Prevention and recognition of problems from narcotic prescribing in your practice

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Prevention and recognition of problems from
narcotic prescribing in your practice

• Diversion
• Addiction
• Failure to relieve pain
• Norman Wetterau MD normwetterau_at_aol.com

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Detox Admissions and E.D. Visits for Narcotic
Painkillers, 1995-2002
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Should you treat chronic nonmalignant pain with
opioids?

• 1. Few studies of long term use. Most show little
  or no long term benefit.
• Martell, Bridget et al Annals of Internal
  Medicine January 16, 2007
• 2. AAFP resolution 2004 calling on the federal
  government to fund for research into the benefits
  and risks of long term opioids for chronic
  nonmalignant pain.

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Assess effectiveness and need for medication

• Chart Audit in Tricounty Family Medicine 2005
• Medication increased 17 some large increases
  same 6 decreased 2
• Functional improvement yes 4, no 4, questionable
  10, not mentioned 8
• Is the medication working yes 8 no 7
• Questionable 10 detox. 1patient

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Problems

• Opioid nonresponsive. In spite of larger and
  larger doses and switching opioids, they do not
  improve in function and pain control.
• Often the pain becomes less after the opioids are
  tapered. Some do well on Suboxone
• Use of short acting with inadequate pain control.
  A rollercoaster of pain relief, opioid effect and
  withdrawal.

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Addiction

• Evidence of dependence (tolerance and withdrawal)
  plus
• Impaired control over drug use
• Compulsive use
• Continued use despite harm
• Craving
• WWW .drugabuse.gov

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PLEASURE

• Quick onset of action
• Smoking tobacco versus a nicotine patch
• Snorted oxycotin versus swallowed
• Vicodin versus methadone
• YOU CAN BECOME DEPENDENT ON LONG ACTING
  NARCOITCS, BUT ARE LESS LIKELY TO BE ADDICTED.
• You are much more likely to become addicted
• if you have a history of another addiction

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Why do people use non-medically

• To feel good
• For various aches and pains
• Snorted or given IV for a real high
• To prevent withdrawal in those addicted to IV
  narcotics

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Types of diversion

• Criminal multiple prescriptions and physicians
• One physician and one or two customers
• Taking someone else's drugs, no sale

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Case 1

• A 26 yo woman was referred to me for opioid and
  pain problems.
• She had transferred to the referring
  physician six months before and a copy of her
  entire chart was sent with her. The initial visit
  indicated she had been seeing another physician
  for back pain, had been on vicodin and that the
  vicodin was not controlling the pain. The record
  of the referring physician contained very
  accurate accounts of each narcotic prescription
  including MS contin, Durgisic patches and regular
  vicodan prescriptions. It also included notes
  that various narcotics were lost or were not
  working, but when they were not working they were
  flushed down the toilet rather than brought in.
  Unfortunately there was very little additional
  history, much of which might have alerted the
  physician that this patient might develop
  problems with narcotics.
• What initial information might the physician
  obtained?

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Three strikes and you are out

• Did not contact the previous physician
• Did not ask patient about previous alcohol and
  drug use, or psychiatric or drug related
  hospitalizations.
• Did not obtain a urine drug screen.

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For all new patients asking for narcotics

• Contact previous physicians, preferably by
  telephone on the first visit

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The voyage to the land of improved function and
less pain

• The Ships name Opioid

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Opioids for Chronic Pain

• Navigating a minefield
• Preparing for the voyage

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Dont let the patient or the doctor drown!
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The minefield

• Some people are trying to obtain opioids for
  reasons other than pain - for their addiction,
  to sell, to treat their depression or life
  stresses.
• Some people are at risk for developing addiction.
• In some individuals the narcotics will not really
  relieve the pain. If the patients continue on
  the opoiods, it will be difficult for them to
  stop, even though they are no better.
• BUT SOME PEOPLE MAY GET PAIN RELIEF AND GET
  THEIR LIFE BACK

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Preparing for the voyage

• Who is a good candidate?
• History shows no indication of substance abuse
  problems (other than opioid dependence), past or
  current
• No or few risk factors

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Preparing for the Voyage

• Who can come, but needs a life jacket and visits
  to the ships doctor?
• - Past SA problems other than opioids
• - Risk factors such as FH of SA problems
• - Use of tobacco
• - Psychiatric problems
• - Patients who have had problems in the past
  but are honest about them.

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Preparing for the Voyage

• Who is likely to drown, so they should stay
  behind?
• Active SA problems
• -HX of opioid problems in the past
• -Patients who are not being honest with you

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Preparing for the Voyage

• Where are you going?
• To improve functional status, not just lessen
  pain
• How will you know if you are off course or lost?
• - The pain gets no better
• - The dose needs continual increases
• - The patient isnt taking the medication you
  prescribe

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On the Voyage

• How do you get the information you need to decide
  if you are off course or lost?
• - Urine drug screens tell you whether the
  patient is taking the medication you prescribe
• - Urine screens tell you if the patient is
  taking other drugs that put him/her in danger of
  overdose
• - Asking about functional improvement
• - Pill counts

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Patients who want to go to the same pain free
place, but might consider a different ship.

• People who were identified as at risk for long
  term narcotics
• People who have not already tried other
  approaches to their pain relief
• People whose pain is more emotional or related to
  life stresses.
• People who understand the risks and benefits and
  choose not to be prescribed opioids

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Patient assessment

• 1. The Pain Subjective pain scale, patients
  description, how it effects his/her life
• 2. The Pain Objective
• What is causing this pain?
• What diagnostic tests have been done?
• What treatments have been tried and how did they
  work?
• Can it be fixed? Your opinion and patients
  opinion
• You need to obtain this information
• 3. Is the pain from the medical condition or
  secondary to depression or the stress of life?

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Screen for conditions that put people at risk for
problems with opioids

• 1. Past history of SA problems, including drug
  use and a lot of binge drinking in HS and
  college.
• 2. Current alcohol problems, including binge
  drinking and current drug problems including use
  of marijuana
• 3. FH SA and alcohol problems
• 4. Depression, especially proceeding the pain
• 5. Past history of problems with pain medicines
• 6. Past history of significant legal problems

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For all new patients asking for opioids

• Contact previous physicians, preferably by
  telephone on the first visit

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Screening continues Ask or use a questionnaire

• Start with alcohol
• How many drinks do you consume in an average
  week? (men 14, women 7)
• What is the most drinks you have had on one
  occasion in the past month (5)
• Helping patients who drink too much A
  Clinicians Guide NIAAA NIH Publication No.
  07-3769, Revised 2007

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Screening continuesAsk or use a Questionnaire

• Ask if they have ever had a problem with alcohol
  in the past
• - If positive screen, give them a CAGE or an
  AUDIT
• - An AUDIT score over 8 is positive
• - The first 3 questions of the AUDIT are
  Quantity questions. If questions 4-10 are all
  negative, the patient may be able to stop
  drinking while taking the medication.

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Screening continues

• Ask about Smoking Do you smoke? How much?
• Do you every smoke anything other than tobacco?
• Or Do you every smoke marijuana?
• Both tobacco and marijuana smoking is associated
  with addictive problems. Tobacco may be
  associated with alcohol problems. Marijuana
  smoking is associated with use of other illegal
  drugs, disrespect for norms and rules, and a
  desire to have a mind altered state.

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Screening continues

• In the past five years
• 1. Have you used drugs to get high? Stimulants,
  tranquilizers, cocaine, marijuana or narcotics
• 2. Have you used drugs that were not prescribed
  for you?
• 3. Have you ever been treated for a drug or
  alcohol problem?
• 4. Do you have a family history of alcohol or
  drug problems?
• Have you ever questions are triggers and
  require further information when, how often, do
  you still do this?

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Urine drug screen

• Obtain one tell patient that you periodically do
  this with patients prescribed controlled
  substances.
• I have found some positive screens and obtained
  help and treatment for the patients.
• Reference Urine Drug Testing in Primary Care
• Goukrlay DA Heit HH Caplan Y. Booklet CME
  Activity of the California Academy of Family
  Physicians 2004

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Other screening questions

• Mental health
• Have you ever been treated for psychiatric
  problems?
• Do you have frequent mood swings?
• Do you often feel sad or down?
• Have you often been bothered by little interest
  or pleasure in doing things?
• Reference Ebell, M, Routine Screening for
  Depression, Alcohol Problems, Domestic Violence,
  from afpserv_at_aafp.org

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Other screening questions

• Have you ever had an accident after drinking or
  taking drugs?
• Ask specifically about the accident that caused
  their chronic pain.
• How many times in your life have you been
  arrested?

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Triage

• Low Risk (No hx of SA Few or no risk factors)
  Primary care physicians treat these patients
• Medium Risk (Past history of SA problems but not
  opioids or multiple risk factors) Primary care
  physician consults or co-manages. Avoid break
  through meds or multiple meds. Consider Methadone
  or suboxone
• High Risk Active SA problem or hx of opioid
  abuse Primary care physicians do not prescribe
  they refer.

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Those for whom primary care physicians should not
prescribe outpatient opioids

• 1. Current drug or alcohol addiction
• Dangerous death from alcohol, Valium and Vicodin
  and other combinations
• Refer for SA treatment
• 2. Past history of opioid addiction if needed
  refer. Treat with kappa drug like Talwin,
  Suboxone, or very structured use of other
  opioids.

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Goals of Treatment

• Do functional assessment use a form or ask what
  they cannot do in terms of job, household work,
  social activities etc
• Explain that the medication may not get rid of
  all their pain
• Explain that if the narcotics are working, they
  will be able to do things there are not currently
  able to do.

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Spending 10 or 20 minutes obtaining a careful
history, including a detailed SA history,
contacting previous physicians and pharmacists,
and another 10 minutes carefully reviewing old
charts might save you future hours and many
future headaches
If you dont have the time, dont prescribe the
opioids!
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Educate the patient

• 1. The use of medication is to reduce pain and
  increase function
• 2. The medicine does not always work, and so
  would be stopped to prevent problems
• 3. Sharing the medication could result in
  criminal charges
• 4. Do not leave medication where others,
  including teenagers, can find it.

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Patient Agreement

• 1. Use to educate the patient
• 2. Often give it to patient to read at home,
  share with SO, and return to the office with SO
  so as to make sure everyone understands.
• 3. Give information about usefulness and
  potential problems of opioids, including
  dependence and addiction. The problems are
  presented as medical issues that, if recognized,
  can be helped, rather than bad behavior.

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Patient Agreement

• 4. Include the fact that use of narcotic is a
  trial, to be stopped if it is not working or if
  there are problems
• 5. Include information on how the medication is
  prescribed -- need to come to office, single
  pharmacy
• 6. Include the side effects of medicine, dangers
  of overdose or driving if tired.
• 7. Get the patients agreement to give urine
  tests, and unannounced pill counts if asked.

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The VoyageStaying on Course
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Follow up 4 or 5 As

• 1. Analgesia
• 2. Adverse Effects
• 3. Activities of Daily Living
• 4. Aberrant behaviors
• 5. Affect
• Also consider urine tests, pill counts, talking
  with significant others

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Example

• 30 yo woman on Vicodin four a day for 6 months.
  She wants a refill.
• 1. Analgesia OK, Later wants to go off of them
  since they make her sick and do not get rid of
  the pain
• 2. Adverse Effects constipation, vomits
  frequently
• 3. Activities of Daily Living almost nothing -
  dusts
• 4. Aberrant behaviors none
• 5. Affect depressed
• Plan What might you do for her?

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Dosage

• Initially increase the dose to provide
  reasonable pain control with acceptable side
  effects. If you start with short acting, switch
  to a long acting.
• Ask how she feels when she wakes up, before the
  next dose and a hour after the dose. Look for
  evidence of withdrawal like sweating, or abd
  pain.
• You cannot do all of this on the telephone
• See every week or two at first.

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Critical General Principles

• Prescribing narcotics is a trial,
• as with most other medications. They will be
  stopped
• if they do not work
• or if there are problems.

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Critical General Principles

• 2. There is no ethical obligation to prescribe or
  continuing prescribing narcotics for chronic
  pain. Stop if they are not working or if the
  patient is unable to take them as prescribed.
• Patients are told they will not be prescribed
  other medications if there are contraindications,
  such as Ibuprophen and Coumadin.
• It is unethical to stop without a taper or
  referral

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General Principles

• 1. Look at functional status, not just pain
  score. If the patients functional status does
  not improve, then either increase or change the
  opioids, or discontinue them. Try to make a
  decision to discontinue before the person is
  dependent.
• 2. Do not treat pain with benzos

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Use of Opioids in patients with other addictions
but not opioid addiction

• 1. If Current Require concurrent treatment for
  their addiction, and or possibly require that
  they stop. Do not ignore.
• 2. Treat the pain adequately. Use adequate doses
  of opioids
• 3. Careful follow-up. Pill counts, urine tests,
  have someone else keep or administer medication,
  but combine this with positive support and the
  belief that the patient will be able to take the
  medication correctly. I am your coach and want
  to make sure you are successful.

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Patients with other addictions

• 4. Open Discussion about addiction and problems.
• 5. Use long acting. Avoid short acting for
  breakthrough pain, or if used, only prescribe a
  few.

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Getting off a sinking ship
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Have an exit strategy

• 1. Have a member of your group who has some
  interest in addiction and can prescribe
  buprenorphine.
• 2. Taper slowly yourself
• 3. Refer out

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Buprenorphine

• Dissolve under tongue
• Neltrexone is part of this, so a person who takes
  it IV goes into withdrawal
• Long acting agonist with ceiling effect.
• Little euphoria due to slow onset and long half
  life
• Blocks effects of IV heroin
• A physician who takes the 8 hour certifying
  course can prescribe this for narcotic addiction.
  Go to ASAM.org

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Pain in patients currently addicted to narcotics

• 1. Detox and rehab. Pain often becomes less.
  (Cleveland Clinic Experience)
• 2. Buprenorphine
• 3. Careful use of methadone, or duragesic patches
  if also having pain. Prescribe for pain since it
  is illegal to prescribe for addiction.
• 4. Treatment of addiction
• 5. 12 steps for recovery from chronic pain

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Case 2

• This patient has had stable chronic back pain
  controlled by 50 mcg. Duragesic patch and 8
  vicodin a day. The dose has not increased for
  over a year. The patient says the medicine helps,
  but he has not returned to work. He also says he
  needs all of this medication and cannot cut back.
  He usually looks comfortable when in the office.
  Are there any ways we can check to see if he is
  actually taking all this medication and not
  selling it?

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Monitor Medications

• Urine tests for presence of the medication
• Ask if they took their medication that day
• Ask for the specific medication
• CONSIDER
• Blood acetemetaphine level
• Urine for drugs of abuse (toxic 8) since they may
  divert to buy other drugs

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Monitor Medications

• Count Pills Tell patient that you are doing a
  quality assurance project and that you are
  calling patients and having them bring in their
  bottles of all pills to make sure it is what you
  have in your records.

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Diversion

• 1. Patient said the substance was taken that day
  but it is not in the urine.
• 2. Next day, repeat and do pill count.
• 3. Make sure the lab level is low enough to pick
  up the medication.
• 4. Make sure that specific medicaton was tested
  for.
• 5. See if they go into withdrawal once the
  medicine is stopped.

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Is the medicine working and still needed?

• If working pain is reduced and function improved
• After a time taper and see if they still need the
  drug. Taper slowly and see if the original reason
  for needing the medication is still there

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Case 3

• This 26 yo female was begun on Vicodin for back
  pain. Because her situation seemed stable, a
  prescription was written for 2 qid , 240 with 5
  refills. The patient returned a month later and
  saw another physician in the group. She asked for
  a new prescription and was given one. The new
  physician required that she come in monthly.
  However it was discovered that she continued to
  get refills for the first prescription and went
  to a second drug store to get the new
  prescription fills and paid in cash. When
  confronted, she said that the 8 vicodan a day had
  not been controlling the pain.
• What is the differential diagnosis and what
  options are available to the physician?

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Case 4

• This 40 yo woman fell on her back in a comp
  injury. Her husband worked 18 hours a day and her
  oldest son got married. Xrays were normal. She
  was extremely depressed, but had no insurance
  coverage for mental health treatment. The comp
  carrier initially denied permission for Physical
  Therapy or antidepressants. Because the pain was
  so bad, the physician began oxycotin 20 mg tid
  and worked the dose up to 100 tid. Finally
  antidepressants were added, and she received
  injections and physical therapy, but nothing
  helped. The pain spread to include her whole
  back. Her skin was tender to light touch.
• After a year she asked her physician for
  something for pain . She said the pain was worse
  than ever, worse even than before she began the
  medications.
• What is the differential diagnosis? What might be
  done?

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Increasing doses without improvement

• 1. Tolerance usually increase is small
• 2. Pain was not narcotic responsive
• neuropathic pain, pain due to depression
• and psychosocial causes
• 3. Narcotic hyperalgesia
• 4. Diversion
• 5. Addiction

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Addiction

• Use to feel good and not for pain relief
• Tolerance and withdrawal
• Life centers around obtaining the drug
• Craving apart from the pain
• Physicians cannot prescribe opioids except
  Buprenorphine except for pure addiction

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Tri-County Family Medicine

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