The Epidemic Of Prescription Opiate Abuse: Strategies for Family Physicians

1
The Epidemic Of Prescription Opiate
AbuseStrategies for Family Physicians
Kevin Kunz, M.D. Hawaii Update 2006 Hawaii
Academy of Family Physicians Foundation February
19, 2006
2
Addiction Medicine

• The specialty of medicine devoted to the
  diagnosis, treatment, prevention, education,
  epidemiology, research, and public policy
  advocacy regarding addiction and other
  substance-related health conditions

Its not just for specialists!
ASAM
3
How Many Americans Have a Drug Problem?

• Nicotine 20
• Marijuana 14
• Alcohol 6-12
• Opioids 3-5?
• Any illicit drug(excl.MJ) 8
• Prescription drugs 3-5
• Perspective 45 take a RX qd there are
  gt150,000 OTCs
• 1965 300 Rx drugs 2005 9,000 Rx drugs
  (RxList.com)

4
Annual Mortality from Drug Use
Tobacco 500,000 deaths Alcohol
125,000 deaths Other Drugs lt 50,000 deaths
5
Historic waves. of drug problems

• Stimulants
• 1895 medical cocaine, Parke Davis Co.
• 1932 medical amphetamine, Benzadrine
• 1980 crack cocaine
• 1995 methamphetamine, ice
• Opioids
• 1885-1925 opium, medical heroin
  (Bayer)
• 1950-70 heroin, 4 pure
• 1990 heroin, 48 pure
• 2005 pharmaceutical opioids
• Intoxicants
• marijuana, LSD, Club
  Drugs

6
Opioid Cycle

• 1860-1900 Hypodermic syringe.protects against
  addiction. Thus, MS reasonable for all pain.
• 1920 80 of addicts have acquired the habit
  from legitimate Rx Dr. A. Lambert, AMA
  Pres.
• 1930-50s Opioids illegal, unnecessary,
  dangerous
• 1960s Hospice Movement death with dignity
• 1980s Liberalization of opioids for non-terminal
  pain
• 1996 Oxycontin released, echoes syringe
  situation,
• 2000 Oxycontin epidemic, teens to parents,
• 2001 Purdue retracts less addicting, experts
  apologize
• 2006 No retreat in sight

7
Epidemic Pattern

• Medicinal to illicit use
• Epidemic spread
• Norm breakers, to risk takers, criminals,
  subcultures
• to youth weak impulse control, least stable
  values Acceptance with older groups, use
  increases, evolves to cultural pattern (good
  citizens)
• Cultural pattern is not an epidemic

8
Cultural Pattern
9
Medicinal to Illicit Drugs

• Cocaine for vitality, alcoholism,
  hay fever
• Marijuana AMA fought MJ Stamp Act,
  Savitex
• Heroin Bayers blockbuster for
  cough
• Amphetamine for depression , dieters,
  drivers, ADD
• Morphine Gods own medicine

10
The Drug Epidemic Cycle

• Acceptance Acceptance
• Doubt Re-emergence
• Rejection
  Permissiveness
• Sanctions Loosen sanctions
• Hibernation

11
New trends, not new drugs

• Route of use
• (1865 syringe, inhalation, SL, lollipop)
• New forms
• (Miltown/Soma MJ/Marinol/ Sativex
  ER/SR/CR, Pallidone)
• New potency
• (fentanyl, aprazolam)
• Designer drugs
• (tramadol, modafanil, new, me too)

12
Opioids and the Brain
Description Opium-derived, or synthetics which
relieve pain, produce morphine-like addiction,
and relieve withdrawal from opioids Medical Uses
relief, cough suppression, diarrhea Methods of
Use Oral, intravenous, smoked, snorted,
sublingual, inramuscular, transdermal
13
Opiate or Opioid? Whats the Difference?

• Opiate
• A term that refers to drugs or medications that
  are derived from the opium poppy, ( heroin,
  codeine, morphine, hydrocodone, oxycodone and
  buprenorphine)
• Opioid
• A more general term that includes opiates as well
  as synthetic medications, (fentanyl methadone,
  meperidine ) that produce analgesia and other
  effects similar to morphine.

14
Opioid Categories

• Agonist Relieve pain and alter mood
• Natural opium, morphine, codeine
• Semi-syn. hydrocodone, oxycodone, heroin
• Synthetic fentanyl, meperidine, methadone
• Antagonist Displace agonist/block receptor
• Naloxone, naltrexone
• Partial Agonist Agonist and antagonist actions
• Butorphanol (Stadol), Pentazocine (Talwin),
  buprenorphine (Buprenex, Suboxone,Subutex)

15
Antagonist, Partial Agonist, Agonist
No limit, up to death
Opiate
Full Agonist
(morphine)
Effect
Partial Agonist
(buprenorphine)
Antagonist
(naltrexone)
Dose of Opiate
16
Opioid Agonist
methadone
tramadol fentanyl meperidine codeine
17
Opioid Antagonist

• Naloxone Narcan
• Naltrexone Trexan, ReVia, Vivatrex

18
Opioid Partial Agonist

• Buprenorphine Buprenex, Suboxone, Subutex
• Stadol
• Pentazocine Talwin

19
Epidemiology New Users 1965 to 2002
Thousands ofNew Users
Marijuana
Opioid Analgesics
(National Survey on Drug Use and Health, SAMHSA,
2002)
20
New Drug Mis-Use 1965-2002
Fig 5.2
Thousands ofNew Users
(National Survey on Drug Use and Health, SAMHSA,
2002)
21
Drug Abuse Warning Network
Increase in Poisoning Deaths Caused by
Non-Illicit Drugs --- Utah, 1991--2003MMWR,
1/21/05
22
As Prescriptions Increase, Emergency Room
Reports Have Increased at the Same or Faster rate
23
High Rates in Non-medical Use of Oxy Vicodin
Generation Rx

• 18 of teens have abused Vicodin
• Equal or greater abuse of OTC/Rx than cocaine,
  Ecstasy, LSD, ketamine, heroin, GHB, ice
• Rx Meds safer (50), less addictive (33)
• Ease of access medicine cabinets
• Drugs are fun vs Drugs help kids when they are
  having a hard time
• Rx med abuse has penetrated teen culture
• April 21, 2005. Partnership for a Drug Free
  America. 17th annual study of teen drug abuse.
  N 7,300, error margin /- 1.5

Source Monitoring the Future Study, 2004.
24
This is not a new problem.

• 1900 1 in 200 Americans either
  cocaine or opium addicted
• 2005 hydrocodone 1 prescribed
  drug in America

25
Definitions

• Dependence
• Tolerance
• Abuse
• Addiction
• Pseudoaddiction

26

• Physical Dependence
• A state of neuro-adaptation to the presence of a
  drug in which a withdrawal syndrome emerges on
  abrupt cessation, rapid dose reduction,
  decreasing blood levels, or administration of an
  antagonist
• Tolerance
• A state of adaptation in which exposure to a
  drug induces changes that result in a diminution
  of one or more effects over time
• Physical dependence and tolerance are not
  addiction!

27
Definition Dependence

• DSM IV criteria (need 3 in one year)
• 1. Tolerance
• 2. Withdrawal (within minutes to several days)
• 3. Used in greater amounts or longer than
  intended
• 4. Unsuccessful attempts to cut down or
  discontinue
• 5. Much time spent pursuing or recovering from
  use
• 6. Important activities reduced or given up
• 7. Continued use despite knowledge of persistent
  physical or psychological harm
• ( 3/7 required for Dx, 4/7 common in legitimate
  pain pts)
• Profound and enduring changes in neurocircuitry

28
Abuse

• Use of a drug in a manner that is potentially
  harmful to self or another
• Use of a medication for a purpose or in a manner
  that is not intended by the physician
• From some perspectives, use of any illegal
  substances

29
Addiction

• A primary, chronic, neurobiologic disease, with
  genetic, psychosocial and environmental factors
  influencing its development and manifestations.
• Characterized by behaviors that include one or
  more of the following impaired control over
  drug use compulsive use continued use despite
  harm and craving.
• Addiction is a brain disease, expressed as
  behaviors.

30
Loss of Control impairment in ability to
consistently control use
31
Pseudo-Addiction

• In pain patients, from undertreated pain
• Seeks opioids to relieve pain (or withdrawal?)
• Conflicts with clinicians doctor shopping,
  hoarding, manipulating
• When adequate analgesia provided
• No loss of control
• No further pre-occupation
• No adverse consequences of use

32
Substance Use Continuum
LOWRISKUSE
AT-RISKUSE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity,/- physical
dependence
- - -
- -
-/ -


33
Risk and Exposure
34
At-Risk Substance Use
Alcohol
Per Week
Any Occ
Men
Women
65yo
12 oz beer 5-6 oz wine 1-1.5 oz liquor
Illicit Drugs - any use
Prescription Drugs - any misuse
35
Risk from Exposure

• Armstrong just Dr. Pepper
• Cheney
• 1 beer at lunch, nobody under the
  influence
• I didnt see it (upper body) at the time I
  shot
• Sheriff case closed
• Whittington
• We all assume certain risks in what we
  do.. Accidents do and will happen.

36
Symptoms of Substance Addiction

• Loss of control

• Preoccupation withobtaining the substance

• Compulsive use

• Physical dependence ()

37
Loss of Control Pain Rx

• Not able to take medications as prescribed
• Repeat reports of lost, stolen, destroyed Rx
• Frequent request for early refills
• Abusing other meds or drugs, and/or EtOh
• A hijacking of the pleasure/reward machinery of
  the brain
• Drives to eat and procreate become drives to
  obtain and use substances
• Withdrawal signs symptoms in office
• Often with benign manipulations

38
Use Despite Harm Pain Rx

• Overly sedated or intoxicated with use
• Declining function due to use
• Work
• Relationships
• Recreation
• Spirit fading, emotions flat or erratic

39
At-Risk Prescription Use

• Non-medical use of prescriptions drugsUse
  without a valid prescription
• Use with a prescription but
• For a reason other than why it was prescribed
• At a higher dose than prescribed
• More frequently than prescribed
• In a manner not prescribed (chew, snort, etc.)
• Obtaining a prescription deceitfully

40
Commonalities Licit and Illicit Opioids

• Psychoactive potential
• Reinforcement potential
• Decrease negative symptoms
• Increase positive symptoms
• Tolerance and withdrawal potential

41
The Epidemic - Whos Fault?

• Physicians?
• Pharmaceutical Industry?
• Society Culture?
• Consumer/Patient?

42
Why Has the Abuse of Prescription Opioids Been
Increasing?

• Pain and DSM relief
• Production and availability increased
• Marketing and media attention
• Molecular factors
• User characteristics
• Physician factors

43
Treat Pain !

• JACHO Guidelines 2000
• Mandate pain assessment and treatment
• Nurse and physician education required
• Pain as the fifth vital sign

44
The Good Physician

• We must all die. But that I can spare a
  person from days of torture, that is what I feel
  is my great and ever new privilege. Pain is a
  more terrible lord over mankind than even death
  itself.
• Albert Schweitzer 1953

45
Pain

• an unpleasant sensory and emotional experience
  associated with actual or threatened tissue
  damage, or described in terms of such.
• International Association for the Study of
  Pain
• All pain has 3 components
• sensory
• emotional
• cognitive

46
Acute vs. Chronic Pain
Useful Signals problem
Harmful Is the problem
47
Prevalence and Under-treatment of Chronic Pain

• Prevalence 9.4 in men, 21.2 in women
• 40 to 50 of patients with chronic pain do not
  attain sufficient relief
• 50 of patients change physicians to seek more
  relief.

(Gureje, JAMA, 1998)
48
Sources of Pain
Total Pain
Suffering
49
Three Patients with 8/10 Pain
Emotional
Sociocultural
Spiritual
Neuropathic
Sociocultural
Nociceptive
Emotional
Neuropathic
Emotional
Visceral
Pt. A
Pt. B
Pt. C
50
Pain Assessment Intensity

• Use standard scale such as 0 to 10 scale 0
  no pain 10 worst pain imaginable such as

• Accept patients reports
• Objective signs of acute pain are extinguished
  with chronic pain

51
Functional Scale(Cindy Evans, PhD., 2003
Handout at Kaiser Pain Symposium 2005)

• 0 No Pain
• 1-4 Functional not in the way, not limiting
• 5-7 Uncomfortable hard to move, concentrate,
  affects activities and life
• 8-9 Severe cant leave home, in bed, unable
  to do anything, high impact on all
  activities/life
• 10 Unbearable out of control, needs stat
  attention

52
Pain Treatment Modalities

• Non-pharmacologic
• Behavioral, Psychosocial Interventions
• Physical Modalities
• Invasive Procedures
• Hygenic
• Pharmacologic
• Non-opioids
• Opioids

53
Non-Pharmacologic Heres A Novel
StrategyEducation!
sites of pain
Back Head Joint Limbs Chest Abdomen Other 1 2 3 4

number of sites
54
Increased Production DEA Quotas, 1990-2000

• Morphine 300
• Hydrocodone 500
• Hydromorphone 600
• Oxycodone 1200
• Fentanyl 1700

55
Rx Opioids In Hawaii(Source K. Kamita, Chief,
NED, State of Hawaii. 11/7/03)

• Prescriptions
• 2,310,398
• 564,258
• 561,658
• 506,408
• 335,502
• 326,446

• Drug
• APAP/hydrocodone
• Tussionex
• Endocet
• OxyContin
• Morphine sulfate
• Methadone

56
Marketing ..
57
(No Transcript)
58
Increased Availability
!
59
Media Attention
60
Medication Mania

• Societal phenomenon, perception of safety
• High efficacy of certain meds
• Patient expectation, DTC, pressure to prescribe
• Difficult access, payment for non-pharm Rx

61
Molecular factors

• Ligand-gated ion channel
• Receptor, neuortransmitter
• Affinity
• Activity
• Dissociation

Neurotransmitter docked
62
Molecular Factors

• .

buprenorphine
63
Mesolimbic Dopamine System and Drug Misuse

• Circuit 1
• LIKE
• Pleasure circuit
• Meso-accumbens
• Circuit 2
• WANT
• Desire and urge circuit
• Basolateral n. of amygdala
• Circuit 3
• Need
• Pathologic desire demand circuit
• Periaqueducal gray of brain stem

64
Mesolimbic Dopamine SystemModulates

• Tolerance
• Withdrawal
• Craving
• Self-administration

65
.
Rx medication or
66
Physician Factors

• Dated
• Duped
• Disabled
• Dishonest
• Medication Mania

67
Host Factors

• Vulnerabilities
• impulsive, risk-taking, harm-avoidant
• Co-morbidities
• Inherited differences in metabolism
• Inherited differences in response to intoxicating
  effects
• Inherited differences in cue response and
  inherent ability to control use

68
Potential Problem Patients

• Adolescents
• MH issues, multiple contacts, AOD, Rates up
  with age
• Pain Patients (seen by specialists)
• 10 misuse, more with abuse/dependence
• Primary Care Patients
• SA Hx, co-morbid psych condition, believes
  addicted
• Substance Abusers
• Elderly Higher incidence of chronic pain,
  Directions misunderstood, Medication sharing,
  Polypharmacy, alcohol, Rebound syndromes,
  Family/peer enabling, Misinterpretation of
  drug effects

69
Users At-risk if Exposed

• Genetically vulnerable (60/40)
• Vulnerable by history
• Past problems/consequences with any drugs
• Present problems with any drug (even nicotine)
• Family history of substance abuse
• Mental Health Co-morbidity
• Untreated mood disorders (I.e.anxiety,
  depression, PTSD) Personality disorders
• Psychosocial, Environmental Problems (Axis IV)
• GAF Global Assessment of Functioning (Axis V)

70
Screening Tools for Risk

• CAGE, CAGE-AID
• Brief MAST
• Opioid Risk Tool
• Substance Abuse History
• Mental Health History
• Screening Interview
• Personal or family history of drug or alcohol
  problem?
• Personal or family history of mental health
  problem?
• Active addiction?
• Abstinence or recovery?
• Current substance use patterns?

71
Endorsement of Opioids forTreating Chronic Pain

• American Pain Society
• American Society of Addiction Medicine
• Federation of State Medical Boards
• US Drug Enforcement Agency

72
(No Transcript)
73
Advantages of Long-Acting Opioids
Adverse Effects
Ineffective
74
Advantages of Long-Acting Opioids (continued)
75
Opioids Can Worsen Pain?

• Recent studies have shown that continuous
  opioid exposure produces exaggerated pain and,
  importantly, such pain occurs while the opioid is
  continuously present in the system
• Vanderah, et al., Pain 925-9, 2001

76
(No Transcript)
77
Indications for Opioids - 2005

• Chronic pain of moderate to severe intensity
• Significant functional disability
• Inadequate response to other treatments

78
Opioids The Bad News
79
Opioids for Chronic Pain Effectiveness and Risk
of Addiction

• No long-term randomized trials
• Several short case series studies suggest
  effectiveness
• Rates of opioid use disorders vary from 2 to 45
• Prior substance use disorders are the major risk
  factor for abuse and addiction
• Aberrant medication-related behaviors are common
  and often are not associated with abuse,
  addiction, and diversion

(Passik SD, Pain Medicine, 2003 Vallerand AH,
NCNA, 2003)
80
Pain Reinforcement

• Opioids stimulate dopamine release
• Produce euphoria, and a sense of comfort in most
  people
• Opioids reinforcing, freely self-administered by
  most animal species
• Learned association between opioid taking and
  pain relief, which could perpetuate pain in the
  absence of opioid administration
• The experience of chronic pain is complex, shaped
  by a variety of cognitive, behavioral,
  psychological and other variables, all of which
  can be modulated with opioids neurophysiologically

81
Chronic Pain among Chemical Dependent
PatientsRosenblum et al., JAMA, May 14, 2003
82
Hyperalgesic responses in methadone maintenance
patients

• COLD PRESSOR -- TOLERANCE (SEC)
• Doverty, et al. Pain 9091-96, 2001

plt0.0001
83
Opioid Disorder in Past Four Weeks According to
Different Levels of Pain
Nearly Linear Relationship of Pain and Opioid Use
Disorder
84
CHRONIC OPIOID INTAKE BIOLOGICAL RESPONSES

• Transcription factors and 2nd messenger molecules
• cAMP c-fos CREB, ERK
• Neurotrophins
• Ngf,gdnf,bdnf
• Cytokines
• Cannabinoid receptors
• Hormonal, neurohormonal (testosterone)
• Novel pain pathways
• Opioid System Nociceptin, nocistatin,
  dynorphin(promotes pain and tolerance)

85

• Strong Opioid consensus
• Use aggressively for severe acute pain
• Use aggressively for terminal pain (cancer, AIDS)
• Trial for severe CNMP
• Weak or no Opioid consensus
• Use in less well-defined syndromes (CRPS, PPS,)
• Use in pain syndromes with moderate pain and
  complex psychosocial components ( FM, LBP)

86
Strategy Balance in Opioid Analgesia

• Risks
• Physical adverse effects
• Psychological adverse effects
• Dependence, misuse, abuse, addiction
• Diversion, public health risks

• Benefits
• Relief of Pain
• Improved Function
• Quality of Life

87
OPIOID THERAPY FOR CHRONIC PAIN ?

• evidence now suggests that prolonged, high-dose
  opioid therapy may be neither safe nor
  effective.It is therefore important that
  physicians make every effort to control
  indiscriminate prescribing, even when they are
  under pressure by patients to increase the dose
  of opioids.
• BALLANTYNE MAO, NEJM, 3491943-53, 2003

88
Opioid Withdrawal

• Not usually life-threatening
• Can be very uncomfortable
• Patient may not understand
• Increases pain
• Acute and Protracted Phases
• Can evolve and continue during pain Rx
• Management acuity high
• Precedes addiction treatment

89
Opioid Withdrawal Syndrome

• Acute and protracted phases
• Can occur after even 2 weeks of opioid use
• Cessation of opioids causes a rebound
• Duration of acute withdrawal is dependent upon
  the half-life of the drug used
• Peak of withdrawal occurs 36 to 72 hours after
  last dose
• Acute symptoms subside over 3 to 7 days
• Protracted symptoms may linger for weeks or
  months

90
Acute Opioid Withdrawal(locus coeruleus rebound)

• 5-7 days in length
• Runny nose, sneezing,
• sweating, yawning,
• restless, insomnia
• Piloerection, twitching,
• myalgia, arthralgia,
• abdominal cramps
• Tachycardia,fever,
• hypertension,tachypnea,
• anorexia, diarrhea,
• vomiting, dehydration

91
Protracted Opioid WithdrawalVTA and NA(Ventral
Tegmental Area and Nucleus Accumbens)

• Anergia
• Ahedonia
• Sleep disturbance, poor appetite
• Emotional lability/dysphoria
• Stress incompetence
• Drug craving and obsession
• Deep muscle aches and pains
• Reduced libido, impotence, anorgasmia

92
Opioids Decrease D2 Receptors
Source Wang, G-J et al., Neuropsychopharmacology,
16(2), pp. 174-182, 1997.
93
Management of Withdrawal
94
Opioid Withdrawal Rx Options

• Taper by 50 every several days (Goodman
  Gilman)
• Substitute longer acting mu opioid and taper
  (methadone, propoxyphene)
• Provide symptomatic relief with non-controlled
  medications
• Buprenorphine
• Rapid Opioid Detox, UltraRapid Opioid Detox (ROD
  in hospital UROD now discredited)

95
Opioid Substitution

• Illegal if patient has pure dependence, or
  addiction - must have pain Dx also ( cant give
  an addict methadone or Vicodin to relieve
  withdrawal discomfort, or treat dependence)
• Legal to substitute and/or taper if patient has
  pain only, or pain and dependence
• In US, treatment of depedence or addiction alone
  can only legally be treated at a methadone
  clinic, or by a physician certified to use
  buprenorphine

96


97
Withdrawal Differences
, morphine, hydrocodone, etc.
98
Buprenorphine

• High affinity, low dissociation
• Displaces/blocks other opioids, long duration of
  action
• Partial agonist at mu receptor (MS is full
  agonist)
• Ceiling effect (increase dose effect peaks)
• Low abuse, diversion potential
• Pain dose .2 - .4 mg SL q 6 hours
• Addiction dose 2 8mg q.d.
• Off-label pain use in US
• NIDA study underway

99
Buprenorphine

• Analgesic with 20 years world wide use
• moderate to severe pain bupmorphine 130
  (IV/IM)
• Temgesic sublingual, IM/IV, transdermal
• Treatment for opioid dependence, addiction
• world wide use 10 years, 3 years in US
• Orphan drug is US, on WHO Essential Drug List
• Excellent safety profile
• Training for Certification/Waiver
• 8 hours of CSAT approved CME
• www.asam.org,hhtp//buprenorphine.samsha.gov/
• Online courses available
• CD Available from AAAP today

100
94 to 98
85 to 92
100
90
80
70
27 to 47
60
Receptor Occupancy
50
40
30
20
10
0
2 mg
16 mg
32 mg
Dose
Source Greenwald, MK et al, Neuropsychopharmacol
ogy 28, 2000-2009, 2003.
101
44 Pain Bup Patients(K. Kunz, Presented at 5th
Annual Kaiser Pain Symposium, 8/05)

• Detoxed 10
• Were taking no other illicit/controlled drugs
• Length of detox 4-8 weeks
• Return to opiates 1
• Co-occurring psych disorder 4
• Terminated Bup Induction 4
• All taking other controlled drugs (Ambien, Soma,
  Ritalin)
• All had unstable medical conditions
• All returned to mu opioid agonists
• Co-Morbid Pain and Addiction 10
• Detoxed 3, 2 returned to mu opioids, 5 current on
  Bup
• Overall rotation/succesful detox 76
• 20 stable and satisfied on Bup Rx for pain

102
64 Addiction Bup Patients(K. Kunz, Presented at
5th Annual Kaiser Pain Symposium, 8/05)

• M 46 F 18 Age 19-66
• Heroin 30 Prescription Rx 16 IDU 24
• Psychiatric Co-morbidity 50 initally
• Using other illicit drugs 50 initially
• Status
• 26 detoxed (70 still clean)
• 42 left care (16 relapse, 4 jail, 2 move, 2 ?,
  1 killed)
• 31 still on Bup, from 2 weeks to 2 ½ years
• None using controlled or illicit drugs
• All employed
• 25 with co-morbid psych Rx

103
Medications for Opioid Relapse Prevention

• Methadone
• Naltrexone
• Suboxone
• (buprenorphine and naloxone)

104
Standard Treatment

• Same modalities as for all other CD Rx
• Education, IC, IOP, Residential, Aftercare
• Medications may have a place
• Community 12-step, mutual-help
• Psychosocial, Family Therapy
• Functional rehabilitation
• Special attention if need for controlled Rx

105
Physician Solutions

• Education, training mandates
• American Pain Society, American Academy of Pain
  Management
• Screening all patients for risk before
  prescribing controlled medications
• Urine Drug Testing
• Peer consultation, review, co-management
• Consent to treat, informed consent forms

106
Last Word

• I just minimized or dismissed the issues of
  abuse, addiction and diversion
• ten years later, and we recognize that was a
  big error..we need to talk about the use of
  opioids and other prescription drugs from the
  perspective of two skill setshow to prescribe,
  but at the same time, (doctors) have to have a
  skill set in addiction medicine, how to assess
  the risk of abuse and diversion and addictionor
  they shouldnt use them.
• Dr. Russell Portenoy ABC National
  Radio 12/5/04
• ( Foremost US Pain Expert)

The End
107
Symptomatic Relief for Acute Opioid Withdrawal

• Clonidine
• NSAIDs for aches and pains
• Bentyl, loperamide for GI symptoms
• Robaxin, Flexeril for muscle spasms, kicking
• Tiganm Zofran for nausea
• Vistaril for anxiety, insomnia
• Psychosocial support, hydration

108
Sample Clonidine Protocol

• Clonidine transdermal patch 0.1mg
• 0.1 mg clonidine per day for 7 days
• Assess every six hours for additional po
  clonidine dosing 0.05 mg to 0.2mg determined by
  COWS as well as pre dose evaluation of sedation
  level, resting blood pressure, and orthostatic
  changes in blood pressure pulse rate

109
Monitoring Opioid Recipients (continued)
A
nalgesia
A
dverse Effects
A
ctivity
A
dherence
110
Contact Information

• Kevin Kunz, M.D., M.P.H., FASAM
• 76-6115 Kuakini Highway, B-104
• Kailua-Kona, Hawaii 96740
• 808-327-4848
• Recovery_at_aesoft.net
• Hawaii Society of Addiction Medicine
• Dr. George Carlson, President
• Liza Lee, Administrator
• HMA, 1360 S. Beretania St.
• Honolulu, Hawaii
• 808-536-7702