OPIOID TREATMENT GUIDELINES

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OPIOID TREATMENT GUIDELINES

• For chronic non cancer pain

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Acknowledgment

• Dr Helen Kerr, SMO, ATODS, Brisbane

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Clinical Guidelines for the use of Chronic Opoid
Therapy(COT) in Chronic NonCancer Pain (CNCP)

• Journal of pain Vol 10, no.2 Feb 2009pp113-130
• American Academy of Pain Medicine Opioids
  Guidelines Panel
• Roger Chou, Gilbert J Fanciullo, Perry G. Fine,
  Jeremy A. Adler, Jane C. Ballantyne, Pamela
  Davies, Marilee I Donovan, David A Fishbain,
  Katey M Foley, Jeffrey Fudin, Aaron M. Gilson,
  Alexander Kelter, Alexander Mauskop, Patrick G
  OConnor, Steven D Passik, Gavril W Pasternak,
  Russell K. Portenoy, Ben A. Rich, Richard G.
  Roberts, Knox H. Todd, and Christine Miaskowski
  for The American Pain Society
• Research conducted at the Oregon Evidence based
  Practice Centre with funding from The American
  Pain Society (APS)

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PANEL OF EXPERTS

• Oregon Evidence-based Practice Centre
• Department of Anesthsiology, Pain Management
  Centre Massachusetts
• Pain Research Centre, Utah
• Palliative Care Beth Israel/Memorial
  Sloan-Kettering
• Physiological Nursing, University of San
  Francisco
• Seattle Cancer Care Alliance/Wisconsin
• School of Medicine Miami/Yale
• Albany College of Pharmacy Health Sciences
• Epidemiology Prevention for Injury Control,
  California
• New York Headache Centre
• Division of Bioethics, University of California

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DEVELOPMENT OF GUIDELINES

• 21 EXPERTS
• PANEL MEMBERS HAVE TO DISCLOSE CONFLICTS OF
  INTEREST
• 8034 ABSTRACTS
• AT LEAST 2/3 MAJORITY FOR RECOMMENDATIONS TO PASS

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CHRONIC PAIN

• Defined as pain that persists beyond normal
  tissue healing time and is assumed to be 3 months

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OPIOID USE IN PAIN

• Acute pain
• Chronic pain related to active cancer
• Pain in Terminal cancer or any end of life
  condition

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CHRONIC NON CANCER PAIN (CNCP)

• Back pain
• OA
• Fibromyalgia
• Headache
• CNCP is a leading cause of disability and can
  affect the ability to work, function or on the
  quality of life

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Issues to address

• Pain
• Functional impairment
• Psychosocial factors
• Compensation issues
• Depression
• Financial/ job loss
• Lack of Support

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Benefits vs Risks

• Opioid therapy may be a useful component of pain
  management
• Adverse effects
• Adverse outcome associated with abuse
• Addiction with an increase in prescription opioid
  misuse
• Diversion
• Mortality associated with opioid misuse

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G R A D E

• Grading of Recommendation
• Assessment
• Development
• Evaluation
• Strength of recommendation strong or weak
• Quality of evidence high, moderate, poor

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Patient selection and Risk stratification

• History, physical examination, tests, Risks of
  abuse, misuse or addiction (strong
  recommendation, low quality evidence)
• Trial of COT in moderate to severe CNCP (moderate
  to severe pain is having an adverse impact on
  function or quality of life)
• (strong recommendation, low quality evidence)
• A benefit-to-harm evaluation i.e. ongoing
  history, physical examination, tests during COT
  (strong recommendation, low quality evidence)

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Can non opioid treatment be used first?
Appropriate diagnostic tests

• Trigeminal neuralgia anticonvulsant
• RA - disease modifying drug
• Polymyalgia rheumatica corticosteroid
• Migraine headache abortive or prophylactic
  therapy
• COT considered only after moderate to severe pain
  is non responsive to nonopioid therapy.

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Who may be unlikely to respond to COT?

• Poorly defined pain condition
• A likely somatoform disorder
• Unresolved compensation or legal issues
• To avoid unrealistic patients expectation, the
  patient should be counselled that total pain
  relief with COT is rare. Trials suggest
  improvement averages less than 2-3 points on a
  0-10 scale

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Who may be likely to abuse COT?

• Personal history of alcohol or drug abuse
• Family history of alcohol or drug abuse
• Younger age
• Presence of psychiatric conditions

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Who may be likely to suffer adverse effects from
COT?

• Pre-existing constipation
• Nausea/vomiting
• Pulmonary disease
• Cognitive impairment

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Management plan

• Informed consent
• Goals, expectations, potential risks
  (constipation, nausea, sedation, overdose, abuse,
  addiction, hyperalgesia, endocrinologic or sexual
  dysfunction) and alternatives to COT (strong
  recommendation, low quality evidence)
• A COT management plan or Signed contract
• Patients responsibility
• Clinicians responsibility (weak recommendation,
  low quality evidence)

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MANAGEMENT PLAN

• Obtaining opioids from one designated pharmacy,
  one prescriber or one medical centre only
• Limited prescriptions of daily, weekly or
  biweekly instead of monthly
• To lock up their opioid medication safely to
  prevent thefts
• Regular clinic visits
• Enumeration of behaviours that may lead to
  discontinuation of opioids
• Random urine drug screens/ IV track marks

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When to taper or reduce off COT?

• Failure to make progress toward therapeutic goal
• Intolerable adverse effect
• Repeated or serious aberrant drug related
  behaviours
• Doctor shopping
• IV use
• Request for frequent scripts

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Initiation and titration of COT

• Clinician and patient should regard initial
  opioid treatment as a trial from several weeks to
  several months only to determine whether COT is
  appropriate (strong recommendation, low quality
  evidence)
• Opioid selection, initial dosing and titration
  should be individualised according to the
  patients health status, previous exposure to
  opioids, attainment of therapeutic goals,
  predicted or observed harms (strong
  recommendation, low quality evidence)

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Monitoring of COT

• Periodic UDS/ checking for injecting track marks
• Frequent or intense monitoring weekly in
• those with a prior history of addictive disorder
• those in an occupation demanding mental acuity
• older adult
• unstable environments
• co-morbid psychiatric or medical conditions,
• feedback from interviews with family member or
  carer
• Patients at low risk of adverse outcome every 3
  to 6 months

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High risk patients

• More frequent monitoring if considering COT in
  patients with CNCP and history of drug abuse.
  Consultation with mental health or addiction
  specialist is strongly recommended (strong
  recommendation, low quality evidence)
• Aberrant drug related behaviour noted
• Is COT appropriate?
• Restructure COT
• Referral for assistance in management
• COT not appropriate - Discontinue COT

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Dose escalations, high dose COT

• When repeated dose escalations, evaluate
  potential cause and re-assess benefits vs harms
  (strong recommendation, low quality evidence)
• High doses of COT requires more frequent
  follow-up visits (strong recommendation, low
  quality evidence)
• Consider opioid rotation if intolerable adverse
  effects or inadequate benefits despite dose
  increase (weak recommendation, low quality
  evidence)
• Taper or wean off if aberrant drug related
  behaviours or if risks outweigh benefits (strong
  recommendation, low quality evidence)

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Causes of Dose escalations

• Substance use disorder
• Diversions
• High dose means gt200mg of oral morphine or
  equivalent
• Hyperalgesia
• Neuroendocrinologic dysfunction
• Immunosuppression

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Discontinuing COT

• Opioid withdrawal can be very unpleasant but are
  generally not life threatening
• Slow reduction (10/week) lt60-80 mg of morphine,
  rapid reduction (25-50 every few days)
• DISCONTINUE IF
• Ineffective COT patients report improvement in
  well-being and function without any worsening of
  pain
• OR
• Pain hypersensitivity

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CONSTIPATION FROM COT

• In older adults or any patient likely to develop
  constipation, consider routinely initiating bowel
  regimen before the development of constipation
• Increase fluid and fibre intake
• Stool softeners, laxatives

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Nausea or vomiting from COT

• Tends to diminish over days or weeks of continued
  COT
• Oral or rectal anti-emetics

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Sedation from COT

• Tends to wane over time
• Counselled about driving, work and home safety
  (strong recommendation, low quality evidence)
• Counselled on the effects and risks of
  concomitant exposure to other drugs or substances
  with sedating properties

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Other adverse effects of COT

• Hypogonadism
• Decreased libido, sexual dysfunction or fatigue
  should be tested for hormonal deficiencies
• Myoclonus
• Pruritus
• Respiratory depression

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Pychotherapeutic cointerventions

• CBT is effective for CNCP in helping them focus
  on coping with pain to improve function
• Progressive relaxation
• Biofeedback

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Break through pain

• Short acting opioid has been proven to be
  effective
• Low risk patient - as needed opioid with routine
  follow up and monitoring
• High risk patient - more frequent monitoring and
  follow up

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Opioids in pregnancy

• Pregnant women with CNCP should be counselled
  against COT
• Low birth weight
• Premature birth
• Hypoxic-ischaemic brain injury
• Neonatal death
• Opioid withdrawal syndrome
• Prolonged QT syndrome

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STEP BY STEP MANAGEMENT OF CNCP

• History, physical examination, tests, Risks of
  abuse, misuse or addiction
• Trial of non opioid treatment
• Medication for neuropathic pain, steroids
• CBT, Progressive relaxation, Biofeedback
• Non opioid treatment unsuccessful
• Is the pain causing moderate to severe impairment
  in function?
• Yes, trial of COT