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Lessons Learned from the MMA/BOLIM Chronic Pain Project

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Title: Lessons Learned from the MMA/BOLIM Chronic Pain Project


1
Lessons Learned from the MMA/BOLIM Chronic Pain
Project
  • ME Assn of Psych Physicians
  • April 30, 2010
  • Noel J. Genova, MA, PA-C

2
Learning Objectives
  • Efficacy of chronic opioid therapyevidence ,
    lack of evidence, opioid-responsive conditions.
  • Documentationthe 6 As
  • Screening for misuse and addiction, and referring
    for treatment if appropriate.
  • Recognition of medication diversion.
  • Polypharmacy.

3
Table of Contents
  • Description of the MMA/BOLIM Chronic Pain Project
  • Initial objectives of the Project, and
    qualitative information found during chart review
    (200 participants, 1000 charts reviewed).
  • Emerging issues (from chart reviews and
    Integrated Pain Mgt Conference Group).

4
MMA/BOLIM Chronic Pain Project
  • Started in March, 2008. Funded by Maines Board
    of Medicine, administered through Maine Medical
    Association.
  • Intended as a service to licensees and all Maine
    prescribers.
  • All visits confidential, and free of charge to
    the practices.

5
Initial Objectives
  • Raise awareness of drug-related deaths,
    particularly from methadone.
  • Help prescribers prevent diversion.
  • Teach prescribers to recognize and treat
    addiction.
  • Review records for appropriate documentation of
    initial evaluation and on-going monitoring of pts
    on opioids.

6
Initial Objectives, contd
  • Assist prescribers in use of the Prescription
    Monitoring Program.
  • Discuss methods for urine drug screening.
  • Offer sample treatment agreements.
  • Review Maines Chapter 11 Rules for Use of
    Controlled Substances for Treatment of Pain (in
    other states, the FSMB model rules).

7
Last Years News
  • Treatment of chronic, non-terminal pain with
    opioid medications has had the unintended
    consequence of increased diversion of
    medications, increased non-medical use of
    prescription medications by young people, an
    increase in drug-related deaths nationally, and
    possibly an increase in opioid misuse or
    addiction among patients treated for chronic pain.

8
Last Years News, Contd.
  • Risks of chronic opioid therapy (COT) include
    endocrine abnormalities, aggravation of pain,
    worsening depression, sleep disturbances
    (including sleep apnea) and worsening function.
    This is especially concerning, because the
    indications for the use of the therapy is
    increased pain relief, increased function, and
    overall improvement in well-being.

9
The Problems are On-Going
  • Drug-related deaths in Maine were again higher
    than MVA-related deaths in 2008.
  • Prescribers are generally well-aware of these
    issues, and are looking for how to reduce risks,
    while continuing to treat pain effectively.
  • Non-medical use of prescription analgesics
    remains a serious problem among youth.

10
Maine Drug Related vs. MVA deaths90 caused by
at least one prescription drug78 had narcotics
present Office of Medical Examiner
1997 2000 2005 2006 2007
MVA related 192 169 169 188 183
Drug related 34 60 176 167 154
11
Deaths per 100,000 related to unintentional
overdose and annual sales of prescription
opioids by year, 1990 - 2006 Source Paulozzi,
CDC, Congressional testimony, 2007
12
Methadone Related Deaths 2005Larger Circle
indicate higher rates NYT 8.17.08
13
Where Pain Relievers Were Obtained Non-medical
Use among Past Year Users Aged 12 or Older 2006
Source Where Respondent Obtained
Bought on Internet0.1
Drug Dealer/Stranger3.9
Other 14.9
Source Where Friend/Relative Obtained
More than One Doctor 1.6
More than One Doctor3.3
Free from Friend/Relative7.3
Free from Friend/Relative55.7
One Doctor 19.1
Bought/Took fromFriend/Relative4.9
OneDoctor 80.7
Bought/Took from Friend/Relative14.8
Drug Dealer/Stranger1.6
Other 12.2
1 The Other category includes the sources Wrote
Fake Prescription, Stole from Doctors
Office/Clinic/Hospital/Pharmacy, and Some Other
Way.
14
BENZOS
  • May be used by psychiatrists in pts treated for
    chronic pain with COT.
  • Implicated in many drug-related deaths, esp in
    combo with methadone.
  • Many pts on benzo stimulant from psychiatry,
    COT prn butalbital.
  • Methadone clinics do not report to the PMP.
    Consider drug testing adult pts on any
    chronically used controlled med.

15
Learning from the Project
  • Use of drug screensIm a doctor, not a cop.
    Must screen for addictiona treatable,
    potentially fatal medical condition.
  • Alcohol abuse is often missed or ignored.
  • Polypharmacy with controlled substances starts
    insidiously, and is difficult to stop. Benzos
    and butalbital often used w/COT.

16
Urine Drug Testing
  • History of substance use and abuse very
    important, but not entirely accurate
  • Studies from pain treatment centers consistently
    show 40 of urines with unexpected results.
  • Interpretation of results can be trickydevelop a
    relationship with your lab.

17
Learning from the Project, Contd
  • We are not trained to obtain the elements of the
    history, particularly in monitoring of opioid
    analgesics (the 6 As).
  • Prescribers want to learn to use the PMP.
  • Many prescribers find confrontation of patients
    with aberrant behaviors to be very difficult,
    time-consuming, and draining. Training is needed
    on this issue.
  • Psychiatry may be able to help PCPs on this issue.

18
The 6 As
  • Analgesia
  • Activity (function)
  • Aberrant Behaviors
  • Adverse Affects
  • Affective Aspects (mood, sleep. Remember
    usefulness of CBT)
  • Adjuncts (pharmacologic and non-pharmacologic)

19
Barriers to Best Practices
  • Lack of strong evidence-based studies.
  • Lack of access to a full range of adjuncts, esp
    in rural areas. Lack of reimbursement for
    intensive interdisciplinary therapies.
  • Local culture which equates treatment of pain
    with use of opioid medication.
  • Lack of reimbursement for the time needed to
    treat pts comprehensively.

20
2009 Guideline
  • Chou, R, Fanciullo GJ, Fine PG, et al Clinical
    Guidelines for the Use of Chronic Opioid Therapy
    in Chronic Noncancer Pain The Journal of Pain
    Vol 10, 2 February, 2009 pp. 113-130.
  • Appendices regarding Screening and Brief
    Intervention for Addiction are especially useful
    and important.

21
2009 Guideline (contd)
  • Addresses Efficacy and Risk Assessment
  • Sparse evidence for use in chronic back pain,
    daily headache, and fibromyalgia.
  • Good appendices with tools for screening for risk
    of misuse or addiction, consent forms, and
    documentation tools.
  • Monitoring process not evidence-based, but may
    reveal a community standard.

22
Emerging Objectives
  • Management of patients on high-dose opioids who
    are not responding well.
  • Discontinuing chronic opioid therapy.
  • Treatment of acute pain (e.g. associated with
    surgery) in patients who are on buprenorphine or
    methadone.
  • Use of medical marijuana for chronic pain.

23
Emerging Objectives (Contd)
  • Substituting evidence-based treatments for COT in
    patients with fibromyalgia, chronic headaches and
    migraine, and chronic low back pain for which
    there is no structural cause identified (in pts
    who are not doing well on COT).
  • These conditions may have psychiatric component.
    Psych can help PCPs.

24
Pts on High-Dose Opioids
  • No real definition of high-dose opioids, but
    general agreement on 200 mg/day equivalent of
    morphine.
  • 160 mg/day of oxycodone.
  • 60-120 mg/day of methadone (extreme care must be
    used in dosing methadone).
  • 100 microgram q 3 days fentanyl patch.

25
High-Dose Opioids--References
  • Ballantyne JC and Mao J Opioid Therapy for
    Chronic Pain NEJM 34920 Nov 13, 2003
    1943-53.
  • Chang G, Chen L, and Mao J Opioid Tolerance and
    Hyperalgesia The Medical Clinics of North
    America 91 (2007) 199-211.

26
Recommendations
  • Be sure to document efficacy of high-dose
    opioids.
  • Screen for misuse and/or addiction.
  • Be aware of the possibility of opioid-induced
    hyperalgesia.
  • Be Careful With Benzos and Other Controlled
    Substances! Psychiatry Primary Care may
    Polypharmacy.

27
Discontinuing Opioid Meds
  • May be indicated if med not effective.
  • Consider possibility of opioid-induced
    hyperalgesia, which may indicate need to taper
    and/or D/C COT.
  • May be necessary if pt misusing the med.
  • Some pts want to D/C med.
  • Condition may have improved or resolved (e.g.
    after surgery).

28
Case Example
  • A 40 yo man with chronic pain after extensive
    injuries sustained 15 yrs ago when he fell off a
    roof. He is on 480 mg of oxycodone daily, has
    8/10 pain, cannot work, and his wife has asked
    him to leave, as he is unable to participate in
    family activities.

29
Discontinuing Opioid Meds
  • Taper can be slow (10/week), or rapid. See
    www.Pain-Topics.com, March, 2006 Kral, Lee A.
  • Buprenorphine can be used if the pt does not
    tolerate discontinuation of COT. Certificate
    needed if med used for opioid addiction, but not
    if used for chronic pain.
  • DEA is concerned about mislabelling pts as
    chronic pain. Document carefully!

30
Buprenorphine
  • If used for pain, Dx must be clearly indicated on
    Rx.
  • Efficacy for pain relief controversial.
  • In Maine, has street value.
  • If used for opioid addiction, and the pt has a
    chronic pain condition, may want to consult with
    a specialist in pain management.

31
Buprenorphine (contd)
  • Is an opioid agonist. Competes with other
    opioids for binding sites. Can induce
    withdrawal, and prevent efficacy of other
    opioids.

32
Recommendations
  • If treating pts for non-terminal chronic pain,
    always have an exit strategy.
  • Be prepared to discontinue COT, if indicated.
  • Have a back-up plan for pts who do not do well
    with a standard taper.

33
Acute Pain in Pts on Opioid Agonist Therapy (OAT)
  • Why is the pt on OAT?
  • Technical expertise required to avoid risk of
    drug interactions.
  • Buprenorphine may precipitate withdrawal if
    combined with other opioids.
  • Methadone maintenance may predispose pts to
    opioid-induced hyperalgesia.

34
OAT (contd)
  • ReferenceAlford D, Compton P, Samet J Acute
    Pain Management for Patients Receiving
    Maintenance Methadone or Buprenorphine Therapy
    Annals of Internal Medicine 17 Jan. 2006
    144127-134.

35
Case Example
  • 35 yo man presents for day surgery. He had not
    revealed that he was on methadone maintenance,
    and standard questionnaires in the surgical
    intake process did not include this piece of
    medical history. The pts post-procedure pain
    was difficult to control, and the pt became
    combative.

36
Recommendations
  • Review definitions of addiction, dependence, and
    tolerance.
  • Work with someone who is experienced in this
    situation.
  • Incorporate elements of the history that allow
    the pt to reveal history of addiction without
    feeling judged, or scared that pain control will
    be withheld.
  • Psychiatry can help PCPs and med team.

37
Medical Marijuana
  • Legal in some states, including Maine.
  • May be useful for chronic pain.
  • Proponents note its safety, esp. compared to COT.
  • It can be a drug of abuse.
  • Little research on this Schedule I drug.
  • No psych dxes currently included in
    certification list in ME.

38
Reference
  • Ben Amar, Mohamed Cannabinoids in Medicine A
    Review of their Therapeutic Potential Journal of
    Ethnopharmacology 105 (2006) 1-25.

39
Recommendations for Physicians
  • Document indication for use, efficacy, dose, and
    its place in overall therapeutic plan.
  • Physicians should follow any advice available for
    certifying use. (In Maine, Maine Medical
    Association.)
  • Physicians should not certify pt for use if not
    comfortable in doing so.

40
Soft indications for COT
  • Many dxes for use non-specific, such as chronic
    pain, chronic back pain.
  • Multiple fibromyalgia-related websites browsed
    (Arthritis Foundation, NIH, Mayo Clinic, National
    Fibromyalgia Foundation). None advised use of
    strong opioid medication.
  • No place for COT for tx of chronic H/A.

41
References
  • Chou R, Qaseem A, Snow V, et al Diagnosis and
    Treatment of Low Back Pain A Joint Clinical
    Practice Guideline from the ACP and the Am Pain
    Soc Annals of Internal Medicine 2 Oct, 2007
    Vol 147, 7 478-91.
  • Chou R and Huffman L Meds for Acute and Chronic
    LBP same issue 505-14.

42
Recommendations
  • Review your diagnoses and treatment plans for pts
    with chronic pain.
  • Discuss latest treatment options with pts. They
    may have changed since the current plan was put
    in place.
  • Consider tapering and/or D/Cing COT if pt not
    doing well.
  • Work with COT prescriber on taper strategy.

43
Summary Recommendations
  • Keep up with medical literature if you prescribe
    COT. It is rapidly changing.
  • Pay close attention to documentation.
  • Be aware of community standard of care.
  • Identify resources for treatment of chronic pain
    and addiction.
  • Be vigilant for risk of diversion.
  • Communicate with Primary Care.

44
Questions? Comments?
  • Thank you for your attention.
  • Noel J. Genova, MA, PA-C
  • MMA/BOLIM Chronic Pain Project
  • tel 671-9076
  • e-mail NoelPAC_at_aol.com.
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