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Acute Pain Management in Times of Epidemic Prescription Drug Abuse

Acute Pain Management in Times of Epidemic Prescription Drug Abuse. Rumm Morag, MD, FACEP Department of Emergency Medicine Salem Hospital. Objectives. U nderstanding the direct correlation between opiate sales and the prescription overdose death rate

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Acute Pain Management in Times of Epidemic Prescription Drug Abuse

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  1. Acute Pain Management in Times of Epidemic Prescription Drug Abuse Rumm Morag, MD, FACEP Department of Emergency Medicine Salem Hospital

  2. Objectives • Understanding the direct correlation between opiate sales and the prescription overdose death rate • Utilize adjuvant non-opiate treatments for management of acute pain • To understand the role of the Oregon Prescription Drug Monitoring Program • Inform regarding IRON ED

  3. What is Pain? • Pain is a real condition • An unpleasant sensory experience

  4. Pain is… • Something different to every person • Does not show up on lab testing or imaging and may have no objective findings • So we must begin this discussion with definitions we can all agree upon…..

  5. Defining Pain • Pain is subjective • Has physical and emotional components • Difficult to quantify • Common • Costly • Difficult to manage

  6. Pain is common • The most common reason for physician consultation in the United States • The most common symptom presenting the Emergency Department • 42% of all Emergency Department visits are due to subjective pain Platter et al. JAMA. 2008;299:70-78

  7. Pain is Political • Joint Commission calls pain the “fifth vital sign” • Emphasis on patient satisfaction (not outcomes) • IOM Report stresses “poor pain control by MDs” • Pain aversive culture expects “No Pain at all” • Public expectation to receive “Stronger Medication” Phillips DM, JCAHO standards. JAMA. 2000;284:428-429 IOM 2011, Washington DC: The National Academies Press

  8. Consequences of “Better Pain Control” • Prescription drug abuse is the Nations fastest growing segment of drug abuse • CDC calls prescription drug abuse an “epidemic” • In 1999 fewer than 3000 prescription opioid deaths* • By 2008 there were nearly 15,000 opioid deaths* Office of National Drug Control Policy PaulozziPharmacoepidemiol Drug Saf. 2006;15:618-627 *National Vital Statistic Reports Vol 58 no 19;2010 *Paulozzi. MMWR, CDC Nov 1, 2011 vol 60

  9. Results of Pain Aversive Culture • Prescription drug overdose is the second leading cause of injury death after car accidents nationwide • Deaths from prescription opiate overdose outnumber deaths from cocaine and heroine combined • Increased prevalence of pills available to the public • More interactions, abuse, diversion, addiction Warner et al. NCHS data brief #81. Natl Center for Health Statistics, 2011 Paulozzi. MMWR, CDC. Nov 1, 2011, vol 60

  10. What this means for Oregon • Highest rate of prescription opiate abuse age 18-25 • Fifth highest overall rate of prescription opiate abuse • In past few years more Oregonians died of prescription overdoses than car accidents* • Substance abuse costs Oregon $5.9 billion/year** Oregon State Attorney General’s Office *CDC Natl Vital Statistics Reports Vol 58:19, 2007 **2009-2011 Domino Effect II Report, Legislative Assembly and Governors Council on Alcohol and Drug Abuse Programs

  11. Pressure to Prescribe • We clinicians want to improve pain control • Federal recommendations to treat pain more aggressively • Federal reimbursement to be linked to satisfaction data • Without regard to outcome data or safety data • Increased direct consumer pharmaceutical marketing • Positive feedback cycle: More opiate use/dependence results in more specific requests for opiates • We prescribe more opiates now than ever before in history

  12. American Culture • Americans are 4.6% of the worlds population • We consume 80% of the global opiate supply • We consume 99% of global hydromorphone • We consume 67% of worldwide illicit drugs • It is statistically impossible that we as a society have so much more pain than the rest of the world Paulozzi. MMWR. CDC. Nov 1, 2011, vol 60 USDOJ/DEA www.deadiversion.usdoj.gov/arcos/index.html

  13. U.S. Opiate Sales • Opiate analgesic sales have quadrupled over the last decade (1999-2010) • Individuals with chronic pain have had a 740% increase in milligram morphine equivalents daily prescribed from 1997 to 2010 • This translates to an increase from 96 mg MSO4 equivalents/day to 710 mg MSO4 equivalents/day on average for each chronic pain sufferer Manchikanti. Pain Physician. 2008 Mar;11(2 suppl): S63-88

  14. http://www.ncsl.org/issues-research/health/drug-overdose-death-rate-postcard.aspxhttp://www.ncsl.org/issues-research/health/drug-overdose-death-rate-postcard.aspx

  15. Death rates parallel sales Source: National Vital Statistics System & Drug Enforcement Administration, ARCOS

  16. Office of National Drug Control Policy, 2011 • Current Focus is on: • Education: directed at parents and youths • Dangers of abuse, proper storage and use • Monitoring: electronic monitoring programs • Disposal: develop drug disposal locations • Enforcement: improve law enforcement resources • Notably absent is physician education, awareness

  17. State and Local Involvement • FDA proposes (REMS) Risk Evaluation and Mitigation Strategy • State Drug Prescription Monitoring Programs • Exist in 37 states. Established in Oregon 2011. • Specialty and State Consensus Guidelines • ACEP policy recommends judicious use of opiates and utilization of electronic drug monitoring programs DHHS, FDA Federal Register. Nov 7, 2011, 76. 68766-68767 ACEP Policy. Optimizing Pain… Ann Emerg Med. 2010;56:77-79 ACEP Policy. Electronic prescription monitoring. Ann Emerg Med. March 2012

  18. The Buck Stops Here! • Each day nearly 100 Americans die from prescription opiate overdose • This is a 300% increase in the past 8 years • These medications are by prescription only • We are prescribing them • These deaths are iatrogenic • Not a single death has been attributed to pain US DHHS, CDC 2010 www.wonder.cdc.gov Natl Center Health Stats 2009 www.cdc.gov/nchs/data/databrifs/db22.htm

  19. Impact on Public Health • 1.2 million Emergency visits due to misuse or abuse of prescription pharmaceuticals in 2009 • Compared to 1.0 million visits from illicit drugs • Increased ED utilization by 98.4% from 2004 • Prescription opiates are frequently diverted or sold for non-medical use by patients or their friends • Nonmedical use of opiates cost insurance $72.5 billion annually in health care costs www.oas.samhsa.gov/2k10/dawn034/edhighlights.htm www.oas.samhsa.gov/nsduh/2k9nsduh/2k9resultsp.pdf www.insurancefraud.org/downloads/drugDiversion.pdf

  20. Here is the Challenge • Ensure the best quality of care for patients with pain • Balance “Do No Harm” with “Pain Control” • Do this in the greater context of epidemic prescription opiate abuse and overdose deaths • Challenge is to limit opportunities for abuse without reducing access for those in need of help • How can we do this?

  21. How to control pain and manage an epidemic? • Utilize non-opiate adjuvants for pain • Talk with your patients about opiates • Hold your patients accountable for their medication • Reduce the overall number of pills available in society for diversion • Focus on Reasonable care!

  22. Have a written policy

  23. Oregon Prescription Drug Monitoring Program

  24. Oregon Prescription Drug Monitoring Program

  25. Care Management Plans • Identify those with frequent needs • Identify cause of frequent needs • Develop Action Plan: Standardization • When and how to use urine screening • When and how to use pain contracts • Proper use of state drug monitoring programs • Criteria to decide how long patients should receive opioid analgesics • Criteria to decide when to refill or discontinue

  26. Red Flags • Frequent or Recurrent visits with “pain” • Especially with negative findings • Allergy Lists • “Everything but” allergies • Allergy to Agonist/Antagonist • Pentazocine (Talwin), Butorphanol (Stadol), Buprenorphin (Subutex, Suboxone) • More concerned with Rx than Symptoms • Behavior out of proportion to exam findings

  27. Physician Education • DEA Licensure is individual • Physicians choice in prescribing • Patients with objective painful findings deserve proper analgesia • Education to focus on “reasonable care” • Sprains, strains  NSAIDS • Most non-cancer pain without clear objective findings should not receive opiates on initial presentation

  28. Acute Back Pain • Proper HPI, Exam, Testing • NSAIDS • Muscle Relaxants • Steroids for radicular symptoms • Early activity/return to work • Physical therapy, ROM exercises, proper body mechanics • Avoid opiates for acute pain !

  29. Opiates are detrimental • There exists a clear association between early opioid use (<6 weeks) for acute Low Back Pain and poor outcomes • Longer disability duration, higher medical costs • >8000 patients with 2 year follow up • Disabled 69 days longer, had 3 x increased surgery rate, had double the disability rate at 1 year • Authors conclude that “it is suggested that the use of opioids for the management of acute low back pain may be counterproductive to recovery” Spine 2007, Sept 1; 32(19):2127-2132.

  30. Back Pain Guidelines • Medical workup seeking objective findings/etiology • Grade A recommendations (quality evidence) • Stay active, early return to work, APAP, NSAIDS • Grade B recommendations (some evidence) • Reassure, set expectations (90% improve in 6 wks) • Grade C recommendations (consensus, opinion) • Ice, topical NSAIDS, exercises J FamPract. 2009 Dec; 58(12):E1.

  31. Acute Headache • What has been shown to reduce symptoms • NSAIDs, triptans, ergot alkaloids, compazine, barbiturates, opiates, parenteral medications • Marginal evidence • IV fluids, Steroids • What hasn’t been shown to help • Zofran, phenergan, reglan, benzodiazepines • Rebound headaches associated with opiates American Academy of Neurology, Headache Consortium, Guidelines

  32. Acute Headache Treatment • Compazine 10 mg IV + Toradol 30 mg IV • Droperidol(Inapsine) 1.25 mg IV • Olanzepine (Zyprexa) 10 mg ODT • With single dose of PO Zyprexa 85% of severe headaches resolved in 1 hour AcadEmerg Med. 2008 Sept;15(9):806-811. J Emerg Med. 2011 Oct; 41(4):389-396.

  33. Dental Pain • Multiple medical societies agree that Dental pain is best treated by a dentist! • PCN, clindamycin • NSAIDs • Nerve blocks are effective but short lived • Neuropathic agents may be attempted • Set limits on opiates if given! • Insist they see a dentist

  34. Neuropathic Pain • Acute neuropathic radicular pain should receive an initial trial of steroids • Medrol dose pakand NSAIDS • With spasms? Add muscle relaxant • Most neuropathic medications are for chronic management and don’t work well for acute pain exacerbations • Gabapentin (Neurontin) • Pregabalin (Lyrica) • Venlafaxine (Effexor)

  35. Neuropathic Pain • Opiates do not control neuropathic pain • Most reach critical sedation while still reporting uncontrolled pain • Try amitriptyline 25 mg PO for acute pain • May be prescribed as outpatient with qhs dosing • Avoid outpatient Rx in patients with overdose risk, depression, prior prescription misuse/abuse • Talk with patient about dangers of TCAs with overdose !

  36. Acute Exacerbation of Chronic Pain • This is NOT considered to be ACUTE • This is a manifestation of chronic pain • Have you had this before, “Not like this!” • Some have “run out of medicines” • Not an Emergency, wont get a refill anymore • Personal responsibility (social not medical) • Most have “cabinet full of pills” • Try adjusting the existing medications

  37. The IRON ED Institutional Reduction of Outpatient Narcotics from the Emergency Department • Letter mailed to all MDs to inform of new policy • ED will only treat ACUTE pain with outpatient Rx • Emphasis on primary provider as single point of ongoing narcotic access

  38. Our Experience • 2 years of IRON ED • Press Ganey scores same or higher • ED MDs report greater job satisfaction • Less confrontation regarding prescriptions • Over 60% reduction in prescribed opiates

  39. Thank YouRumm Morag M.D.rmorag@hotmail.com

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