Opioids 101

Lori Montgomery MD CCFPClinical Lecturer, Depts of Family Medicine and

AnesthesiaMedical Director, AHS Chronic Pain Centre

Disclosure

Grants/Research Support: NoneSpeakers Bureau/Honoraria: None Consulting Fees: None

RobinHad a flare-up after

shovelling snowWent to EDSent home with a six-

pack of PercocetLiked it.

Opioids

Do they work?What’s the downside?How do we try them safely?

Pain therapy tool boxOpioids

Canada 753mg/capitaUS 693 mg/capita

77

Canada

US

Ireland

88

US

Canada

UK

99

Austria

Canada

US

Do they work?

Opioid Therapy for Chronic Pain, Ballantyne JC, and Mao J, N Engl J Med 2003;349:1943-53.

Opioids for Low Back Pain: BMJ State of the Art Review, Deyo RA, Von Korff M, Duhrkoop D, BMJ 2015; 350:g6380 doi: 10.1136/bmj.g6380

Efficacy

Meta-analysis of 15 RCTs; duration 4-6 weeks; pain intensity (including NeP) reduced by about 30%

Kalso et al, Pain 2004

Meta-analysis of 8 RCTs in NeP; duration <28 days; significant benefit

Eisenberg et al, JAMA 2005

EfficacyMeta-analysis of 41 RCTs; duration 16 weeks; pain intensity reduced with strong opioids, not with weak or non-opioids; more than 1/3 abandoned treatment for lack of efficacy

Furlan et al, CMAJ 2006

Meta-analysis of 6 RCTs in LBP; duration <16 weeks; no significant reduction in pain intensity

Martell et al, Ann Intern Med 2007

EfficacyFurlan AD et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012;2012:953139.

Noble M et al. Long-term opioid management for chronic noncancer pain. The Cochrane database of systematic reviews 2010:Cd006605.

Agency for Healthcare Research and Quality R, MD. The Effectiveness and Risks of Long- Term Opioid Treatment of Chronic Pain. http://www.ahrq.gov/research/findings/evidence-based- reports/opoidstp.html2014.

In OA, research demonstrating long-term improvements in pain/function is lacking. In elderly patients with OA, the risk of opioids may be even greater than the risk of NSAIDs. Opioids should not be routinely used in OA; if necessary, they should be used for short-courses in carefully selected patients.

Ivers, Dhalla, Allan, TFP ACFP 2012

Efficacy

Smith, HS. Pain Physician, 2012;15:ES1-ES7

The down side

Constipation

Nausea and vomiting

Sedation during titration (driving, work)

Pruritis

Hyperhidrosis

Dry mouth

Peripheral edema

Sleep disruption

The down side: short term

GERD symptoms

Myoclonus

Opioid-induced hyperalgesia

Hormonal effectsDirect pituitary and hypothalamic effectsDirect hormone effects

Elevated prolactin, ACTH, ADHDecreased TSH, FSH, LH, GH, cortisol

(Immune dysfunction) (mood problems)

Addiction and Diversion

Death???

The down side: long term/high dose

Long term side effects are beginning to be elucidated

Problem opioid use is a growing public health issue

They don’t always work in chronic pain

We know less about their use than we think

No long term outcome data

There is likely an upper limit, but we don’t know what it is (180mg? 200mg? 400mg?)

The down side

2222

Who is using opioids?Opioid users report poorer self-rated health, more severe pain, more inactivity, more unemployment, higher use of the health care system

Eriksen et al, Pain 2006

Patients with chronic low back pain are the most likely to be prescribed opioids (also the most common CP diagnosis)

Morasco, Pain 2010

2323

Who is using opioids?

Patients with higher levels of distress (low mood, catastophizing ) appear to be less likely to respond to opioid therapy

Wasan, Pain 2005

Patients with histories of mental illness and substance abuse are more likely to be started on opioid therapy

These patients are typically excluded from opioid studies

Edlund MJ, Sullivan MD et al, Clin J Pain 2010

Starting

Canadian Guideline for Safe and Effective Use of Opioids for Chronic

Non-Cancer Pain

http://nationalpaincentre.mcmaster.ca/

opioid/

Canadian Guideline for Safe and Effective Use of Opioids for Chronic

Non-Cancer Pain

National guideline sponsored by regulatory bodiesEvidence-based set of 24 recommendationsRecommendations outline safe and effective treatment methods.

Canadian Guideline for Safe and Effective Use of Opioids for Chronic

Non-Cancer PainCluster 1: Deciding to Initiate Opioid Therapy

Cluster 2: Conducting an Opioid Trial

Cluster 3: Monitoring Long-Term Opioid Therapy (LTOT)

Cluster 4: Treating Specific Populations with LTOT

Cluster 5: Managing Opioid Misuse and Addiction in CNCP Patients

An overview of the Guideline’s recommendations

Jane Ballantyne

Decision PhaseEstablish a diagnosis

Check on non-opioid treatment response

Check on non-medical treatments

Risk assessment

Informed consent

Plan goals with patient

Ensure patient understands potential outcome

Explain plan “B”

Decision PhaseEstablish a diagnosis

Check on non-opioid treatment response

Check on non-medical treatments

Risk assessment

Informed consent

Plan goals with patient

Explain plan “B”

ToolsSISAP

If you drink alcohol, how many drinks do you have on a typical day?How many drinks do you have in a typical week?Have you used marijuana or hashish in the past year?Have you ever smoked cigarettes?What is your age?

CAGETried to Cut down or Change your patter of drinking or drug use?Been Annoyed by others’ concerns about your drinking or drug use?Felt Guilty about the consequences of your drinking or drug use?Had a drink or used a drug in the morning (Eye-opener) to decrease hangover or withdrawal symptoms?

TICS Two-item Conjoint Screening TestIn the last year have you ever drunk or used drugs more than you meant to?Have you ever felt you wanted or needed to cut down on your drinking or drug use in the last year?

Risk Assessment

Poor stress management with multiple life stressors

Drug abuse in family or household

Regular contact with high-risk people

History of previous addictive behavior (gambling, eating, promiscuity, work, internet etc)

Decision PhaseEstablish a diagnosis

Check on non-opioid treatment response

Check on non-medical treatments

Risk assessment

Informed consent

Plan goals with patient

Explain plan “B”

Opioid Treatment Agreement

Measuring outcome

PainSelf report (behaviour)

Physical function2-3 Specific relevant goalsCollateral history sometimes

Initiating

Start at low dose (e.g SR morphine 15 bid)

Increase dose slowly based on agreed-upon limits

Watch for increased analgesia and function

Manage side effects immediately (e.g. constipation)

Consider rotation or taper if no CLEAR benefit.

Choice of opioidAvoid Demerol

Avoid injectable preparations

Avoid combination preparations

Usually opt for long-acting preparations over short-acting

No need for “breakthrough” dosing

Talk “flare-up management” instead

Q: I’ve given the patient long-acting opioids at the same daily dose as short-acting opioids, but the patient says “they don’t work”. What’s that all about?

Red Flags

• Escalating dose• Early refills• Lost prescriptions• Using drug for reasons

other than pain• Double doctoring

• Forging or stealing prescriptions

• Altering prescriptions• Altering medication

forms• Factitious complaints• Injecting, snorting

Problem drug use“Normal” Addiction

Aberrant drug behaviour

Not necessarily addiction

Check for end of dose failure

Sometimes q6 or 8h

Look for trends of behaviour

Avoid making judgments

Aim for keeping the patient safe

MaintenanceMonthly refills

Pick up will vary according to patient need.

Document 5 As (Analgesia, Adverse effects, Activity, Aberrant drug behaviour, Accurate records)

Manage side effects

Monitor dose MEDD

Maintenance

Watch for “mission creep”Watchful dose 200mg OMEAsk for help before going past this dose

Monitor for long term side effects.

Periodic UDT

Ask for help whenever necessary

How to do it safelyThink carefully before you startAssess risk of problem drug useDiscuss functional goalsSign/enforce an opioid agreementGo slowly, aim for no more than three dose escalations (<200mg MEDD)At every visit, 5As

Montgomery 2013, Adapted from Twycross R, et al. Palliative Care Formulary. Radcliffe Medical Press, Oxford; 1998:86

Acetaminophen

NSAIDs

COXIBs

BuprenorphineTramadol

AntidepressantsAnticonvulsantsCannabinoids

CodeineMorphineOxycodoneHydromorphoneFentanylMethadone

RobinHad a flare-up after

shovelling snowWent to EDCame home with a

six-pack of PercocetLiked it.

Resources for Patients

You tube – understanding painhttp://www.youtube.com/watch?v=4b8oB757DKc

Lorimer Moseleyhttp://www.youtube.com/watch?v=-3NmTE-fJSo

Canadian Pain Coalitionhttp://www.canadianpaincoalition.caNeil Pearson

Web based Pain Self Managementhttps://www.pathwaythroughpain.com

Doc Mike Evans: Best advice for people taking opioid medications

https://www.youtube.com/watch?v=7Na2m7lx-hU

Resources for You

Physicians for Responsible Opioid Prescribing

http://www.supportprop.org

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

http://nationalpaincentre.mcmaster.ca/opioid/

Benzodiazepine Taperingwww.benzo.org.uk/manual

Lorimer Mosely (2002). Explain Pain

ReferencesBallantyne JC, Mao J, Opioid Therapy for Chronic Pain, N Engl J Med 2003;349:1943-53

Deyo RA, Von Korff M, Duhrkoop D, Opioids for Low Back Pain: BMJ State of the Art Review, BMJ 2015;350:g6380 doi: 10.1136/bmj.g6380

Graziotti P, Goucke R, The use of oral opioids in patients with chronic nonmalignant pain: Management strategies, Australian Pain Society

Kirkpatrick AF, Derasari M, A Protocol-Contract for opioid use in patients with chronic pain not due to malignancy, Journal of Clinical Anaesthesia 1998; 10:435-443

Schug SA, Large RG, Opioids for chronic non-cancer pain, Pain: Clinical Updates Nov 1995 IASP press, Volume III (3)

A consensus statement and guidelines from the Canadian Pain Society: Use of opioid analgesics for the treatment of chronic non-cancer pain, Pain Res Manage 2002; Vol 8, Suppl A

Recommendations for the appropriate use of opioids for persistent non-cancer pain, British Pain Society March 2004

Eisenberg E, McNicol ED, Carr DB, Efficacy and safety of opioid agonists in the treatment of neuropathic pain of non-malignant origin: systematic review and meta-analysis of randomized controlled trials, JAMA 2005; 293: 3043-52

Eriksen , Sjogren P, Bruera E, Ekholm O, Rasmussen NK, Critical issues on opioids in chronic non-cancer pain: an epidemiological study, Pain 2006; 125: 172-9

Isaacson JH, Hopper JA, Alford, DP, Parran T, Prescription drug use and abuse, Postgraduate Medicine Online 2005; 118(1)

Webster LW, Predicting Aberrant Behaviours in Opioid-Treated Patients, Pain Medicine 2005; 6(6): 432-442

ReferencesBrauna Brands Addiction Research Foundation (ed.), Management of Alcohol,Tobacco and other drug problems (www.camh.net)

Mark D. Sullivan; Mark J. Edlund; Lily Zhang; Jürgen Unützer; Kenneth B. Wells, Association Between Mental Health Disorders, Problem Drug Use, and Regular Prescription Opioid Use, Arch Intern Med. 2006;166(19):2087-2093.

Edlund MJ, Martin BC, Devries A, Fan Ming-Yu, Braden JB, Sullivan MD. Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J Pain 2010;26:1-8.

Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E, Opioids for Chronic Non-Cancer Pain: a meta-analysis of effectiveness and side effects, CMAJ 2006; 174: 1589-94

Gilron I, Bailey JM, Tu D et al, Morphine, Gabapentin, or Their Combination for Neuropathic Pain, NEJM 2005; 352: 1324-34

Kalso E, Edwards J, Moore R, McQuay H, Opioids in chronic non-cancer pain: systematic review of efficacy and safety, Pain 2004; 112: 327-80

ReferencesMartell, BA, O’Connor PG, Kerns RD et al, Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction, Ann Intern Med 2007; 146:116-27

Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain 2010;151:625-32.

de C Williams, AC, Psychological distress and opioid efficacy: more questions than answers, Pain 2005; 117: 245-6

Weekes J et al, Prescription Drug Abuse FAQs, Canadian Centre on Substance Abuse, www.ccsa.ca, June 2007

Allan L, Richarz U, Simpson K, Slappendel R, Transdermal Fentanyl Versus Sustained Release Oral Morphine in Strong-Opioid Naive Patients With Chronic Low Back Pain, Spine 30(22):2484–2490