Best Practices in Prescribing Opioids for Chronic Non-cancer Pain
5/22/2015
Best Practices in Prescribing Opioids for Chronic Non-cancer Pain
SCOTT STEIGER, MD, FACP ASSISTANT CLINICAL PROFESSOR DIVISION OF GENERAL...
Best Practices in Prescribing Opioids for Chronic Non-cancer Pain
SCOTT STEIGER, MD, FACP ASSISTANT CLINICAL PROFESSOR DIVISION OF GENERAL INTERNAL MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO SCOTT.STEIGER@UC SF. EDU
Disclosures
No financial disclosures to report I am not anti- or pro-opioid
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5/22/2015
It’s hard to be neither pro- nor anti-opioid
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5/22/2015
Outline Evidence for... Benefits of chronic opioid therapy (a little) Risks of chronic opioid therapy (a little) Strategies to mitigate risks of chronic opioid therapy
Our case: 28 yo M SCD 28 yo M SCD, freq hosp for pain crises, currently on MS-Contin 200 mg tid and 30 mg tid PRN as an outpatient. His insurance plan has notified you that they plan to institute dose limits of 200 mg MSO4 daily.
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5/22/2015
Our Case: 28 yo M SCD, dose limits 28 yo M SCD, freq hosp for pain crises, currently on MS-Contin 200 mg tid and 30 mg tid PRN as an outpatient. His insurance plan has notified you that they plan to institute dose limits of 200 mg MSO4 daily.
Q1: Which is true of opioids for CNCP at or above the equivalent of 200 mg morphine daily (MED)? a) Evidence suggests that MED > 200 mg reduce pain by 50% in ~50% of patients b) Data supporting the benefits of MED > 200 mg in CNCP are lacking c) Patients at very high doses have reported worse pain control d) Both B and C
Our Case: 28 yo M SCD, dose limits 28 yo M SCD, freq hosp for pain crises, currently on MS-Contin ___ tid and ___ PRN as an outpatient. His insurance plan has notified you that they plan to institute dose limits of 200 mg MSO4 daily.
Q1: Which is true of opioids for CNCP at or above the equivalent of 200 mg morphine daily (MED)? a) Evidence suggests that MED > 200 mg reduce pain by 50% in ~50% of patients b) Data supporting the benefits of MED > 200 mg in CNCP are lacking c) Patients at very high doses have reported worse pain control d) Both B and C
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5/22/2015
The benefits of opioids for CNCP % report reducing pain scores by at least half (Chou 2009; Reuben 2015) Max dose 180 mg MED
Risks to patients on chronic opioids Opioid overdose Death from overdose All cause mortality Aberrant use, addiction ED visits Clinical depression Psychosocial problems
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5/22/2015
Risks to patients on chronic opioids Falls and fractures in the elderly LESS likely to return to work
Immune dysfunction Decreased GNRH, low libido Hyperalgesia = MORE difficult to control acute pain Difficult interactions with the care providers
Risks appear to be dose dependent
Chou et al., 2015
What is a high dose of an opioid? MSO4 50 mg is about the same as…. Codeine 60 mg q4h Hydrocodone/APAP 10/500 5 times a day Methadone 5 mg tid Hydromorphone 4 mg tid Oxymorphone ER 7.5 mg bid Fentanyl 12 mcg/hr patch
Opioidcalculator.practicalpainmanagement.com
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5/22/2015
What is a high dose of an opioid?
Daily Opioid dose (MSO4 eq)
Hazard Ratio for OD (95% ci)
None
0.31 (0.12-0.8)
1 to “pain contracts” Toxicology testing is tricky but useful Tapering is tricky, even when necessary