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Evidence-Based Chronic Pain Management: How Well Do Physicians Do It?

Evidence-Based Chronic Pain Management: How Well Do Physicians Do It?. Barbara J Turner MD, MSED Mahlon H. Delp Lecture September 11, 2009 . Chronic Non-Cancer Pain Management. Pain in community and primary care settings Efficacy of opioids for chronic non-cancer pain care

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Evidence-Based Chronic Pain Management: How Well Do Physicians Do It?

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  1. Evidence-Based Chronic Pain Management: How Well Do Physicians Do It? Barbara J Turner MD, MSED Mahlon H. Delp Lecture September 11, 2009

  2. Chronic Non-Cancer Pain Management • Pain in community and primary care settings • Efficacy of opioids for chronic non-cancer pain care • Side effects of opioids • Misuse and death • Reducing misuse • Disparities in use of opioids for pain • Opportunities to improve our care

  3. Prevalence of Chronic Pain • Community-based and primary care population-based surveys • 10-15% of respondents report chronic pain Smith BH, Fam Pract,2001 Hardt J, Pain Med. 2008 • Four-year follow-up survey of 2,200 U.K. primary care patients with chronic pain at baseline • 79% still had constant or frequent pain Elliott AM, Pain, 2002

  4. Efficacy for Chronic Back Pain • Systematic review • 5 trials with different opioid regimens • Assess change in pain from baseline • Reduction in pain, P =0.055 • Limitations • <16 weeks duration • Disparate opioid regimens • Generally moderate opioid doses Martell B, Ann Intern Med, 2007 Deshpande A. Cochrane Database Syst Rev. 2007

  5. Efficacy for Neuropathic Pain • Meta-analysis of 8 studies of opioid therapy (all long-acting) versus placebo • Mean duration of therapy 28 d, range 8-56) • Pain intensity 14 units lower (scale 0-100) after opioids (P<.001) • Limted long-term studies Eisenberg E, JAMA. 2005

  6. Side Effects of Opioids • Number Needed to Harm (NNH) • Nausea (3.6; 95% CI, 2.9-4.8) or 21% in 34 trials • Constipation (4.6; 95% CI, 3.4-7.1) or 15% • Drowsiness (5.3; 95% CI, 3.7-8.3) • Vomiting (6.2; 95% CI, 4.6-11.1) • Dizziness (6.7; 95% CI, 4.8-10.0) • 34 arthritis clinical trials <4 weeks, 22% of subjects withdrew due to side effects Eisenberg, E. JAMA, 2005 Moore RA, McQuay HJ. Arthritis Res Ther, 2005

  7. Withdrawal Effects of Opioid Analgesics • Physical dependence expected • Anhedonia during early withdrawal (mesocorticolimbic system) • Withdrawal hyperalgesia (pain systems) • Physical effects of withdrawal (upregulation of cAMP in locus ceruleus and other locations) • Yawning, sweating, lacrimation, rhinorrhea, anxiety, restlessness, insomnia, dilated pupils, piloerection, chills, tachycardia, hypertension, nausea/vomiting, cramping abdominal pains, diarrhea, and muscle aches and pains

  8. Dilemma: Misuse • Systematic review of prevalence of current aberrant behaviors with chronic non-cancer pain (CNCP) treated with opioids • 5 to 24% in 5 studies in diverse settings • Study quality fair-poor • 900 primary care patients with CNCP, 80% admitted to ever using opioids aberrantly • ask for early refills (42%); • take more medication than prescribed (35.7%); and • feel intoxicated from opioids (32.2%) Fleming MF, Pain Med, 2008 Martell B, Ann Intern Med, 2007

  9. Annual Sales of Prescription Opioids and Unintentional Overdose Death1990 - 2006 Source: Paulozzi, CDC, Congressional testimony, 2007

  10. Dilemma: Overdose Deaths • Of drug overdose deaths in W VA in 2006 • Prescribed opioids contributed to >90% • 56% had no record of being prescribed opioids • 20% were doctor shopping for opioid prescriptions Hall AJ, JAMA, 2009 • Editorial recommends treating pain but monitoring • Urine drug screening • Prescription monitoring programs McLellan & Turner, JAMA, 2009

  11. Use of Methods to Monitor/ Reduce Misuse in Primary Care • Urine drug screen • Two studies, 2 to 18% of patients on chronic opioids • Six studies, 8 to 30% of MDs report ever ordering to monitor chronic opioid therapy • Opioid prescription agreement (contract) • Two studies, 27 to 39% of patients on opioids in academic practices Starrels J, SGIM Annual Meeting, 2009

  12. Evidence that These Methods Reduce Misuse • Systematic review of urine drug screens and opioid prescription agreements • Two good quality, prospective studies in VA primary care settings • Opioid agreements + other monitoring methods significantly reduced misuse by 40-50% • Two moderate quality, chart review studies in pain centers • Urine screen + opioid agreements had small but significant reductions in misuse Starrels J, SGIM Annual Meeting, 2009

  13. Set Up for Disparities in Care • Evidence of benefits not strong, controversy increases variations in care • Drugs have street value • Equi-analgesic doses of generic MS vs OxyContin • 30 day supply $42 vs $723 • Patients can become dependent or die • Physicians can go to jail • Understandably reluctant to take risks

  14. Disparity in Physicians’Management of Pain • Pain-related care accounted for 42% of US ED visits over a 13 year period, opioid Rx increased from 23% (1993) to 37% (2005) of these visits • White patients with pain more likely to receive an opioid (31%) than black (23%) (AOR 0.66; 95%CI, 0.62-0.70) • Physicians nearly twice as likely to underestimate pain in black than white patients (OR = 1.92; 95% CI: 1.31-2.81) Pletcher MJ, JAMA, 2008 Staton LJ, Natl Med Assoc, 2007

  15. Disparities in Primary Care Settings • 400 primary care patients with CNCP • Blacks higher on 10 point pain measure (6.7) than whites (5.6) (p<0.001) • White patients more likely to be prescribed opioid analgesics than blacks (45.7 vs 32.2%, P=0.006) • AOR = 2.67, 95%CI 1.71-4.15 • Adjusting for pain level & duration, age, gender, insurance, education, depression, work hours, disability, PT • Other aspects of pain care similar Chen I, JGIM, 2005

  16. Our Research Question • Are there racial differences in chronic opioid treatment management/ monitoring? • Urine drug screening • Limiting early refills (i.e. less 2 more than one week early) • Office visit monitoring (i.e. at least every 6 months) • New opioid or stronger dose followed by a visit within one month Becker W, SGIM Annual Meeting, 2009

  17. Study Data • Electronic medical records for 6 Penn primary care practices • 4 general medicine, 1 family medicine, 1 geriatrics • Timeframe: 1/1/2004 to 7/1/08 • Demographics, clinical data (recorded diagnoses), tobacco use, prescriptions • Linked administrative data on emergency room visits and hospitalizations

  18. Study Population • Patients aged 18+ • Opioid prescription and 3+ visits from 1/1/2004 to 12/31/074,217 • 3+ opioid Rxes 21d apart within 6 mos not Tramadol 2,153 • Musculoskeletal/neuropathic pain 1,944 • No cancer but can have skin or inactive prostate cancer 1,657 • Exclude race other than white or black 1,626

  19. Demographic and Clinical Conditions by Race

  20. More Clinical Conditions by Race

  21. Monitoring and Health Care Outcomes * P<0.001

  22. Opioid Treatment by Race

  23. Adjusted* Association of Black Race with Outcomes Opioid change – no visit No visit in 6 months Urine drug screen 2+ early refills 3.35 0.5 1 1.5 2.0 Adjusted Odds *Demographics, clinical, duration of opioid use, type of opioids

  24. Possible Physician-Related Reasons for Disparities • Distrust • But no adjusted association of race with misuse Turk DC Clin J Pain. 2008;Ives TJBMC Health Serv Res. 2006 • Fear of confrontation • National primary care MD survey (N=400) • Vignettes (w pictures) differed by race • Challenging patients (e.g., demands a specific narcotic, exhibits anger) vs. more stoic patients • Challenging blacks 2x more likely to receive opioids than whitesBurgess DJ, Soc Sci Med. 2008

  25. Universal Precautions in Pain Management • Diagnosis with appropriate differential • Assess risk of misuse (hx of alcohol or drug use, mental health disorder) • Risks and benefits of opioids, alternatives • Treatment agreement • Trial of opioid therapy (not alone) • Monitoring for misuse on a regular basis • Assess impact on pain and function Gourlay DL, Pain Med 2005;6:107-112.

  26. Goal-Directed Opioid Agreement • Agreement needs to define: • use/refill guidelines; • follow-up guidelines; • single prescriber/pharmacy; • no use of illicit drugs or diversion; • safe storage; • urine screen; • prescription monitoring program (some states) • Goal-directed: if pain/physical function/quality of life is still unchanged after a specified period of increasing dosage of opioids, consider stopping • Multi-modality treatment Hariharan J et al JGIM 2007;22:485–490 Von Korff M, Clin J Pain 2008;24:521–527

  27. Alternative/ Adjunctive Pain Management • Non-narcotic pain medication • Anti-spasmotics • Lidocaine patch • Anti-depressants • Anti-convulsant • Chiropractic care • Physical therapy • Steriod injections • Surgery

  28. Four ‘A’s of Pain Medicine • Analgesia • Activity (functional status) • Adverse reactions • Aberrant behaviors

  29. Summary • Chronic pain common, increasing use of opioid analgesics • Limited evidence for benefit of long-term opioid treatment • Risks – side effects, misuse, overdose, death • Disparities in monitoring practices • Need to adopt standards to monitor • Use multiple pain management strategies

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