Reuben Strayer on Opioids - Pain, Compassion, Addiction, Malingering
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Opioids are extraordinary agents that have been used for millennia for the relief of pain and suffering; however, the history of opioids is also one of abuse and addiction. In the US, we are in the midst of a devastating iatrogenic chapter in this history, a prescription opioid epidemic that kills 15,000 Americans per year by overdose and destroys hundreds of thousands of lives and families. In this presentation we will consider the magnitude and consequences of the current epidemic; describe how clinical organizations and clinicians were appropriated by the pharmaceutical industry so that Americans–5% of the world’s population–consume more prescription opioids than the rest of the world combined; and discuss strategies for managing patients who present to emergency departments with acute or chronic pain complaints that account for our competing mandates to palliate and protect. These strategies center on an assessment of the likelihood that using opioids will deliver benefit or cause harm. For patients at low risk to be harmed by opioids, utilize aggressive multimodal analgesia, including opioids as needed to control acute pain, and prescribe optimal outpatient non-opioid analgesia with a small number of breakthrough opioids if indicated. For patients at high risk to be harmed by opioids, including patients with chronic pain and patients with flags for opioid misuse, avoid using opioids in the ED and outpatient settings, utilize non-opioids to manage symptoms, and, when misuse is suspected, nudge the patient to addiction treatment. The goals of optimal opioid stewardship are to provide effective symptom relief while preventing de novo cases of addiction, to control the supply of opioids in the community, and to protect existing addicts from further harm while promoting recovery. For slides, the HELPCard treatment referral business card, and phraseology to use when managing patients at risk for opioid misuse, go to http://emupdates.com/help
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Reuben Strayer on Opioids - Pain, Compassion, Addiction, Malingering
- 1. Pain, Compassion, Addiction, Malingering: How To Use Opioids reuben j. strayer @emupdates and how to not use opioids slideset and references emupdates.com/help
- 2. no disclosures / conflicts
- 3. responsibilities of the emergency physician resuscitation symptom relief resource stewardship customer service public health identification of dangerous conditions determination of disposition / level of care managing ED flow
- 4. responsibilities of the emergency physician resuscitation symptom relief resource stewardship customer service public health identification of dangerous conditions determination of disposition / level of care managing ED flow
- 5. responsibilities of the emergency physician resuscitation symptom relief resource stewardship customer service public health identification of dangerous conditions determination of disposition / level of care managing ED flow
- 6. The unprecedented increase in opioid pain reliever consumption has led to the worst drug overdose epidemic in US history. Kolodny 2015 CDC:
- 7. Volkow 2014 Baumblatt 2014 MMWR 2015 Reuben 2015 opioids are responsible for 1 in 8 deaths in americans aged 25-34
- 8. Fischer 2013 Boyer 2012 Prescriptions for opioid analgesics in the United States increased by 700% between 1997 and 2007
- 9. IMS 2013 Meier 2013 Kolodny 2015 900% increase in prescription opioid addiction treatment between 1997 and 2011
- 10. Deathrateper100,000 0 2.5 5 7.5 10 '70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 Heroin Cocaine 43,982 drug overdose deaths in 2013 Unintentional Drug Overdose Deaths United States, 1970–2007 National Vital Statistics System, http://wonder.cdc.gov Year c/o A. Kolodny, MD
- 11. c/o L Paulozzi, MD
- 12. Burghardt 2013
- 14. CDC - Prescription Painkiller Overdoses Policy Impact Brief
- 15. morphine equivalence milligrams per person, 2010 japan united states 26.38 663.45 Mehendale 2013
- 16. INCB 2013 Statistics on Narcotic Drugs
- 19. The Epidemic of Untreated Pain
- 20. “Studies indicate that the de novo development of addiction when opioids are used for the relief of pain is low.”
- 25. "I gave innumerable lectures in the late 1980s and '90s about addiction that weren't true.” "Clearly, if I had an inkling of what I know now then, I wouldn't have spoken in the way that I spoke. It was clearly the wrong thing to do.”
- 27. the epidemic of untreated pain opiophobia pain is a vital sign pseudoaddiction pain score zero opioids are effective in chronic non-cancer pain addiction cannot come from treating pain it is better to over treat than to under treat pain safety of high dose opioids always assume a patient claiming pain is in pain oral opioids don’t cause respiratory depression
- 28. When I was in medical school, I was told, if you give opiates to a patient who's in pain, they will not get addicted. Completely wrong. Completely wrong. But a generation of doctors, a generation of us grew up being trained that these drugs aren't risky. In fact, they are risky. Thomas Frieden Director of the U.S. Centers for Disease Control and Prevention
- 29. When I was in medical school, I was told, if you give opiates to a patient who's in pain, they will not get addicted. Completely wrong. Completely wrong. But a generation of doctors, a generation of us grew up being trained that these drugs aren't risky. In fact, they are risky. Thomas Frieden Director of the U.S. Centers for Disease Control and Prevention
- 30. prevent addiction protect addicts and promote recovery control supply
- 31. recreation self limited careful ongoing use no escalation few addiction features escalation misuse addiction opioid prescription opioid use trajectories morbidity, mortality
- 32. recreation self limited careful ongoing use no escalation few addiction features escalation misuse addiction opioid prescription opioid use trajectories morbidity, mortality
- 33. recreation self limited careful ongoing use no escalation few addiction features escalation misuse addiction opioid prescription opioid use trajectories morbidity, mortality
- 34. recreation self limited careful ongoing use no escalation few addiction features escalation misuse addiction opioid prescription opioid use trajectories morbidity, mortality
- 35. recreation self limited careful ongoing use no escalation few addiction features escalation misuse addiction opioid prescription prescribe to fewer patients morbidity, mortality
- 36. Lindenhovious 2009 prescribe to fewer patients
- 37. acetaminophen 1 g q6 + ibuprofen 400 mg q6 Fathi 2015 P Moore 2013 Derry 2013 Teater 2014 Poonai 2014 R Moore 2013
- 38. chasing zero pain function pain10 0 chance of harm
- 39. My job is to manage your pain at the same time that I manage the potential for some pain medications to harm you.
- 40. recreation self limited careful ongoing use no escalation few addiction features escalation misuse addiction opioid prescription morbidity, mortality prescribe fewer pills
- 41. Brands 2010 prescribe fewer pills
- 42. 3 days and flush
- 43. recreation self limited careful ongoing use no escalation few addiction features escalation misuse addiction opioid prescription opioid use trajectories morbidity, mortality
- 45. benefit:harm in chronic pain and addiction opioids provide temporary relief of symptoms but make the problem worse misplaced focus on deception
- 46. opioid misuse spectrum opioid naive diversionrecreation chronic pain addiction
- 47. opioid naive diversionrecreation opioid misuse spectrum terminalillness chronic pain addiction
- 48. pain at the end of life aggressive multimodal analgesia including escalating doses of IV opioids as necessary PO opioids as necessary verify outpatient care everyone else benefit:harm risk factors judgment
- 49. red flags for opioid misuse yellow flags for opioid misuse poly-provider, poly-hospital patient, relation, or provider reports addiction or diversion injects oral opioid preparations obtains drugs through dubious means (e.g on the street) uses others’ meds, steals Rx pads/syringes, forges Rx, false ID many visits, refill requests, dose escalation requesting specific meds, requesting med IV, declines non-opioids from out of town, primary provider unavailable, pt passed by closer institutions allergies to analgesics and other relevant non-opioids opioid/Rx is lost, stolen uninterested in diagnosis or alternative treatments, refuses tests repeatedly misses followup appointments, has been terminated by providers history of substance abuse or incarceration absence of objective findings of acute pain symptom magnification, inconsistency, distractibility rehearsed, textbook presentations deterioration of work/social function, disability
- 50. low risk acute pain no chronic pain no flags for opioid misuse in the ED: aggressive multimodal analgesia including escalating doses of IV opioids prn discharge: optimal outpatient analgesia, +/- breakthrough opioids and guidance
- 51. acetaminophen 1g + ibuprofen 400 mg q6 ice, heat, elevation, immobilization, mobilization set expectations: zero pain is not the goal optimal outpatient analgesia breakthrough opioids if necessary, considering harm prescribe smartly small number - 3 days and flush avoid euphorics avoid combinations
- 52. ditch percocet and vicodin IR Morphine 15 mg tabs 1 tab q3-4h prn pain disp #12 take them off your formulary - if you can Wightman 2012 Cicero 2013 Zacny 2008
- 53. acetaminophen 1g + ibuprofen 400 mg q6 ice, heat, elevation, immobilization, mobilization set expectations: zero pain is not the goal optimal outpatient analgesia breakthrough opioids if necessary prescribe smartly small number - 3 days and flush avoid euphorics - oxycodone is the most abuse prone avoid combinations - to maximize scheduled APAP never ER/LA preparations Bon 2012 Galinkin 2014 Miller 2015 Meier 2012 be especially cautious in 10-30, sedative use and social/psych/substance history
- 54. high risk + chronic pain + flags for misuse avoid opioids in the ED and by prescription use alternate modalities to manage pain express concern that opioids are causing harm and refer
- 55. I know you are in pain and I want to improve your pain, but I believe that opioids are not only the wrong treatment for your pain, but that opioids are the cause of your pain. I think pain medications are harming you, and if you could stop taking them, your pain and your life would improve. Can I offer you resources that will help you stop taking pain medications?
- 57. discharge alternatives to opioids in the ED
- 58. regional and local anesthesia “trigger point injection” alternatives to opioids in the ED
- 59. droperidol or, sadly, haloperidol Richards 2011 alternatives to opioids in the ED
- 60. ketamine Richards 2011 Hocking 2003 Patil 2012 Bell 2009 Visser 2006 alternatives to opioids in the EDlow back pain chronic pancreatitis fibromyalgia myofascial pain syndrome complex regional pain syndrome sickle cell opioid withdrawal neuropathic pain cyclic vomiting gastroparesis abdominal migraine chronic ischemic pain atypical odontalgia phantom pain postherpetic neuralgia post-stroke pain spinal injury pain TMJ joint arthralgia intractable headache
- 61. intravenous lidocaine dexmedetomidine propofol de Pinto 2012 Belgrade 2010 Canavero 1995 alternatives to opioids in the ED
- 62. alternatives to opioids for discharge acetaminophen 1 g q6 + ibuprofen 400 mg q6
- 63. nonanalgesics alternatives to opioids for discharge topicals nonpharmacologics thermotherapy (heat), cryotherapy (ice), exercise, weight loss, yoga, tai chi, meditation lidocaine capsaicin diclofenac anticonvulsants TCAs gabapentanoids
- 65. alternatives to opioids for discharge weed alaska arizona california colorado connecticut DC delaware hawaii illinois maine maryland massachusetts michigan minnesota montana nevada new hampshire new jersey new mexico new york oregon rhode island vermont washington Bachhuber 2014
- 66. maybe risk no history of chronic pain +yellow flags I’m not sure prescription drug monitoring program no opioids challenge
- 67. no opioids challenge My most important job as an emergency doctor is to make sure there’s no emergency, so I would like to do some tests to make sure there’s nothing dangerous happening to you, and also I want to relieve your pain. But you will not receive any opioids while you are here, because I think opioids could be harmful to you.
- 68. opioid naive diversionrecreation chronic pain addiction less interested in opioid alternatives
- 69. electroanalgesia (TENS), counter- irritative therapy, spinal cord and deep brain stimulators, neuroablation, biofeedback, hypnosis, rehab medicine, OT, chiropractor, meditation, acupuncture, shaman there are options for chronic pain patients
- 70. house of health medical social substance psychiatric
- 71. house of health medical social substance psychiatric resuscitation symptom relief resource stewardship customer service public health identification of dangerous conditions determination of disposition / level of care managing ED flow
- 72. want to know more? emupdates.com/help @LNelsonMD @JMPerroneMD @DavidJuurlink @andrewkolodny
- 73. moderate or severe painpatient may benefit from opioids how likely is the patient to be harmed by opioids?* risk stratify using red/yellow flags low risk high risk maybe risk acute pain no chronic pain no red/yellow flags chronic pain +red/yellow flags acute pain +yellow flags in ED: aggressive multimodal analgesia Rx: 1 g acetaminophen + 400 mg ibuprofen q6h +nonpharmacologics (e.g. ice) +/- breakthrough opioid tabs avoid euphorics (e.g. oxycodone) avoid ER/LA preparations avoid combination pills 3 days supply, flush unused pills goal is not zero pain avoid opioids in ED and by prescription use alternate modalities to manage pain express concern that patient is being harmed by opioids and nudge toward recovery prescription drug monitoring program no opioids challenge: I’m going to try to manage your pain without opioids because I’m concerned that pain medications might harm you *pain at the end of life: opioid harms less important, escalate opioids as needed emupdates.com/help
- 77. I can’t deal with this today give the patient what he wants and move on I feel threatened “Here is your prescription. I am not entirely comfortable giving you this prescription because I am concerned that you are being harmed by these pain killers. When you decide that you want to stop using these drugs, and I hope you do, we can help you. Here is a list of resources available to help you stop.” HelpCard
- 78. Prescription pain medications, even when used as directed, can cause patients to become dependent, and I’m concerned that the pills we prescribed for you in the past, even though you were using them appropriately, you may now be dependent on them. We can help you break free of that dependence.
- 79. allergy challenge I understand you’ve had an allergic reaction in the past to nitroglycerine. Sometimes what people think are allergic reactions aren’t, and sometimes these reactions go away. I’m comfortable giving you nitroglycerine - if you have an allergic reaction, we are prepared to manage it, that’s what we do in the ER.
- 80. Brady 2015
- 81. Chang 2014 Mazer 2014 prescribe to fewer patients
- 82. Gomes 2013
- 83. Volkow 2011 Beaudoin 2014 Straube 2013 Hansen 2005 Logan 2013
- 84. Volkow 2011 Beaudoin 2014 Straube 2013 Hansen 2005 Logan 2013 more than one third misuse misusers target EDs a big problem for EM and a big opportunity 1 out of 8 ED patients with headache, back pain, or toothache received prescriptions from ≥8 providers in the preceding 12 months.
- 85. 250 patients: 4,639 unused tablets Rodgers 2012
- 86. Patient perception of postoperative pain has evolved from an expected consequence of surgery to a “measurable” vital sign requiring treatment. Rodgers 2012
- 87. Bates 2011
- 88. “the doctors meant well.”
- 89. Tao 2012
- 91. Hasegawa 2014
- 92. Deyo 2015
- 93. Simon 2015 Harvard Chan School / Boston Globe April 2015 Survey 4 out of 10 americans know someone who has abused opioids in the past five years. in those cases, 20% reported that abuse led to the user’s death.
- 94. “Unlike the other drugs in the other epidemics that we have faced, heroin in the 70s and crack cocaine in the 80s, prescription drugs come from a legal source – they are manufactured by pharmaceutical companies and are prescribed by doctors. Overprescribing is the root cause of this problem.”
- 97. Beaudoin
- 98. Hoppe 2014
- 100. misuse abuse addiction chronic pain Ashworth 2013 Chou 2014 opioids more likely to harm than benefit
- 101. seconds of exposure to heated surface prior to paw withdrawal analgesia hyperalgesia infusion infusion discontinued Brush 2012 Angst 2006 opioid hyperalgesia tolerance
- 102. when subject starts to feel pain when subject can no longer stand the pain and removes hand from water seconds arm in icewater Doverty 2001 opioid hyperalgesia
- 103. “Morphine isn't that great at all.. as in euphoric anyway.” “Morphine is a waste unless you shoot it. And i don't recommend ever shooting anything. So fuck it. Stick with oxy.” “Morphine is best for controlling pain, for a high you are better off using beer or wine or booze than taking morphine for fun.”
- 104. MMWR July 2014