneous electrical nerve stimulation (TENS) • Should be used in conjunction with traditional physical therapy Support Groups

• Allows patients to connect with others who have similar experiences • Typically reserved for patients with chronic pain • Does not focus on providing treatment but rather a means for people to share what they have learned and to encourage others Non-Opioid Pharmacologic Treatment Options Non-Opioid Pharmacologic Treatment Options • Acetaminophen • Non-steroidal anti-inflammatory drugs (NSAIDs) • Glucocorticoids • Antidepressants • Gabapentinoids • NMDA receptor antagonists (ketamine) • Cannabinoids • α-2 adrenergic receptor agonists • Topical analgesics • Opioid antagonist Acetaminophen

• Brand names include Tylenol® and Ofirmev® (IV) • Mechanism of action: not completely understood • Indications/Use • First-line therapy for mild to moderate pain • Drug of choice in pregnancy • Also an antipyretic (reduces fever) • Adverse events • Nausea • Severe skin rash (very rare) • Liver damage • Jaundice

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Acetaminophen continued

• Dosing • By mouth • 325-500 mg every 4 to 6 hours for immediate release • 650 mg every 8 hours for extended release • IV: 650 mg every 4 hours or 1000 mg every 6 hours • Precautions/Contraindications • Severe hepatotoxicity can occur in overdose • Doses greater than 2000 mg can increase INR in warfarin patients • Avoid alcohol  added liver damage • Counseling Points • Educate patients regarding combination products that may contain acetaminophen • Max of 4000 mg/day and combination products have a maximum of 325 mg per dosing unit

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. NSAIDs

• Examples include: ibuprofen, naproxen, diclofenac, indomethacin, and celecoxib • Mechanism of action • Reversible inhibitor of cyclooxygenase (COX-1 and -2) • Celecoxib is a COX-2 selective inhibitor • Inhibits formation of prostaglandins and thromboxane A2 • Indications/Use • First-line therapy for mild to moderate pain • Also has antipyretic and anti-inflammatory properties

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. NSAIDs continued

• Adverse events • Nausea • Dyspepsia • Gastrointestinal (GI) bleeds • Increased blood pressure • Edema • Renal insufficiency • Precautions/Contraindications • Contraindicated in active bleeds and in treatment of perioperative pain in setting of coronary artery bypass grafting (CABG) surgery • Long-term use: Gastrointestinal, renal, cardiac effects (myocardial infarction) • Cox-2 inhibitor: Cardiovascular (CV)/bleed risk, less GI irritation • Counseling Points • Taking with food may reduce risk of nausea

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Ketorolac – A Special NSAID

• Ketorolac (Toradol®) • Indications/Use • Short-term moderate to severe pain • Dosing/Administration • IV: 15-30 mg q6h • IM: 30 mg q6h (may give 60 mg one time dose) • Oral and nasal spray also available • Precautions/Contraindications • Contraindicated post-CABG • Caution in CV disease, acute renal failure, liver failure • Max duration of treatment (for parenteral and oral) is 5 days

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. NSAIDs (Salicylates): Aspirin

• Mechanism of Action • Irreversible inhibitor of COX-1 and -2 • Indications/Use • Alternative agent for mild to moderate pain • Cardiovascular benefit • Analgesic Dosing • 325-650 mg by mouth every 4 to 6 • Maximum daily dose: 4g/day

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. NSAIDs (Salicylates): Aspirin continued • Precautions/Contraindications • Use in caution in patients with history of gastrointestinal bleed/ulceration • Avoid alcohol • Counseling Points • Avoid in children/teenagers with active viral infection – Reye’s syndrome can occur • Avoid in third trimester of pregnancy • Salicylate overdose may cause tinnitus

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Glucocorticoids

• Used in practice of pain management due to anti- inflammatory properties • Injectable corticosteroids most often used • Ex. dexamethasone and cortisone • Injection sites: • Epidural injections • Joint and soft tissue injections • Notable adverse events: • Injection site reactions, fluid and electrolyte disturbances, hyperglycemia, and insomnia

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Antidepressants

• Duloxetine (Cymbalta®) and amitriptyline (Elavil®) most notably used for pain • Duloxetine = serotonin and norepinephrine reuptake inhibitor (SNRI) • Amitriptyline = tricyclic antidepressant (TCA) • Indications/Use • Mainly used as adjuvant therapy for neuropathy, fibromyalgia, and post-herpetic neuralgia (PHN) • Consider for patients with underlying depression and a pain disorder

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Antidepressants continued

Drug Notable Adverse Notes Effects Duloxetine • ↑ Blood pressure • Antidepressants • ↑ Heart rate have boxed warning • Sexual dysfunction for increased risk of • Increased sweating suicidal thinking and Amitriptyline • QTc prolongation behavior in children, • Anticholinergic adolescents, and effects young adults • Tachycardia • TCAs can be used for • Orthostatic suicide hypotension

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Gabapentinoids

• Includes gabapentin (Neurontin®) and pregabalin (Lyrica®) • Control status varies by state • Both are Schedule V controlled-substances in West Virginia • Indications/Use • Commonly used as adjuvant therapy for neuropathy, fibromyalgia, and post-herpetic neuralgia (PHN) • Evidence exists for the use of gabapentin for postoperative pain

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Gabapentinoids continued

Drug Notable Adverse Effects Notes Gabapentin • Dry mouth • Concerns exist • CNS effects regarding abuse (dizziness, and misuse somnolence, • Seizure risk if drowsiness) rapidly • Weight gain discontinued • Peripheral edema • Reduce dose in the Pregabalin • Weight gain event of renal • CNS effects impairment (dizziness, somnolence, drowsiness) • Angioedema

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Muscle Relaxants • Reduce muscle tension/muscle spasms to decrease pain and discomfort • General adverse effects include hypotension, fatigue, dizziness, and somnolence • Examples • Baclofen, cyclobenzaprine, methocarbamol, tizanidine, and carisoprodol • Caridoprodol (Soma®) – a controlled substance • Not recommend in patients with a history of SUD due to concerns with abuse and misuse • Baclofen – use caution in patients with epilepsy; intrathecal formulation available • Cyclobenzaprine – contraindicated in patients with known cardiac disease (arrhythmias, congestive heart failure, and cardiac conduction disturbances)

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Cannabinoids • A class of chemical compounds derived from the cannabis plant • Over 100 different cannabinoids have been isolated • Produce analgesia by binding to cannabinoid receptors, particularly cannabinoid receptor type 1 (CB1) and type 2 (CB2) • May also modulate peroxisome proliferator-activated receptors (PPARs) or transient receptor potential (TRP) channels • Research suggests cannabidiol (CBD) may have significant analgesic and anti-inflammatory activities

Vuckovic S, et al. Front Pharmacol. 2018;9:1259. Cannabinoids continued

• Cannabidiol (CBD) • Non-psychoactive analog of THC that can be found in the cannabis plant • Can be obtained over-the-counter (OTC) • Many formulations exist including an oral solution (CBD oil) • A dietary supplement • Caution: Not FDA-approved • A prescription only formulation (Epidiolex®) does exist for Lennox-Gastaut syndrome and Dravet syndrome, two rare forms of epilepsy • Adverse events include drowsiness, lethargy, decreased appetite, weight loss, and diarrhea Topical Analgesics

• Topical agents/local anesthetics that provide symptomatic relief to various localized muscle, joint, or skin disorders • Available in various formulations including gels, creams, ointments, patches, aerosols, solutions, lozenges, and rectal products • Examples: lidocaine, benzocaine, benzyl alcohol, capsaicin, pramoxine, camphor and menthol • ADEs • Local - application site reactions

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Low-Dose Naltrexone (LDN)

• Full opioid antagonist • At lower doses it is thought to have anti-inflammatory properties • LDN refers to dosages approximately 1/10th of the typical opioid addiction treatment dosage • Not associated with the development of tolerance or dependence • Shown to reduce symptom severity in conditions such as fibromyalgia, Crohn’s disease, multiple sclerosis, and complex regional pain syndrome • Not routinely utilized or recommended

Younger J, Parkitny L, McLain D. Clin Rheumatol. 2014;33(4):451-459. Opioid Analgesics Opioid Analgesics

• Indications/use • Generally reserved for moderate to severe pain • Can be classified into: • Full agonists (most opioids) • Direct and strong attachment to opioid receptors • Partial agonists/mixed agonist-antagonist • Slight attachment and weak attraction to opioid receptors resulting in slight activation of opioid receptor

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Opioid Analgesics continued

• Warnings for all opioids: • Additive sedation particularly in combination with CNS depressants (e.g., benzodiazepines and alcohol) • Risk of hypotension • Increased risk for respiratory depression • Dependence, tolerance, and substance use disorder are major concerns • Patient should be included in the decision-making process to discuss risks and benefits of opioids

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Opioid-Induced Hyperaglesia

• Hyperalgesia is a medical condition that causes an increased sensitivity to pain • Opioid-induced hyperalgesia (OIH) is a state of increased pain sensitization in people who use opioids to treat pain • Can cause opioids to become ineffective over time • At this points risks > benefits • Treating pain with a multimodal approach may reduce the need for opioids, thereby decreasing the risk of OIH

Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. Opioids by Receptor Binding Full opioid agonists Partial Agonist/Mixed Agonist/Antagonist Codeine Buprenorphine Fentanyl Butorphanol Hydrocodone Nalbuphine Hydromorphone Pentazocine Methadone Morphine Oxycodone Oxymorphone Tramadol* Tapentadol* Meperidine Levorphanol *Atypical opioids

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Full Opioid Agonist

• Examples: hydrocodone, oxycodone, fentanyl, morphine, methadone, and codeine • General adverse events include nausea/vomiting, constipation, sedation, and respiratory depression • Methadone dosing for pain management differs from MAT dosing • Contraindicated in patients with significant respiratory depression

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Atypical Opioids

• Includes tramadol and tapentadol • Also inhibit reuptake of norepinephrine (both) or serotonin (only tramadol) • Many drug interactions especially with psychiatric medications • Risk of seizures • Lowers seizure threshold • Adverse event profile similar to other opioids • Less GI side effects

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Partial Opioid Agonist/Antagonist

• Buprenorphine • Indications/Use • Severe pain (chronic) • Butrans® – patch • Buprenex® – injection • Belbuca® – buccal film • Precautions/Contraindications • Dosing for pain management is different than dosing for MAT • Respiratory depression particularly with other CNS depressants • Caution when used with benzodiazepines • Can precipitate withdrawal

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Other Opioid Agonist/Antagonist

• Includes butorphanol, nalbuphine, and pentazocine • Less commonly used compared to other opioid options • Adverse event profile similar to other opioids

DiPiro, JT, et al. 2017. Pharmacotherapy. New York, USA: McGraw-Hill Professional Publishing. Therapy Guidance

• Selecting the most appropriate medication depends on the etiology of pain as well as pain severity • Selection should be individualized • Consider: • Patient preference • Patient’s past medical history • Drug interactions • Medication side effect profile Treatments Based on Pain Types

Nocieptive Nociplastic Neuropathic Nonpharmacologic • Exercise • Exercise • Exercise • Education • Education • Education • Massage • Massage • TENS • Manipulation • Laser • TENS/Laser Pharmacologic • Topical analgesic • SNRI • Gabapentinoid • NSAID • TCA • Opioid

Chimenti R, Frey-Law, LA, Sluka KA. Phys Ther. 2018;98(5):302-314. Mild to Moderate Pain

• Includes both acute/chronic pain • Acetaminophen and NSAIDs are typically used first line for somatic pain of mild to moderate intensity • Adjunctive agents may include topical agents (predominantly peripheral pain), antidepressants, gabapentinoids, and muscle relaxants Chronic Pain

• Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred • Opioid therapy should be considered only if expected benefits for both pain and function outweigh risks to the patient • If opioids are used, they should be used in combination with nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate

• Includes acute postsurgical or trauma- induced pain and cancer pain • Opioids are the drugs of choice in managing severe pain • The use of opioids for chronic non-cancer pain is not routinely recommended • Hyperaglesia/SUD/dependence • Adjunctive agents such as NSAIDs and acetaminophen should be maximized to decrease opioid use Pain and MAT Patients Receiving Opioid Replacement Therapy • Methadone • Not ideal for acute pain management • Patients will likely require an additional opioid to manage acute severe pain in combination with usual dose of methadone • Utilize adjunctive therapy with non-opioids, if applicable • Buprenorphine • Due to binding properties, may prevent additional analgesics from being effective • If acute pain is anticipated (e.g., planned surgery), discontinue buprenorphine for several days prior to the episode and supplement with methadone to prevent withdrawal • If pain is unanticipated (e.g., trauma), opioids with a strong binding affinity to µ receptors, such as fentanyl, are preferred • Utilize adjunctive therapy with non-opioids, if applicable

Prince V. Chronic illnesses. 2011;7:171-185. Naltrexone Use Considerations • For patients prescribed naltrexone for opioid or alcohol dependence, opioids may be ineffective for pain management • Of note, the opioid blocking effects of extended-release injectable naltrexone (Vivitrol®) last ~ 28 days • Oral naltrexone and anticipatory acute pain (e.g., planned surgery) • It is recommended to discontinue at least 72 hours before episode if opioid use is anticipated • Oral naltrexone/extended-release injectable for emergency pain management • Regional analgesia, non-opioid analgesics, and general anesthesia should be considered. Specific agents that may be beneficial include ketorolac, propofol, ketamine and dexmedetomidine.

Prince V. Chronic illnesses. 2011;7:171-185 When to Refer? • Patients struggling with pain and a co-occurring substance use disorder should be referred to a substance abuse treatment center • In addition to the benefits for OUD, methadone and buprenorphine can effectively manage pain • Consultation or referral to a pain management specialist should be considered if: • Patient using 80-100 morphine milligram equivalents (MME) • Patient prescribed multiple sedatives (e.g., benzodiazepines) • Patient consistently requires more opioids • Patient uses illicit substances • Patient refuses non-opioid measures or reduction in opioid dosage

Tennant F. “Opioid Prescribing and Monitoring – How to Combat Opioid Abuse and Misuse Responsibly.” Practical Pain Management. https://www.practicalpainmanagement.com/resource-centers/opioid-prescribing-monitoring/when-call-cavalry- when-why-refer-patient Accessed June 28, 2020. What if Opioids are Indicated?

• Patient should always be included in the decision-making process • Consider using long-acting opioids when possible • The use of short-acting opioids are more likely to stimulate craving and relapse • Increased monitoring • Urine drug screens and pill counts can be helpful in providing accountability with patients • Limit quantities of opioids dispensed at a single time • Patient contracts/pain contracts with clearly defined expectations can help hold patients accountable • Prescription Drug Monitoring Programs (PDMPs) are utilized to monitor patients controlled substance prescription history in most states • Increase recovery-related activities (e.g., 12-step program) • Morphine Milligram Equivalents (MME) Risk assessment • Educate, Educate, Educate about risks of medications and resources available to patients as well as family members/caregivers MME Risk Assessment

• Helps identify patients who may need closer monitoring or other measures to reduce risk of overdose • Dose reductions or tapering • Prescribing of naloxone • Considers all opioids a patient is receiving and standardizes opioid doses for comparison • Dosages at or above 50 MME/day increase risks for overdose by at least two-fold

Prince V. Chronic illnesses. 2011;7:171-185 Calculating MMEs

• Calculate total mg of each opioid patient takes over 24 hours • Convert each to MMEs by multiplying by its conversion factor (see table) • Add the total MME for all opioids

CDC Calculating MME Conversion Factor Chart Calculating MMEs Example

• Over a 24-hour period, patient is administered four tablets of oxycodone 10 mg and two tablets of morphine 10 mg ER tablets • Calculate total mg of each opioid patient takes over 24 hours • Oxycodone = 4 x 10 mg = 40 mg oxycodone • Morphine = 2 x 10 mg = 20 mg morphine • Convert each to MMEs by multiplying by its conversion factor (see table) • 40 mg oxycodone x 1.5 = 60 MME • 20 mg morphine x 1 = 20 MME • Add the total MME for all opioids • 60 MME + 20 MME = 80 MME Opioid Consideration

• When a patient’s total daily opioid dosage from all sources reaches or exceeds 50 MMEs, additional precautions should be implemented • Consider offering a prescription for naloxone • Increase frequency of follow-up • Overdose prevention education to both patients and the patients’ household members

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States , 2016. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2F volumes%2F65%2Frr%2Frr6501e1er.htm#summaryoftheclinicalevidencereview Accessed August 20, 2020. Prescription Drug Monitor Programs • Electronic databases used to track controlled substance prescriptions • Ohio – OARRS • https://www.ohiopmp.gov/ • Kentucky – KASPER • https://ekasper.chfs.ky.gov/ • West Virginia – CSAPP • https://www.csappwv.com/ QUESTIONS? [email protected]