CHALLENGES OF OPIATE
TREATMENT INITIATION
Grace Gallardo, MD
Board Certified Family Practice
Private practice , Oklahoma Pain
Center Oklahoma City
Disclosures
• Speaker, Endo Pharmaceuticals
Risk Assessment
•
•
Forms, tools, “Gut Feeling”
Questionnaire with Score System:
– Family and Personal history of:
• Alcohol abuse
• Illegal drug use
• Prescription drug abuse
– Mental Health diagnosis
• ADD, bipolar, depression, schizophrenia
– Age
• Between 16-45
– History of preadolescent sexual abuse
Adapted from Webster, LR and Webster, RM, Pain Med
Impact of Pain, Stratification Tools
•
•
•
•
•
•
Lifestyle decline
Social withdrawal
Depression
Cognitive decline
Quit working
Deterioration of family relationships
Ready-Set-Go!!
• Focus on function from the beginning
• Set realistic expectations
• Do not start if you are not comfortable
discontinuing
• Avoid polarizing
“I believe or do not believe in opiate treatment”, or
“I am pro-con opiate treatment”, should be neither
a metaphysical nor a political vision or position.
Remember
• Opiates do not work for all pain conditions
• They may not work for every patient
• Not every patient is a candidate
• Monitor closely for side effects
– response may involve discontinuation or opiate rotation
DEFINE RISKS vs. BENEFITS
What Do I Need
• Understand Federal and State Laws
• Good history & physical, previous treatments,
specialist visits, imaging/diagnostic tests
• Look at medication list carefully
– Special focus on sedatives and hypnotics
• Patient education
– Discuss risks and benefits
– Side effects and realistic goals to therapy
– Informed narcotic consent.
…and more
• Periodic reassessment
• Monitoring tools
– Prescription Monitoring Program (PMP)
– Urine Drug Screens
– Pill counts (scheduled and random)
• Across the board, no exceptions!
Opiates, the Good
• Improved function
– Back to work or longer hours
– Improved productivity
– Better care of family
– Improved relationships
– Better sleep
• Decrease in complaints
– more hopeful attitude
– Minimal or controllable side effects
Opiates, the feared
•
•
•
•
•
•
•
Abuse, misuse, diversion, addiction
Tolerance and dependency
Impaired sleep patterns
Negative impact on mood, personality, behavior
Hyperalgesia
Immune system suppression
Delay in functional improvement
...and more
• No precise data exists on rates of
addiction and misuse in patients with
Longitudinal Opiate Therapy who are
legitimately prescribed opiates.
• As prescribers, we need to take
responsibility in understanding the impact
of Opiate Abuse in the community .
Miscellaneous and Pearls
• Consequences of pain and excessive opiate doses
can be difficult to discern.
• Sometimes there is a fine blurry line between use
and misuse, listen to what patient says:
– “I can do more when I take my pain pill, it keeps me
going”. This should raise a concern for stimulant effect
and/or euphoric effect of medication which may lead to
misuse.
– “It helps me sleep”
– “I hurt more because of family or other stressors so I
need more medication”
…and more
• “One more pill and I will be fine” - likely this
patient is relying on opiates for their entire pain
treatment, not coping with pain, and probably
has declining function despite opiate use.
• Lots of denial, rationalization and fear found in
these patients, anxiety arouses or worsens.
• Keep in mind the high variability in patient
response to different opiate treatments, in
effectiveness, and to side effects.
Almost There
• Keep in mind that curves of development of tolerance of pain
control and to side effects do not run parallel, the first one
grows faster.
• Remember that there is an incomplete cross- tolerance
between opiates, always decrease the total daily dose by 2550% when bridging from one opiate to another. Go Slowly.
• Age consideration
– Young - higher risk of abuse, misuse, diversion and addiction
– Elderly- higher incidence of organ failure and frailty.
• Involve the family. Ask the patient to bring them to the visit.
• Up is not always the way to go!!!! May be the fastest though;
stop and think.
Why Are They Abused
• Opiates target the reward system, especially the
dopamine system.
• Results in uncontrollable, unconscious,
impulsive behavior.
• Be vigilant: a large subset of the population is
vulnerable to potential abuse.
References
• www.wix.com/sssanbar/tulsa-pain, great
website.
• Fishman Scott, 2012, Responsible Opiate
Prescribing, 07-83.
• Waldman Steven,2009, Pain Review, 667-675.
And sometimes things can go wrong,
but it’s worth the challenge.