Just the facts on Opioid Management Opioid Classifications Prudent Prescription Practice Using Evidence-Based Medicine (EBM) Pure-agonists Partial agonists- Mixed agonists- Central acting Opioid Misuse/Abuse antagonists antagonists analgesics Think twice about the risk of misuse versus Took from Dealer, friend/family stranger, Natural or synthetic Stimulate analgesic Limited use in chronic Emerging class of medical necessity with each script: 5% or other agents that don’t have a opioid receptors with pain because of ceiling synthetic opioids that Almost 90% of prescription painkiller misuse 12% ceiling for analgesic little effect on toxicity, effect for analgesia inhibit reuptake of and abuse comes from drugs prescribed legally efficacy or antagonize lower abuse potential which does not increase serotonin and to users or their friends and family. Most of the effects of other opioids but added side effects with dose escalation norepinephrine prescriptions come from primary care and Bought from friend/family 11% internal medicine doctors, not specialists. Obtained free from friend/family 55% Healthcare provider accountability: Precribed by Short-Acting Long-Acting The Centers for Disease Control has urged doctor 17% “Normal-release” or “immediate-release”, often used “Controlled-release”, “extended-release”, or States to ensure providers follow evidence- for intermittent or breakthrough pain and combined “sustained-release”, highly potent and can stabilize based treatment guidelines for the safe and with other analgesics like acetaminophen or aspirin. medication levels for round-the-clock analgesia. effective use of prescription painkillers. Duration of action is 3-4 hours. Increased risk of hypogonadism. EBM Takeaways from Official Disability Guidelines (ODG) Acute Pain Subacute Pain Routine long-term opioid Not recommended therapy for non-malignant except for short-term Increasing duration of Chronic Pain pain is NOT recommended. use for severe cases, Evidence does not support use may lead to Recommended only not to exceed two dependency and overall effectiveness and as 2nd/3rd line option indicates risk of numerous weeks. Patients higher prevalence of at doses ≤ 120 mg adverse effects, including should be warned of work disability, risks and side effects. daily oral morphine psychological dependence depression, anxiety, (MED) equivalent in with difficultly weaning. and substance abuse. cases not at risk of misuse or diversion. 18,000 Annual Deaths in the USA from 16,000 Opioid Pain Relievers (OPR) 14,000 OPR deaths now far exceed 12,000 those from heroin/cocaine. Consider one- 10,000 Overdose and death month limit for 8,000 risk increases non-malignant 6,000 significantly pain patients 4,000 with higher 2,000 doses. 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Steps before therapeutic opioid trial: ODG Opioid Drug Formulary: Opioids should only be part of a tailored treatment plan. Prior to First-Line: (Yes or No) starting, consider alternatives, and screen for risk of addiction, Brand Name Generic Name Status abuse or adverse outcome using tools like “Opioid Risk Tool” or Abstral Fentanyl transmucosal N “Screener & Opioid Assessment for Patients with Pain-Revised”. Actiq® Fentanyl lollipop N Obtain history of alcohol/substance abuse use. Opioids may not be Avinza® Morphine ER N helpful for conversion or somatization disorder, or pain from Buprenex® Buprenorphine (injection for detox) Y psychological factors (anxiety, depression, history of substance Butrans™ Buprenorphine(transdermal) N Codeine Codeine Y abuse). While patients may misuse opioids for these, there are Combunox Oxycodone/ibuprofen N better alternatives. Document the basis for any clinical decision to ConZip Tramadol ER N withhold opioids on inconsistencies in history, presentation, Darvocet® Propoxyphene/acetaminophen N behaviors, or physical findings for patients requesting them. Darvon® Propoxyphene hcl N Darvon-N® Propoxyphene napsylate N • Determine if pain is nociceptive or neuropathic (neuropathic Demerol® Meperidine N may require higher dose, though opioids would not be first-line Dilaudid® Hydromorphone Y therapy) and if there are underlying psychological issues. Duragesic® Fentanyl transdermal Y • A therapeutic trial of opioids should not be employed until the Embeda Morphine ER / Naltrexone Y Exalgo Hydromorphone ER N patient has failed a trial of non-opioid analgesics. Fentora® Fentanyl buccal N • Doctor and patient should set goals; continued use of opioids Fioricet® Butalbital (a barbiturate) N should be contingent on meeting those goals. Kadian® Morphine ER N • Baseline pain and functional assessments should be made to Lazanda Fentanyl nasal spray N include social, physical, psychological, daily/work activities, Levo-Dromoran® Levorphanol Y history of pain treatment, and effect of pain and function. Lortab® Hydrocodone/acetamin. Y Methadose® Methadone (link to rules) N • Assess likelihood patient could be weaned from opioids if there Morphine Morphine Y is no improvement in pain and function. Morphine Morphine ER Y • Conduct physical and psychological assessment; if subjective Nucynta™ Tapentadol N complaints don’t correlate w/imaging or physical findings or if Onsolis™ Fentanyl buccal film N psychosocial concerns exist, obtain specialist opinion. Opana® Oxymorphone N • Discuss risks and benefits with the patient or caregiver. Oxecta Oxycodone N OxyContin® Oxycodone ER N • Use written consent or pain agreement to document patient OxyIR® Oxycodone Y education, treatment plan, and informed consent. Percocet® Oxycodone/acetaminophen Y • Conduct urine drug screen for opioid misuse, illegal drug use. Percodan® Oxycodone/aspirin N • Check State Prescription Monitoring Program for duplicate Prialt® Ziconotide (morphine pump) N prescribers or inconsistent prescription fills. Suboxone® Buprenorphine (for pain) N Suboxone® Buprenorphine/Naloxone (detox) Y Subsys® Fentanyl sublingual spray N Subutex® Buprenorphine (for detox) Y When to continue opioids: Talwin Pentazocine lactate N Talwin NX Pentazocine/Naloxone N • If the patient has returned to work. Tylenol #3 Codeine/acetaminophen Y • If the patient has improved functioning and pain. Ultracet® Tramadol/Acetaminophen Y Ultram ER® Tramadol ER Y Ultram® Tramadol Y Vicodin® Hydrocodone/acetaminophen Y When to discontinue opioids: Vicoprofen® Hydrocodone/ibuprofen N Determine if treatment failure is due to correctable causes such as under-dosing or an inappropriate schedule. If not, weaning should Provided with permission, occur under direct medical supervision as slow taper. Official Disability Guidelines (ODG) Published by Work Loss Data Institute • Continuing pain with intolerable adverse effects. • Lack of significant benefit (persistent pain or no improved function despite doses of opiates up to 120 mg/day MED). • Resolution of pain, or patient requests discontinuing. • If serious non-adherence is occurring. • Evidence of illegal activity (diversion, forgery, or stealing). • Car accident or arrest related to opioids, alcohol, or illicit drugs; suicide attempt; aggressive or threatening behavior. • Repeat violations from opioid contract or evidence of abuse/addiction. Consider referral to addiction specialist. www.worklossdata.com .