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Neuro Exam 1 > Opioid Chronic Pain > Flashcards

Opioid Chronic Pain Flashcards

1
Q

A Balancing Act:

Public Health . . .opioid for chronic pain

A

• A crisis of abuse of prescription opioid medication
• Opioid-Involved Overdose Deaths in New Mexico
– 2017: #17 rank; 16.7 deaths per 100,000
• However ~ 5 years ago NM was ranked #1 in US in accidental OD rates
– Did NM programs for prevention of accidental opioid OD help; or did everyone catch up to us

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1
Q

A Balancing Act:

Patient’s Expectations . . . opioid for chronic pain

A
  • Being pain free
  • “Magic bullet” medications
  • Unlimited supply of medications –> Opioids, possibly gabapentin/pregabalin
  • Heavy reliance on medication
  • Denial of patient safety concerns
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2
Q

A Balancing Act:

Provider Realities

A

• Previous expose to alcoholism and addiction: 5%-10% of general population
• One addict can effect 7-10 people
• 40% prevalence of current or past substance abuse in patients receiving chronic opioids
• The impact of the CDC Guidelines for Safe Opioid Prescribing, 2016
• Chilling effect; no studies on how this may affect patients
• The challenge (stigma) of prescribing long term opioids
• Substance abuse, misuse and dependence
• Regulatory fears
⇒ clash of provider & patient values

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3
Q

Basic Concepts of Prescribing Opioids

A 
• Principles of medication management & prescribing
evidenced based medicine
efficacy and safety
• Use of corticosteroids as an analogy
control symptoms; often not curative
Long term use and high dose dangers
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4
Q

CDC Guidelines for Safe Opioid Prescribing (PART 1)

A

• Primary Care Providers
– Family medicine, Internal medicine
– Physicians, nurse practitioners, physician assistants
• Treating patients >18 years with chronic pain
– Pain longer than 3 months or past time of normal tissue healing
• Outpatient settings
• Does not include active cancer treatment, palliative care, and end-of-life care

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5
Q

CDC Guidelines for Safe Opioid Prescribing (PART 2)

• Recommendation #5

A

– When opioids are started, clinicians should prescribe the lowest effective dosage.
– Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to >90
MME/day.

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6
Q

Prior to Initiating Opioid Medication . . . what should be done

A 
• Non opioid medication maximized
• Use of screening tests such 
– SOAPP
– ORT
• Controlled Substance Agreement (CSA)
• Review of NMBOP PMP report
• Baseline UDM
• Discuss risks and benefits of using controlled substances w/ patient
• Pause & think
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7
Q

Initiating Opioid Medication. . . what to consider

A
  • Complete Critical 1st Assessment
  • Start low and go slow
  • Start on short acting (SA) opioid
  • Reassess in ~ 2 weeks
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8
Q

Practical/General Dosage Range Guidelines for Use of Opiates in Chronic Pain
(MED = Morphine Equivalent Dose OR MME = Morphine Milligram Equivalent)

A
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9
Q

Opioid Equianalgesic Doses:

A
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10
Q

PK data for oral opioids

A
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11
Q

PK of Tramadol & Tapentadol. . .

A
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12
Q

Caution with Methadone. . . important things to note

A
  • Variable half-life (8-59 hours) and duration (6-8 hours). . . Dose q 6-12 hours
  • Multiple drug interactions. . . Avoid w/ alcohol, azole antifungals, thioridazine
  • Can ↑ QTc Interval @ ≈ 100mg/day. . .If ↑ QTc, Decrease dose
  • Can accumulate in the elderly
  • No changes in dose until 5-7 days after starting methadone
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13
Q

Methadone (possible) Equianalgesic Doses:

A
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14
Q

Approximate Fentanyl Patch

Equianalgesic Doses:

A
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15
Q

Fentanyl Patch Cautions. . . Important things to note

A
  • Fentanyl is ≈ 100x > potency than morphine. . .Not for opioid naive patients
  • Takes 24 hours before full effect is known, therefore not for breakthrough or acutepain
  • Fentanyl is highly lipophilic: caution if ↑ BMI
  • Different generic products are not truly interchangeable
  • Can only titrate in 3 day increments
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16
Q

Reassessment of Opioid Medication Regimen

4 A’s of monitoring opiate therapy

A
  • Analgesia
  • activities of daily living
  • adverse effects
  • aberrant drug-related behaviors
17
Q 
Opioid Conversion Examples
.
Patient is on Oxycontin 30mg TID, plus 
Hydrocodone/APAP 7.5/325 TID. What is 
the patient’s total daily opioid dose?
A
18
Q

Undesired Outcomes of Opioid Use. . .

A 
– Physical Dependence
– Tolerance-larger doses for same effect
– Addiction vs Pseudo-Addiction
– Withdrawal
– Hyperalgesia
– Aberrant Medication Related Behavior
19
Q

Signs/Symptoms Associated with
Aberrant Medication-Related Behavior
• Portenoy and Payne’s Aberrant Behavior. . .

A
  1. Selling prescription drugs
  2. Forging prescriptions
  3. Stealing drugs
  4. Injecting oral formulations
  5. Obtaining prescription drugs from non-medical sources
  6. Concurrently abusing alcohol/illicit substances
  7. Escalating doses on multiple occasions despite warnings
  8. “Losing” prescriptions on multiple occasions
  9. Repeatedly seeking prescriptions from other providers/ED without informing the provider or after warnings to desist
  10. Evidence of deteriorating function due to drug use
20
Q

Urine Drug Monitoring . . . when would it be appropriate?

A
  • Suspected medication related aberrant behavior
  • Fear of damaging provider-patient relationship
  • Always make sure the test ordered will test for the medication in question
  • Always document when patient last took a dose of the medication being tested
  • High risk medication, not high risk patents. . .Good data drives good therapy
21
Q

Types of Urine Drug Testing . . .

Immunoassay Presumptive Screen vs. GC-MS or LC-MS/MS Definitive Quantitative

A
22
Q

Windows of Detection in Urine
.
Indicates how long after administration a person
excretes the drug and/or its metabolite(s) at a
concentration above a specific test cutoff
concentration. . . what are the dates for Amphetamines, THC, Benzodiazepines Opioids, Cocaine (benzoylecgonine metabolite)

A
23
Q

CDC Guidelines

• Recommendation #4

A

When starting opioid therapy for chronic pain,
clinicians should prescribe immediate-release
opioids instead of extended-release/long-acting (ER/LA) opioids.

24
Q

Long Acting vs Short Acting Opioid Medication . . .

Since release of CDC Guidelines, there has been movement away from use of LA opioid medication, however:

A 
– Since Assume pain at consistent level
– Increase adherence
– When patient goes for an extended period of time and 
cannot take a SA opioid; ie: sleep, work
– Question of aberrant behavior
– > 6 doses of SA opioid/day
25
Q

Long Acting vs Short Acting Opioid Medication… benefit of Long Acting?

A
26
Q

Current Opioid Abuse Deterrent Formulations (ADFs): Advantages and Disadvantages

A
27
Q

ADF Opioid Medication & Catch 22

A
  • Most ADF products are ER or LA opioid medication & the latest CDC guidelines do not advocate for ER or LA products
  • All ADF products are brand name products & therefore most insurance co. will not pay for them
  • Since most insurance co will not pay for ADF products, then these products will not be able to demonstrate post marketing data that these products impacted opioid abuse
28
Q

Use of Buprenorphine for Pain . . . PROs and CONs

A 
• Pro
– Partial agonist w/ ceiling effect for analgesia & adverse events
– Simpler dosing
– Less drug-drug interactions
– Better safety profile
– CIII
– More optimal choice for patients that have demonstrated aberrant behavior/addiction
– Do not need DEA “X” for CNCP treatment
.
• Con
– If on opioid medication, MAY need to decrease until ≤ 30MME
– May not be adequate for severe pain
– Insurance obstacles
29
Q

Safety of Opioids… things that opioid can do to your body that we need to be careful about . . . GENERAL (3 things)

A
  1. Endocrine system changes
  2. Impact of concomitant sleep apnea
  3. Opioid hyperalgesia
30
Q

Safety of Opioids

• Endocrine system changes

A

– Opioids inhibit the release of gonadotropin releasing hormone & corticotropin
releasing factor from hypothalmus
– Which in turn inhibits the pituitary hormone release of LH, FSH, ACTH & β-endorphins
– Resulting in secondary hypogonadism

31
Q

Safety of Opioids

Impact of concomitant sleep apnea

A

– Opioids cause central sleep apnea by decreasing medullary responsiveness to
carbon dioxide levels and thereby worsens obstructive sleep apnea
– Compounded by concomitant use of any other CNS depressant; ie:
benzodiazepine

32
Q

Safety of Opioids

Opioid hyperalgesia

A

– Heightened pain perception with opioid use, in the absence of disease progression
– Treated by decreasing opioid dose

33
Q

Opioid Medication & Hormonal Changes . . .

A

Opioids can suppress serum testosterone levels primarily by acting on opioid receptors in the hypothalamus
– Decreased release or disruption of the normal plasticity of GnRh secretion
– Results in reduction of the release of LH and FSH from pituitary gland and of testosterone or estradiol from the gonad

34
Q

Opioids & Dangerous Medication Combinations: Carisoprodol . . .important to note..

A
  • DO NOT USE CARISOPRODOL (Soma®)!!!
  • METABOLIZED TO MEPROBAMATE WHICH IS AN ANXIOLYTIC (reduces anxiety)
  • “HOLY TRINITY” (DEA) = CARSIPRODOL (Soma®) + Benzodiazepine + Opioid = ↑ risk of death drastically!!!
35
Q

Opioids & Dangerous Medication Combinations: Benzodiazepines. . . important to note

A

– GREATLY INCREASE THE RISK OF ACCIDENTAL OVERDOSE WHEN USED
CONCOMMITANTLY W/ OPIOID MEDICATION
– AVOID, DON’T USE TOGETHER, STOP USING WITH OPIOID MEDICATION

36
Q

Opioids & Dangerous Drug Combinations

A

• Benzodiazepines facilitate inhibitory effects of GABA on the respiration at the GABA-A receptor in the medulla
• Opioid-induced ventilatory depression results from slowed breathing frequency and reduced tidal volume, & also from a blunted ventilatory responsiveness to
hypoxia and hypercapnia
• Together these mechanisms can potentiate each other or be synergistic & can be very dangerous very quickly

37
Q

Summary: Gabapentinoids & Opioid Overdose Risk

A

• Increase in use of gabapentin & pregabalin is most likely
due to fallout from CDC Guidelines for Safe Opioid Prescribing
• Concomitant gabapentinoids & opioid Rx are significant
risk factors for overdose death
• Alternatives to gabapentoids need to be recommended
for clinicians managing opioid-dependent patients with
neuropathic pain or generalized anxiety
• Use of gabapentinoids at higher doses should be used
with caution in patients concomitantly prescribed opioid
medication
• Gabapentinoids may suppress respiration &/or decrease
opioid tolerance

38
Q

Opioids & Dangerous Drug Combinations: Cyclobenzaprine

A

• From the New Mexico Department of Health
– Cyclobenzaprine was involved in 3% of NM opioid fatal OD
– 82% of NM cyclobenzaprine OD fatalities involve opioids

39
Q

Do’s & Don’ts With Opioid Medication . . . the DOs

A

• DO
– Emphasize the importance of sustained improvement in functional levels allowed by opioids
– Describe opioids as having potential to “take the edge off” of the pain to allow
greater function START with low dose short-acting, perhaps 2-3 tablets per day as needed prn (specify up to maximum of 2-3 tablets per day)
- Systemize decision process when filling or refilling opiate Rx
- Remove stigma

Neuro Exam 1 (7 decks)

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