Match Context and Document information

These search terms are highlighted: dea verification

URL:	https://www.deadiversion.usdoj.gov/...nov_2018/bielawski.pdf
Depth:	4 clicks away from Home
Size:	2,037,834 bytes
Modified:	2024-05-28 12:28:35
Categories:	-None-
Title:	Reducing Opioid Prescribing
Description:	-None-
Keywords:	-None-
Meta data:	-None-
Body:	Bret Bielawski, DO FACP Reducing Opioid Prescribing "Primum non nocere" Disclosures Objectives  Be able to articulate to a patient the reasons why you are NOT going to prescribe opioids  List the four main standards of care when judiciously prescribing opioids  Be able to articulate why it is time to taper off opioids Overview  Why this occurred  Avoiding Opiates  Four Standards of Care  Time to Reassess How did this start? "only four cases of reasonably well documented addiction" NEJM 1980 302:123 "We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse." Pain 25 (1986) 171-186 Joint Commission Pain Standard PC.01.02.07  Rational: The identification and treatment of pain is an important component of the plan if care. Patients can expect that their health care providers will ask them about whether they have pain. When pain is identified the individual is assessed based on his or her clinical presentation and in accordance with the care, treatment, and services provided by the organization. Pain is NOT the "5 th Vital Sign" The "5 th Vital Sign" Lanser P, Gesell S. Pain management: the fifth vital sign. Healthc Benchmarks 2001;8:68-70, 62. JACHO Guide 2001  "Some clinicians have inaccurate and exaggerated concerns" about addiction, tolerance and risk of death."  "This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control."  The Joint Commission published a guide sponsored by Purdue Pharma. www.rwjf.org/en/grants/grant-records/1997/07/supporting-quality- improvement-and-jcaho-standard-setting-for-pa.html http://money.cnn.com/2007/05/10/news/companies/oxycontin/index.htm?cnn=yes Federation of State Medical Boards  "No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed." www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf. Accessed April 17, 2013 https://www.statnews.com/2016/06/27/opioid-addiction- orrin-hatch-ron-wyden/?s_campaign=stat:rss What is the largest source of Rx opiates for non-medical use? a) Prescribed by > 1 physician b) Bought from a drug dealer/stranger c) Given by friend/relative d) Bought from a friend/relative e) Stolen from a friend/relative Where is the largest source of Rx opiates for non-medical use? a) Prescribed by > 1 physician b) Bought from a drug dealer/stranger c) Given by friend/relative d) Bought from a friend/relative e) Stolen from a friend/relative Sources of opioids for non-medical purposes 70% 20% 10% Friend or Relative Prescribed Jones CM, Paulozzi LJ, Mack KA. Sources of Prescription Opioid Pain Relievers by Frequency of Past-Year Nonmedical Use: United States, 2008-2011. JAMA Intern Med. 2014 Other Who Rx the most opioids in MI ? A.Surgery B.Pain management C.ER/UC D.Primary care E.Oncology Who Rx the most opioids in MI ? A.Surgery (9%) B.Pain management (10%) C.ER/UC (5%) D.Primary care (64%) E.Oncology (1%) "This is why I'm not going to prescribe narcotics . . ." Which of the following is not associated with opioids? A. Opioid induced hyperalgesia B. Hypothalamic hypogonadism C. Physical dependence D. Disturbed sleep architecture E. Improved pain control with higher doses Which of the following is not associated with opioids? A. Opioid induced hyperalgesia B. Hypothalamic hypogonadism C. Physical dependence D. Disturbed sleep architecture E. Improved pain control with higher doses Opioid Induced Hyperalgesia  Paradoxical increase in pain  Diffuse allodynia unrelated to the original pain source  Increasing pain with increasing dosage Lee, Marion et al. (2011) "A Comprehensive Review of Opioid-Induced Hyperalgesia." Pain Physician, 14:145-161 Hypothalamic hypogonadism  Low testosterone and estrogen.  Osteoporosis  57% long acting and 35% short acting American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2-guidance. Pain Physician. 2012 July;15:S67-116. Disturbed Sleep Architecture  Opioids decrease total sleep time, sleep efficiency, delta sleep, REM sleep and increase time spent in light sleep. 1 Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Phys 2008;11:S105-S120 Tolerance A condition in which higher doses of a drug are required to produce the same effect as during initial use. Physical Dependence An adaptive physiological state that occurs with regular drug use and results in a withdrawal syndrome when drug use is stopped. Withdrawal: 4-24 hours "Flu-like and leaky" . Fever/Sweating . Rhinorrhea . Muscle cramps . N/V/D/Abd cramping . Insomnia . Mydriasis . Piloerection Addiction Compulsive use of a drug and overwhelming involvement with its procurement and use. ~80% heroin users started with prescription opioids Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers - United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100. What's the difference? Morphine Heroin 6-MAM Heroin Hydrocodone Oxycodone Morphine Safer Alternatives CDC Guideline for Prescribing Opioids for Chronic Pain - 2016 1. Use behavioral and physical therapies before medication, particularly opioids. https://stacks.cdc.gov/view/cdc/38440(Accessed 10-2016) Safer Alternatives  Heat and cold treatments  Exercise (Home Exercise Program), Handouts  Yoga  Physical and occupational therapy Safer Alternatives  Emotional and psychological support  Mindfulness training  Acupuncture  OMM World Health Organization Analgesic Ladder Acetaminophen or NSAIDs Short-acting opioid PRN ± non-opioid around the clock ± adjuvant agent Sustained release opioid or continuous infusion + short-acting opioid PRN ± non-opioid ± adjuvant agent Safer Alternatives  Non-opioid medication  Compounded agents  Lidocaine patches  Gabapentin  Pregabalin  Duloxetine Which of the following is the most important step(s) to take before prescribing opioids? A. Risk assessment B. MAPS C. Urine Drug Screen D. Pain Management Agreement E. All the above Which of the following is the most important step(s) to take before prescribing opioids? A. Risk assessment B. MAPS C. Urine Drug Screen D. Pain Management Agreement E. All the above Standard of Care Risk assessment MAPS Urine Drug Screen (UDS) Pain Management Agreement Standard of Care Risk assessment MAPS Urine Drug Screen (UDS) Pain Management Agreement Opioid Risk Tool (ORT) 1. Age: 16-45 2. Hx Substance Abuse  Alcohol  Illegal Drugs  Prescription Drugs 3. Family Hx Substance Abuse  Alcohol  Illegal Drugs  Prescription Drugs 4. Mental Illness  ADD/OCD/Bipolar/Schizophrenia  Depression - separate scoring 5. Hx Preadolescent Sexual Abuse Opioid Risk Tool (ORT) opioidrisk.com Low Risk 0-3 Moderate Risk 4-7 High Risk ≥ 8 Opioid Risk Tool (ORT) Standard of Care Risk assessment MAPS Urine Drug Screen (UDS) Pain Management Agreement Who Rx the highest doses (MME) in MI? A.Surgery B.Pain management C.ER/UC D.Primary care E.Oncology Who Rx the highest doses (MME) in MI? A.Surgery B.Pain management C.ER/UC D.Primary care E.Oncology Primary care is the 1 st largest Rx of lorazepam. Who is the 2 nd ? A.Surgery B.Pain management C.Psychiatry D.Primary care E.Oncology Primary care is the 1 st largest Rx of lorazepam. Who is the 2 nd ? A.Surgery B.Pain management C.Psychiatry D.Primary care E.Oncology Doctor Shopping and Overdose Death: 2009-2012 < 25 Deaths 1.4-2.3/100 3 2.4-3.1 3.2-4.1 4.6-6.0 A Profile of Drug Overdose Deaths Using the Michigan Automated Prescription System (MAPS) Office of Recovery Oriented Systems of Care Staff: Su Min Oh Standard of Care Risk assessment MAPS Urine Drug Screen (UDS) Pain Management Agreement Drug Testing  Detect non-prescribed drugs  Detect the absence of drugs  Point Of Care testing (in office)  High rates of false +/-  No toxicologist to consult Standard of Care Risk assessment MAPS Urine Drug Screen (UDS) Pain Management Agreement But, wait, there's more . . . Store SECURELY Encourage those on opioids to: Store SECURELY  "Is there a more secure area to keep your pills besides your":  Drawer at work  Purse  Glove box  Medicine Cabinet Dispose PROPERLY Dispose PROPERLY  Do you really need to save them "just in case"?  Give them a list of disposal sites How to Dispose of Unused Medicines  Take drugs out of their original containers and mix them with an undesirable substance, such as used coffee grounds ... www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsing MedicineSafely/UnderstandingOver-the-CounterMedicines/ucm107163.pdf (Accessed 5-2015) Never SHARE Encourage those on opioids to: Never SHARE  Felony  Don't want to create any more addictions What are you going to change? Three classes  Patients not on opioids  work hard provide more effective and safer options  Patients on opioids  reassess frequently  Opioid addiction  Families Against Narcotics https://www.npr.org/sections/health- shots/2016/01/11/462390288/anatomy-of- addiction-how-heroin-and-opioids-hijack-the-brain Transitioning Off Opioids "Plant the seed!" First Do No Harm! "Primum non nocere"