Opioids: Safe Prescribing, Patient Care and Pain

Management

Gary W. Pushkin, M.D., F.A.C.S.

• Immediate Past President of MedChi, The Maryland State Medical Society • Member Board of Councilors, AAOS • Executive Board of the International Academy of Independent Medical Evaluators (IAIME) • Speaker for The Maryland Patient Safety Center

Disclosure Statements

• Practicing partner at Cohen & Pushkin, M.D., P.A. • Fellow American Academy of Orthopaedic Surgeons • 35 years experience evaluating and treating injured workers • 25 years experience doing IMEs • Eagle Scout (And Eagle Scout Dad!)

Education &

Awareness

At the recent AAOS 2019 annual meeting there were

81 presentations mentioning opioids!

Study

While representing < 5% of the world’s population, USA consumes 80% of global

opioids supply!

Patient Education

Misuse of prescription pain medicine accounts for nearly half a million emergency department

visits per year.

More than 75% of these people are using drugs that have been

prescribed to another person

Take one to 2 pills every four hours as needed for pain.

What does this mean to you?

A Common Prescription

Osteoarthritis

Osteoarthritis of the hip or knee is a common condition affecting

millions of patients. • Symptoms may include stiffness loss of mobility as well as pain. • How best to manage pain in the non- operative setting can be challenging in the subject of much debate

Opioids remain a common treatment for osteoarthritis

Osteoarthritis

The American Association of hip and knee surgeons (AAHKS) has taken the position that the use of opioids for the treatment of

osteoarthritis should be avoided and reserved for only exceptional

circumstances

Osteoarthritis

The American Association of hip and knee surgeons (AAHKS) has taken the position that the use of opioids for the treatment of

osteoarthritis should be avoided and reserved for only exceptional

circumstances

Developing Guidelines…

Self-management programs, lower extremity and core strengthening, low-impact aerobic exercises, engaging in physical activity consistent with national guidelines, patient education on activity modification and understanding disease progression Prescribed physical therapy, range-of-motion, strengthening, and aerobic exercise programs; appropriate use of ambulatory aids; neuromuscular education; and other common modalities

Treatment of Osteoarthritis of the Knee

Hinged knee brace and/or unloading brace Nonsteroidal anti-inflammatory drugs (oral or topical) Narcotic medicine for refractory pain (oral or transcutaneous opioids): monitored, intermittent, or low dose in conjunction with other therapies. Tramadol Acetaminophen Intra-articular corticosteroids Arthroscopic partial meniscectomy or loose body removal Realignment osteotomy Arthroplasty

Treatment of Osteoarthritis of the Knee

Treatment of Osteoarthritis of the Knee

Self-management programs, including: • lower extremity and core strengthening, • low-impact aerobic exercises, and engaging in physical activity • Prescribed physical therapy, appropriate use of ambulatory aids; neuromuscular education; • Nonsteroidal anti-inflammatory drugs (oral or topical) • Acetaminophen • Realignment osteotomy • Arthroplasty

Appropriate Use Criteria

Management of Osteoarthritis of the Hip

AUC (1) Risk factor assessment and optimization (2) Activity modification (3) Assistive devices (4) Oral medication management: nonopioids (ie, NSAIDs and acetaminophen) or tramadol (5) Intra-articular steroids (6) Physical therapy (as nonsurgical treatment) (7) Arthroplasty (8) Hip preservation surgery (9) Arthrodesis.

* 270 Clinical Scenarios were evaluated

Management of Low Back Pain

• Steroids and NSAIDs • Physical therapy • Other modalities

• Chiropractic/manipulation • Acupuncture • Usually for 6 to 12 weeks

• Precision (ESI) injections

Radicular symptoms with

Management of Low Back Pain

INDICATIONS FOR EPIDURAL STEROID INJECTIONS

• Disc herniation • Spinal stenosis • Compression fractures • Facet or nerve root cyst • Postherpetic neuralgia

Patient Education

• In patients older than 65 there's an increased risk of falls, overdoses constipation • Preoperative narcotics make post op pain control more difficult • Lead to worse outcomes • Increased risk of readmission • Increased risk of early revision

Patient Education

Studies have shown that nearly half of the patients prescribed

controlled substances for osteoarthritis are older than 65

years of age

Patient Education Pain education, research, and

treatment historically have focused narrowly on the pathophysiological

mechanisms involved in chronic pain. YET

pain creates a complex biopsychosocial phenomenon.

LEGISLATION

Effect of narcotic prescription limiting legislation on opioid utilization following

lumbar spine surgery

CONCLUSIONS: The institution of mandatory statewide opioid prescription limits has resulted in a significant reduction in initial and 30-day opioid prescriptions following lumbar spine surgery. This investigation provides preliminary evidence

that narcotic limiting legislation may be effective in decreasing opioid prescriptions after lumbar spine surgery for both opioid-naıve and opioid-tolerant

patients.

1. Opiates are for severe pain only

Patient Education Preoperatively

2. NSAIDs are for mild/moderate pain 3. Ice/cryotherapy is an effective analgesic 4. The majority of patients do not take > 10 pills 5. The majority of patients do not take pills > 1 week after surgery

Patient Education Preoperatively

Patients with a past history of depression or increased VAS pain score

used more opioids postoperatively This disappeared with patient education

Conclusions 1. Current prescribing practices suggest ~ 3 times over prescription of opioids after arthroscopic meniscectomy

2. Lack of patient education is a cause of increased post-operative opioid use

PRESCRIPTION NARCOTIC ALERT In Electronic

Health Records Factors that trigger an alert 1. Early refill 2. 2+ onsite administrations of opioids or benzodiazepines within the previous 30 days 3. 3+ opioid or benzodiazepine prescriptions in the previous 30 days 4. History of overdose 5. Positive blood alcohol, marijuana or cocaine toxicology screen

Challenges for Orthopaedic

Surgeons

Challenge #1 - Balance adequate pain control versus excessive prescriptions of opioids

Challenge #2 - The appropriate amount of opioids is poorly defined

In 2017, HHS (Health & Human Services) issued over $800 million in grants to support access to

opioid-related treatment, prevention, and recovery, while making it easier for states to receive waivers

to cover treatment through their Medicaid programs.

Education &

Funding

The Department also published resources and media materials to raise awareness of the epidemic

and efforts to prevent its escalation.

Steps to Prevent Epidemic Escalation

Step 1. Self Care:

Steps to Prevent Epidemic Escalation

• Mindfulness meditation/relaxation techniques; • Engagement in meaningful activities; • Family & social support; • Safe environment/surroundings

• Nutrition/weight management, exercise/ conditioning, & sufficient sleep;

Step 2. Patient Centered Medical Home in Primary Care:

Steps to Prevent Epidemic Escalation

• Routine screening for presence & severity of pain; • Assessment and management of common pain conditions; • Support from MH-PC Integration; OEF/OIF, & Post-Deployment Teams; • Expanded care management ; • Pharmacy Pain Care Clinics & Pain Schools;

Step 3. Secondary Consultation

Steps to Prevent Epidemic Escalation

• Multidisciplinary Pain Medicine Specialty Teams; • Rehabilitation Medicine; • Behavioral Pain Management; • Mental Health/SUD Programs

Step 4. Tertiary Interdisciplinary Pain Centers

Steps to Prevent Epidemic Escalation

• Advanced pain medicine diagnostics & interventions; • CARF accredited pain rehabilitation

Patient Education

www.iprcc.nih.gov/sites/default/files/HHSNational_Pain_Strategy_508C.pdf

Patient Education Appendix J Core Competencies for

Pain Education 4 Domains

Core competencies for pain management from an inter-professional consensus summit have been

endorsed widely and supported by national healthcare organizations across the major health

professions. (51)

Steps to Prevent Epidemic Escalation

They provide a starting point for accrediting and credentialing organizations to help guide

educators to develop and revise curriculum that advances care for effectively preventing and

managing pain.

Appendix J. Core competencies for pain education

Patient Education Appendix J Core Competencies for

Pain Education 4 Domains

Understand the multidimensional nature of pain which includes the science, nomenclature, experience of pain, and pains impact on the

individual and society.

Understand how pain is recognized, assessed, quantified and communicated

and how how does the individual, the health system and society affect how

pain is measured.

Domain 1

Domain 2

Patient Education

• Collaborative approach to decision-making, • Diversity of treatment options, • The importance of patient agency, • Risk management, • Flexibility in care, • Treatment based on appropriate understanding

of the critical condition.

How is pain managed?

This includes an understanding between acute pain, acute -on- chronic pain,

chronic/persistent pain, and pain at the end of life.

Domain 3

Patient Education

How do different clinical conditions influence pain management?

1. Understanding the needs of special populations, 2. How to assess and manage care in different settings and in transitions of care, 3. Understand the role of other professionals on a pain management care team, 4. Develop individualized pain management plans that integrates the perspectives of patients, their social support systems and healthcare providers in the context of available resources the 5. Describe the role of the clinician as an advocate to meet treatment goals.

Domain 4

Appendix K. Suggested learning objectives for a public awareness campaign. To increase public awareness about pain and people with pain, the committee recommends developing a campaign that will cover the following learning objectives

(listed in order of priority):

Steps to Prevent Epidemic Escalation

Appendix K. Suggested Learning Objectives

Steps to Prevent Epidemic Escalation

Suggested Learning Objectives 1. Chronic pain is a disease. 2. Chronic pain is manageable. 3. Chronic pain is more prevalent than cancer, diabetes, and heart disease combined. 4. Chronic pain is real. 5. Most Americans will experience chronic pain or care for someone with chronic pain. 6. People in chronic pain deserve respect, compassion, and access to timely treatment. 7. Many people in chronic pain nevertheless live productive lives.

Steps to Prevent Epidemic Escalation

Suggested Learning Objectives 8. The goal for chronic pain management is to alleviate pain and restore function. Patients should be aware of realistic treatment expectations.

10. Chronic pain may require a spectrum of medical and surgical treatments and/or non-medical interventions, including self-management strategies along with the active participation of people with chronic pain in their own pain care management.

9. Chronic pain may cause depression and depression increases the severity of pain.

Steps to Prevent Epidemic Escalation

Suggested Learning Objectives 11. Appropriate chronic pain management may involve prescription medications, which require knowledge of risks for adverse effects such as dependency and addiction. 12. Activity level and mood may vary depending on the intensity of chronic pain (good days and bad days). 13. Awareness of conditions and activities that contribute to injury, especially in the workplace, can prevent pain.

Steps to Prevent Epidemic Escalation

Appendix L. Learning objectives and potential outcome measures for an educational campaign on safer use of

pain medications.

Learning Objectives Increasing the number of people with chronic pain who report that they:

Appendix L. Learning Objectives

Steps to Prevent Epidemic Escalation

Appendix L. Learning Objectives

1. Talk with their clinician about their hopes and expectations and share activities of daily living or function that are important to them. 2. Work with their clinician to develop a plan of treatment consistent with their goals. 3. Know that analgesic medications can be an appropriate pain management option in selected and monitored patients and they are not the only option.

Steps to Prevent Epidemic Escalation

Appendix L. Learning Objectives

4. Know their prescription medication is only for them and do not share it with others. 5. Store their medicine in a safe place where children or pets cannot reach it. 6. Dispose of unused medication properly. 7. Take medicine only if it has been prescribed or approved by their doctor. 8. Do not take more medicine or take it more often than instructed. They call their doctor if their pain worsens.

Steps to Prevent Epidemic Escalation

Appendix L. Learning Objectives

9. Know how to understand and recognize expected and unexpected adverse effects such as dependency and addiction and to discuss risks with their doctor. 10. They talk to their doctor before taking prescription medications in combination with other drugs, including alcohol, sleeping pills, or anti-anxiety medication.

Steps to Prevent Epidemic Escalation

Appendix L. Learning Objectives

11. Have discussed with family and friends how to recognize and respond to overdose, including the use of naloxone. 12. Encourage family and friends to utilize Poison Control Centers as a confidential resource and to report possible opioid exposure and/or abuse by calling the Poison Help line.

Steps to Prevent Epidemic Escalation

Potential Outcome Measures Potential Outcome Measures Where possible, existing data sources should be employed to

monitor measures such as:* 1. Proportion of patients who

a. discuss daily activities (quality of life) with their provider b. discuss expectations about the outcomes of pain treatment and side effects with their provider c. have a functional contract (defined) with their provider and discuss with their provider other appropriate treatments

Steps to Prevent Epidemic Escalation

Potential Outcome Measures

2. Number of patients taking opioids who: a. report storing their medication safely b. do not save expired un-wanted, or unused medications (CPDA) c. report calling their doctor if pain worsens d. dispose of unused medication properly (CPDA) e. take opioids not prescribed for them f. take higher or more frequent doses than prescribed g. report mixing pain medicines with alcohol, sleeping pills, or any illicit substance

Steps to Prevent Epidemic Escalation

Potential Outcome Measures

3. Number of overdoses reported in national emergency department data

*A potential data source for some of these research questions is

Research America’s National Poll on Chronic Pain and Drug Addiction

(CPDA).

4. Number of reports to the National Poison Data System

OPIOID DISPOSAL

FDA FLUSH DOWN TOILET

EPA says this will cause the drugs to end up in our drinking water!

Strategy

Encourage patients to properly return or dispose of unused portions of opioids.

A study by the Virginia Orthopaedic Society showed that only 28% of patients and 40% of providers had ever received defined or

formal education on opioid management and Disposal.

Patient Responsibilities

1. Medications are to be used as prescribed. 2. If medications are not adequate for pain control, adjustments/increases in the amount of medication used should not be done without discussion with the prescribing provider. 3. Failure to follow a recommended plan of treatment, including delays in advised care or surgical intervention will result in cessation of providing prescriptions for pain medication.

4. Obtaining additional pain medication from another provider after prescriptions have been provided by the current orthopaedic provider is not permitted.

Patient Responsibilities

6. Pain medications should be obtained from a single pharmacy

5. Pain medications should be obtained from a single provider.

Medication Prescription Refills

1. Refills of pain medications may be prescribed if appropriate.

2. Medication refills may be requested Monday through Friday during normal office hours. As it may take up to 24 hours for review of refill requests, some refills may not be completed until the next full office day. 3. Medication refills (including late requests) are not available evenings or on weekends or holidays.

Medication Prescription Refills

4. An “On Call” provider WILL NOT refill prescriptions for pain medications.

5. Medication refills will not be provided because of missed or cancelled appointments. 6. Pain medication refills must be obtained in person by the patient, unless the patient authorizes another party to pick up the medication. This person must be listed in the chart and must bring a valid picture identification.

Medication Prescription Refills

7. It is preferable to have patients contact single pharmacy and have the pharmacy leave a refill message with the prescribing Orthopaedic provider Insert phone #s. Patients may leave a refill request at these numbers as well. The following information must be provided for refill messages with refill requests:

Patient Education

Acute pain is an unpleasant, though normal sensory

experience in response to a noxious stimulus and plays an

important protective role by alerting a person to actual or

potential physical injury.

Modalities to Treat Chronic Pain

• Medications • Regional Anesthetic Interventions • Surgery • Psychological Therapies • Rehabilitative/Physical Therapy • Complementary And Alternative Medicine (CAM)

Strategy

Drop-Off at: • CVS Pharmacy • Walgreen’s Pharmacy • Police Station

Strategy

In Home Method: • MIX pills with trash (used coffee grounds, kitty litter, dirt) or ground charcoal • Place in sealed bag • Throw bag in trash