Brenda Lau MD, FRCPC, FFPMANZCA, MM

Learning Objectives
 Incorporate the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain and apply elements into a busy practice
 Help you effectively utilize supporting tools such as the
›
Brief Pain Inventory (BPI) and the
›
Opioid Risk Tool (ORT), and
 Implement improved opioid monitoring practices, including documenting the
› 6 A’s and using the Opioid Manager*
›
Weaning guidelines
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The Canadian Guideline for Safe and Effective
Use of Opioids for Chronic Non-Cancer Pain
 What is it?
›
An evidence-based guideline with 24 recommendations outlining how to use opioids to treat patients with CNCP
 Why was it developed?
›
Existing treatment information and guidelines were found to be outdated
 Why was it necessary?
›
To improve the safety and care of CNCP patients being treated with opioids, and to safely manage potential side effects (including addiction) and the risk of opioid misuse http://nationalpaincentre.mcmaster.ca/opioid/ ,
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The Canadian Guideline for Safe and Effective
Use of Opioids for Chronic Non-Cancer Pain
 Available at: http://nationalpaincentre.mcmaster.ca/opioid/
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The Canadian Guideline for Safe and Effective
Use of Opioids for Chronic Non-Cancer Pain
CNCP = Chronic Non-Cancer Pain
*Courtesy of: “Toronto Rehabilitation Institute” Available at: http://nationalpaincentre.mcmaster.ca/opioid/
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Effects of Chronic Pain on the Patient
Physical
Functioning
Mobility
Impaired Immununity
Sleep disturbances
Fatigue
Loss of appetite
Social Functioning
Diminished social relationships (family/friends)
Decreased sexual function/intimacy
Decreased recreational and social activities
Moods
Depression
Anxiety
Anger
Irritability
Societal
Consequences
Health care utilization
Disability
Loss of work days or employment
Substance abuse
Ashburn MA, et al. Lancet. 1999;353:1865-1869. Harden RN. Clin J Pain. 2000;16:S26-S32.
Agency for Health Care Policy and Research. Clinical Practice Guideline No. 9. 1994. Meyer-Rosberg, K et al. Eur J Pain. 2001;5:379-389.
Zelman D, et al. J Pain. 2004;5:114. Manchikanti L, et al. J Ky Med Assoc. 2005;103:55-62. Hoffman NG, et al. Int J Addict. 1995;30:919-927.
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Deciding to Initiate Opioid Therapy – Cluster 1
 Pain is moderate to severe
 Pain has significant impact on function and QOL
 Non-opioid pharmacotherapy has been tried and failed
 Opioids indicated for specific pain condition
 Opioid risk assessment has been done & documented
 Informed consent (goals, risks, benefits, AEs, complications …)
 Patient agreeable to have opioid use closely monitored (UDS, treatment agreement, freedom of information …)
 Responsible prescribing of opioids
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Opioid Risk Tool & Checklist
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Universal Precautions in Pain Medicine
1.
Diagnosis with appropriate differential
2.
Psychological assessment
›
Including risk of addictive disorders
3.
Informed consent
›
Verbal v. written/signed
4.
Treatment agreement
›
Verbal v. written/signed
5.
Pre trial assessment of pain/function and goals
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Content of a Treatment Agreement
 One prescriber (include name)
 One dispensing pharmacy (include name)
 Will comply with safe/secured storage of opioid; Will comply with no driving while titrating
 No sharing/selling of opioid; No accepting of any opioid medications from anyone else
 Will not change the dose or frequency of taking the medication without consulting the doctor
 Strict rules with respect to medication loss, early refills, possible abuse or diversion
(e.g. Dr._________ will not prescribe extra medication for me. I will have to wait until the next prescription is due.)
 Strict rules with respect to concomitant usage of other sedating medications, OTC/prescription opioids, recreational drugs (e.g. 222’s, Tylenol® #1 …)
 Will comply with scheduled office visits and consultations
 Will comply with pill/patch counts and random UDS when requested, and with limited quantity of opioid dispensed per prescription
 Adverse effects, medical complications and risks (including addiction) of opioids understood
 Freedom of information permitted
 Understanding and agreement that if there is no demonstrable improvement in functionality, the physician reserves the right to wean patient off his/her opioid medications.
 Understanding that if these conditions are broken, Dr. _______ may choose to cease writing opioid prescriptions for me
Patient’s Signature
Physician’s Signature
Date
Date 10

Universal Precautions in Pain Medicine
6.
Appropriate trial of opioid therapy
›
+/- adjuvants
›
Replace short-acting opioid with long-acting opioid at equivalent dose
›
Limit the number of pills/patches that a patient may have at one time
7.
Reassessment of pain score and level of function
8.
Regular assess the “Six A’s” of pain medicine
›
Analgesia
›
Activities
›
Adverse effects
›
Ambiguous drug taking behaviur
›
Accurate medication record
›
Affect
9.
Periodically review Pain Diagnosis and co morbid conditions including addictive disorders
10.
DOCUMENT, DOCUMENT, DOCUMENT (Passik 2000)
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Conducting an Opioid Trial Summary – Cluster 2
 Start low, go slow
› Titrate to “optimal dose”
›
Remember safety issues when selecting opioids, including altered pharmacokinetics (e.g. liver/kidney) &/or drug interactions
› Comprehensive review before nearing the “watchful dose”
 Document progress / opioid effectiveness
 Monitor adverse effects, medical complications, risks
›
Opioid Manager*
› 6 A’s
 If risks outweigh benefits, then: switch, taper ± discontinue
*Courtesy of: “Toronto Rehabilitation Institute” Available at: http://nationalpaincentre.mcmaster.ca/opioid/.
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Opioid Manager
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Goals Guide Treatment Options
Psychological
Chronic pain self-management programs
Goals
Physical / Rehabilitative
Complementary and
Alternative Medicine
Medical
Pharmacological
Interventional
Adapted from Jovey RD, 2008
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The Analgesic Toolbox
Nonopioid
Opioid
Acetaminophen, ASA, COXIB, NSAID
Buprenorphine transdermal system, codeine, fentanyl transdermal system, hydromorphone, morphine, oxycodone, tramadol
Choice exists between IR (immediate release) and
CR (controlled release) formulations for many agents
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Basis for Opioid Selection
Selection Criteria:
Current /past efficacy and side effect profile of short-acting opioid
Convenience and compliance potential
Cost (coverage by drug plan or ability to pay)
Patient preference
History of abuse/misuse/diversion (screen)
Concomitant health conditions necessitating adjustments in dosage and/or dosing interval of some opioids (e.g., morphine or codeine in renal failure)
Compromised oral route
Evidence of molecule efficacy for different pain characteristics
Chou R et al, 2009; Gardiner-Nix; Wisconsin Medical Journal, 2004 ; Jovey RD et al, 2002 16

Opioids: Initial Dose and Titration
Opioid Start
Dose
Convert to CR when reaching
Minimum time interval for increase
Codeine
CR Codeine
15-30mg q4h
50mg q12h
Tramadol +
Tylenol
1 tab q4-6h prn
(4/d)
CR Tramadol Zytram XL
150mg
Tridural 100mg
Ralivia 100mg
IR Morphine
100mg daily
3 tabs
5-10mg q4h prn up to 40mg /d
20-30mg
1 week
2 days
1 week
1 week
2 days
5 days
1 week
Suggested dose increase
(max)
15-30mg/day
(600mg/d)
50mg/d
(300mg q12h)
1-2 tab q4-6h prn
(8/d)
(400mg/d)
(300mg/d)
(300mg/d)
5-10mg/d
CR Morphine 10-30 mg q12h Min 2 d 5-10mg/d
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Opioids: Initial Dose and Titration
Opioid Start
Dose
Convert to CR when reaching
Minimum time interval for increase
Suggested dose increase
(max)
IR Oxycodone 5-10mg q6h prn up to
30mg/d
CR Oxycodone 10-20mg q12h up to 30mg/d
20mg daily 1 week
Min 2 days
5mg/day
10mg/d
IR
Hydromorphone
CR
Hydromorphone
OROS
Hydromorphone
1-2mg q4-6h prn up to
8mg/d
3mg q12h up to 9mg/d
8mg OD
6mg
Maalis-Gagnon, Elafi Altlas 2010
1 week
2 days
1-2 mg/d
Min 2 days 2-4mg/d
25-100% of starting dose
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PO Opioid Analgesic Equivalence table
Morphine
Codeine
Oxycodone
10mg
60mg
7.5mg
(O:M= 2:1 acute
1.5:1 chronic)
Hydromorphone
Meperidine
Methadone
Transdermal fentanyl
2mg(H:M=5:1)
100mg
Variable
25ug/h = 60-134 mg
37ug/h = 135-179mg
50ug/h = 180-224mg
62ug/h = 225-269mg
75ug/h = 270-314mg
100ug/h = 360-404mg
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When to Stop Opioid Therapy
When patient:
 Does not realize meaningful pain relief from therapy
 Has adverse reactions to opioids, such as depression or respiratory depression
 Does not achieve reasonable therapeutic goals such as improved physical or social functioning, even with effective pain relief
Ballantyne JC et al, 2003; Benyamin R et al, 2008; Chou R et al, 2009; Porreca F et al,2009; Slatkin NE, 2009
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Tapering Opioid Therapy
 Discuss with the patient and other responsible persons who may be helpful. Patients with aberrant behaviour or addiction may refuse to comply and leave treatment, seeking opioids elsewhere.
›
Controlled withdrawal from opioids is not dangerous
›
May experience discomfort, anxiety, restlessness, nausea, sweating, etc.
 Reassure patient of alternative plan for pain control.
 Document discussions and provide a written treatment plan
 If the patient is taking a sedative or benzodiazepine, these should be maintained
Ballantyne JC et al, 2003; Chou R et al, 2009 21

Key Learning Points
 2010 National Opioid Use Guidelines (NOUG) serve to improve the responsible use of opioids in Canada
 When considering the use of long-term opioid therapy, screening for addiction risk must be a part of the assessment process
 Improvement in function as measured with the BPI is a key factor supporting the continuation of CR opioids in CNCP
 Management of CNCP is multi-modal using non-opioid medications, interventional techniques and self-management strategies.
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Questions?