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Pain Management and Opioids: Balancing Risks and Benefits

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Pain Management and Opioids: Balancing Risks and Benefits 8/6/2019 Pain Management and Opioids: Balancing Risks and Benefits PRESENTED BY CO*RE, THE COLLABORATION FOR REMS EDUCATION UPDATED 2019 1 | © CO*RE 2019 1 8/6/2019 FACULTY INFORMATION James Cannon, MS, DHA, MBA, PA-C, DFAAPA, practices psychiatry, hospital, and addiction medicine. James received his PA training and Masters of Science from the Arizona School of Health Sciences/A. T. Still University. He additionally holds a Masters of Business Administration and a doctorate in health care administration. He is a certified PA and with a Certificate of Added Qualification in Psychiatry. In addition to authoring numerous articles in medical journals and books, James works with numerous professional groups, including the American Academy of PAs and Association of PAs in Psychiatry. Currently serving on numerous boards that include of the Virginia Association of PAs , PAs for Tomorrow, the Boards of Trustees of A.T. Still University as the only non-physician/dentist director, where he helps guide the envisioned future of the 125 year founding school of Osteopathy and South Hampton Memorial Hospital. James and his wife reside in Chesapeake, VA with two dogs while his daughter attends college in Texas. INSERT CO*RE PARTNER LOGO DISCLOSURE: Nothing to disclose 2 | © CO*RE 2019 2 8/6/2019 ACKNOWLEDGMENTS Presented by AAPA a member of the Collaborative for Risk Evaluation and Mitigation Strategy (REMS) Education (CO*RE), nine interdisciplinary organizations working together to improve pain management and prevent adverse outcomes. This activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies (RPC). Please see this document for a list of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the U.S. Food and Drug Administration. 3 | © CO*RE 2019 3 8/6/2019 CO*RE COLLABORATION 4 | © CO*RE 2019 4 8/6/2019 FACULTY ADVISORY PANEL David Bazzo, MD Ron Crossno, MD Kate Galluzzi, DO Carol Havens, MD Randy Hudspeth, APRN UC SAN DIEGO KINDRED AT HOME PHILADELPHIA COLLEGE KAISER PERMANENTE PRACTICE CONSULTANT OF OSTEOPATHIC MEDICINE NO CO*RE FACULTY HAS ANY RELEVANT FINANICAL RELATIONSHIPS Dennis Rivenburgh, PA-C Ed Salsitz, MD Barb St. Marie, ANP JOHNS HOPKINS SCHOOL MOUNT SINAI BETH ISRAEL UNIVERSITY OF IOWA OF MEDICINE 5 | © CO*RE 2019 5 8/6/2019 BY THE END OF THIS SESSION YOU WILL BE ABLE TO • Describe the pathophysiology of pain as it relates to the concepts of pain management. • Accurately assess patients in pain. • Develop a safe and effective pain treatment plan. • Identify evidence-based non-opioid options for the treatment of pain. • Identify the risks and benefits of opioid therapy. • Manage ongoing opioid therapy. • Recognize behaviors that may be associated with opioid use disorder. 6 | © CO*RE 2019 6 8/6/2019 WHY ARE WE HERE? 7 | © CO*RE 2019 7 8/6/2019 CO*RE STATEMENT Misuse, abuse, diversion, addiction, and overdose of opioids in the United States have created a serious public health epidemic. When prescribed well, and used as prescribed, opioids can be valuable tools for effective pain management. There is potential for unintended consequences of inadequately managed pain from far-reaching prescribing restrictions. This course is in alignment with the FDA Opioid Analgesics REMS Education Blueprint. This course does not advocate for or against the use of opioids. We intend to help healthcare providers manage pain without putting vulnerable patients at risk for misuse or opioid use disorder. The goal is to keep our patients, our communities, and ourselves SAFE. 8 | © CO*RE 2019 8 8/6/2019 PRESCRIBING PATTERNS AND OPIOID-RELATED DEATHS SOURCE: CDC Opioid Overdose Death data, IQVIA opioid prescribing data, Sullum J © 9 | CO*RE 2019 https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm 9 8/6/2019 DEA SCHEDULED DRUGS SCHEDULE DESCRIPTION EXAMPLES High potential for abuse; no I Heroin, LSD, cannabis, ecstasy, peyote currently accepted medical use High potential for abuse, which Hydromorphone, methadone, meperidine, II may lead to severe psychological oxycodone, fentanyl, morphine, opium, or physical dependence codeine, hydrocodone combination products Potential for abuse, which may Products containing ≤ 90 mg codeine per lead to moderate or low physical III dose, buprenorphine, benzphetamine, dependence or high psychological phendimetrazine, ketamine, anabolic steroids dependence Alprazolam, benzodiazepines, carisoprodol, IV “Low potential” for abuse clonazepam, clorazepate, diazepam, lorazepam, midazolam, temazepam, tramadol Cough preparations containing ≤ 200 mg V Low potential for abuse codeine/100 ml Complete list of products covered under the Opioid Analgesic REMS available at: https://opioidanalgesicrems.com/RpcUI/products.u 10 | © CO*RE 2019 10 8/6/2019 FENTANYL AND FENTANYL ANALOGUES OD deaths from fentanyl and fentanyl analogues, such as carfentanil, have increased 540% in three years. Street fentanyl is illegally manufactured; it is generally NOT a diverted pharmaceutical product. Two causes of fentanyl OD death: opioid-induced respiratory depression and rigid chest wall syndrome; higher or repeated doses of naloxone are required to reverse a fentanyl overdose. Fentanyl is also found in heroin, cocaine, and methamphetamine. © 11 | CO*RE 2019 Photo source: New Hampshire State Police Forensic Laboratory 11 8/6/2019 RISKS VERSUS BENEFITS RISKS BENEFITS • Misuse, diversion, and addiction • Analgesia • Abuse by patient or household contacts - Reliable pain control • Interactions with other meds and substances - Quick analgesia (particularly with IRs) • Risk of neonatal abstinence syndrome • Continuous, predictable • Inadvertent exposure/ingestion by household (with ER/LAs) contacts, especially children • Improved function • Life-threatening respiratory depression • Improved quality of life • Overdose, especially as ER/LA formulations contain more MME than IR SOURCE: Nicholson, B. Pain Pract. 2009;9(1):71-81. http://onlinelibrary.wiley.com/doi/10.1111/j.1533-2500.2008.00232.x/abstract 12 | © CO*RE 2019 12 8/6/2019 CHAPTER 1 PAIN 13 | © CO*RE 2019 13 8/6/2019 THE NEUROMECHANISMS OF PAIN Peripheral Pain Modulators: • Serotonin • Histamines • Prostaglandins • Cytokines • Bradykinin • Substance P • Others Descending Neurotransmitters: • Serotonin • Norepinephrine • Endogenous opiates • Others 14 | © CO*RE 2019 14 8/6/2019 MEDIATORS OF PERIPHERAL NOCICEPTION Feeling physical pain is vital for survival; pain is the body’s early warning system. With thanks to Allan Basbaum and David Julius, University of California, San Francisco 15 | © CO*RE 2019 15 8/6/2019 OPIOID RECEPTOR LOCATIONS 16 | © CO*RE 2019 16 8/6/2019 TYPES OF PAIN NOCICEPTIVE / MIXED TYPES NOCIPLASTIC NEUROPATHIC INFLAMMATORY (NOCICEPTIVE / NEUROPATHIC) Pain in response to Pain that arises from Pain that develops Primary injury and an injury or stimuli; altered nociceptive when the nervous secondary effects typically acute function; typically system is damaged; chronic typically chronic Postoperative pain, Fibromyalgia, Post-herpetic sports injuries, irritable bowel neuralgia, trigeminal arthritis, sickle cell syndrome, non- neuralgia, distal disease, specific low back polyneuropathy, mechanical low pain CRPS, neuropathic back pain low back pain Possible development of chronic pain after an acute injury. 17 | © CO*RE 2019 17 8/6/2019 THE BIOPSYCHOSOCIAL SPIRITUAL CONTEXT OF PAIN Sleep/fatigue Resilience Inflammation Anxiety Gender ACEs* Conditioning Grief Nutritional status Depression Catastrophizing Previous pain experience BIOLOGICAL PSYCHOLOGICAL SOCIAL SPIRITUAL Work status Religious faith Intimacy Existential issues Relationships Suffering Finances Spiritual distress Empathy Family Values *ACEs = from Adverse Childhood Experiences HCP Experience of Pain 18 | © CO*RE 2019 18 8/6/2019 PAIN CATASTROPHIZING • “Tell me about your pain…” • Listen for rumination, feelings of hopelessness, or anticipation of negative outcomes. • These feelings are important to identify because they can prolong and intensify pain; or lead to higher levels of suffering and altered perception of pain. • If identified, shift to “tell me about your life.” SOURCE: Pain Catastrophizing Scale © 2009 Dr. Michael JL Sullivan Mapi Research Trust, Lyon, France. Internet: https://eprovide.mapi-trust.org 19 | © CO*RE 2019 19 8/6/2019 CHAPTER 2 TERMINOLOGY 20 | © CO*RE 2019 20 8/6/2019 WORDS MATTER: LANGUAGE CHOICE CAN REDUCE STIGMA “If you want to care for something, you call it a flower; if you want to kill something, you call it a weed.” ―Don Coyhis Commonly Used Term Preferred Term Substance use disorder (SUD) Addiction [from the DSM-5®] Drug-seeking, Using medication not as aberrant/problematic behavior prescribed Person with substance use Addict disorder (SUD) Positive/negative urine drug Clean/dirty urine screen SOURCES: SAMHSHA Resource: https://www.samhsa.gov/capt/sites/default/files/resources/sud-stigma-tool.pdf Scholten W. Public Health. 2017;153:147-153. DOI: 10.1016/j.puhe.2017.08.021 21 | © CO*RE 2019 21 8/6/2019 WORDS MATTER: DEFINITIONS Misuse Use of a medication in a way other than the way it is prescribed Abuse Use of a substance with the intent of getting high Tolerance Increased dosage needed to produce a specific effect State in which an organism only functions normally in the presence of a Dependence substance Transfer of a legally controlled substance, prescribed to one person, to Diversion another person for illicit (forbidden by law) use Occurrence
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