MPhA MTM Fall Symposium
Kathryn Perrotta, PharmD, MBA, BCPS
November 16, 2012




Define the health economic impact of the use of
opioid analgesics in the treatment of pain
Apply evidence based guidelines in moderate to
severe chronic non-cancer pain management
Address abuse, misuse and diversion reduction
strategies (proper disposal options and PMP)
Explore the role of ambulatory care pharmacists
in primary care pain management and
opportunities for collaboration with other
professionals in the health care team

Concern: significant increase in opioid
prescriptions

Sales of opioids quadrupled between 1999 and
2010 (government statistics)

The annual cost associated with all types of pain,
both direct and indirect costs, is estimated to be
in the range of $560 to $635 billion annually in
the United States
Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United
States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.


~60 million Americans have some type of
chronic nonmalignant pain
~40% of patients do NOT receive
adequate pain relief



Detailed History
◦ Onset, duration, quality, character of pain
◦ Ameliorating and provoking factors
Pain Rating
◦ Patient self report: most reliable indicator of pain
◦ Numerous assessment tools available for pain in
adults
 Numeric rating scales (1-10)
Assessment
◦ Is pain due to reversible etiology?
◦ Identify cause of pain
 Reason for specialist?
 Rheumatoid arthritis, knee pain, headache,
etc.

Acute vs. Chronic Pain
◦ Has pain persisted longer than 6 weeks?
 IAP defines chronic pain as “pain that persists
beyond normal tissue healing time, which is
assumed to be 3 months”

Determine Pain Mechanism (3 general types)
◦ Somatic
◦ Visceral
◦ Neuropathic
 Different symptoms
 Different treatment indicated
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of
Chronic Pain Guidelines. Fifth Edition, November 2011.



Result of tissue damage
Release of chemicals from injured cells that
mediate pain and inflammation via nociceptors
Typically recent onset and well localized
Description of Somatic
Pain
Sharp
Aching
Stabbing
Throbbing
Examples
Lacerations
Sprains
Fractures
Dislocations
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain
Guidelines. Fifth Edition, November 2011.


Result from visceral nociception
◦ Solid and Hollow organs
Fewer nociceptors
◦ Result in poorly localized, diffuse and vague
complaints
Description of Visceral Pain
Examples
Generalized ache/pressure
Autonomic symptoms:
Ischemia/necrosis
Ligamentous stretching
Hollow viscous or organ
capsule distension
N/V, hypotension,
bradycardia, sweating
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of
Chronic Pain Guidelines. Fifth Edition, November 2011.


Injury to a neural structure leading to
aberrant processing
Typically chronic pain caused by damage to
peripheral nerves
Description of Neuropathic
Pain
Radiating
Burning
Tingling
“Electrical Like”
www.icsi.org
Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines
Examples
Diabetes
Shingles
MS
Herniated discs
From radiation/chemo



Determine Patient’s Pain Goals
◦ If chronic pain patient may need to counsel on
expectations of pain relief
◦ Assess for risk of substance abuse, misuse, or
addiction
Avoid Unrealistic Expectations in Chronic Pain
Patients
◦ Improvement with opioids generally average < 2-3
points on average 0-10 scale
◦ Concentrate on quality of life and improving
therapeutic goals
Stress importance of utilizing other modalities
◦ Medications that are multi-modal in treating pain
 Alternative therapies
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic
Pain Guidelines. Fifth Edition, November 2011.
Somatic Pain
Visceral Pain
Neuropathic
Pain
•acetaminophen
•cold packs
•corticosteroids
•lidocaine
patches
•NSAIDs
•opioids
•tactile
stimulation
•corticosteroids
•intraspinal local
anesthetic
•NSAIDs
•opioids
•gabapentin
•pregabalin
•corticosteroids
•neural
blockade
•NSAIDs
•opioids
•TCAs
•duloxetine
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of
Chronic Pain Guidelines. Fifth Edition, November 2011.
3.
Perception
of Pain
McCaffery M, Pasero C. Pain Clinical
Manual. 1999:21.
Ascendin
g
input
Spinothalamic
tract
Opioids
2 -agonists
Pain
Centrally acting analgesics
Anti-inflammatory agents (COX-2
selective inhibitors, nonselective
NSAIDs
Descending
Local anesthetics
modulation
Opioids
Dorsal
2-agonists
horn
COX-2 selective
Dorsal root inhibitors
ganglion
Local anesthetics
Peripheral
nerve
Trauma
Peripheral
nociceptor
s
Opioids
Local anesthetics
Anti-inflammatory
agents (COX-2 selective
inhibitors, nonselective
NSAIDs)
Adapted by Dr. Todd Hess (United Pain Center) from Gottschalk et al. Am Fam Physician. 2001;63:1979-1984.
100
Repetitive
stimulation of
spinal neurons
evokes an
increasing level of
response
neuron response
80
60
40
20
0
|----0.5 Hz----|
NMDA receptor
antagonists block
this effect



Intense pain worsening over time
Causes: most frequently trauma to extremity or
surgery/infection
Pathophysiological mechanism of CRPS is ongoing
nociceptor input from periphery to CNS.
◦ Characterized by hyperalgesia, allodynia, vasomotor
changes, abnormal regulation of blood flow and sweating,
joint stiffness, localized skin edema

Treatment of CRPS can be difficult;
◦ Often misdiagnosed and can be irreversible if undiagnosed
◦ Recommended that combined analgesic regimens
(multimodal analgesia) be used to prevent CRPS
•
Reuben, S. Anesthesiology. 2004;101:1215-1224. Burns, A. J Orthop Surgery. 2006; 14(3):280-3.

A variety of different and integrated disciplines:
◦ Pharmacologic
 Complementary/synergistic mechanisms of
action to inhibit effects of pain mediators and
enhance the effects of pain modulation
 Non-opioids used in combination with opioids
can decrease the total amount of opioid
needed for pain control
◦

Acetaminophen

Cox-2s, NSAIDs

Modulating agents
◦ Duloxetine, TCAs, tramadol, etc.

Topical agents
◦ Lidocaine patches

Gabapentin
◦ neuropathic pain prevention and treatment

A variety of different and integrated disciplines:
◦ Non-Pharmacologic:
 Exercise
 Massage
 Acupuncture
 Reiki
 Cognitive Behavioral Therapy
 Physical Therapy
 TENS therapy

A)
B)
C)
Incomplete Cross tolerance of opioids:
A physiological phenomenon following use of
opioids for > 2 weeks
State of adaptation in which exposure to a
drug decreases its effect over time
Due to the different molecular entities of
opioids, a person on an opioid for a long
perioid of time will not be as tolerant to the
effects of a new opioid

Adjunctive Therapy Options

Assess if the opioid is right for patient
◦ Effectiveness
◦ Adverse Effects: N/V, puritis, constipation, respiratory
depression
◦ Renal metabolism/use in liver failure

Be aware of incomplete cross tolerance effect of
opioids
◦ Tolerance may develop to the opioid in use but may not be as
marked relative to other opioids
fentanyl
synthetic
to
non-synthetic
hydromorphone,
hydrocodone
oxycodone
morphine, codeine
Oxycodone
Hydromorphone
(Dilaudid)
Tramadol
Onset of
Action
(minutes)
10-15 (IR)
60-90 (CR)
15-30
60
Peak Response
1 hour
60-90 mins
2-3 hours
Duration of
Effect (hours)
4-6 (IR)
8-12 (CR)
4-6
4-6
Yes
Yes
Yes
Yes
Yes
Yes
Renal
Elimination
Prolonged in
Hepatic Failure
Opioid
Oral
Onset of action
Duration of Action
Codeine
200 mg
15-30 min
3-4 hrs
Hydrocodone
30 mg
15-30 min
4-8 hrs
Hydromorphone
7.5 mg
15-30 min
4-6 hrs
Methadone
Varies*
30-60 min
Varies
Morphine
30 mg
15-60 min
3-6 hrs
Morphine ER
30 mg
60-90 min
8-12 hrs
Oxycodone
20 mg
10-15 min
4-6 hrs
Oxycodone CR
20 mg
60-90 min
8-12 hrs
*Consult APS Guidelines
Hyperalgesia,
myoclonus
Morphine
liver
Analgesia
M-6-G, normorphine
M-3-G
kidney
Confusion,
Sedation,
Respiratory
Depression

Methadone

Clinical Aspects
◦ 1/3 of opioid related overdose deaths while only a
few percent of total opioid prescriptions
◦ Do NOT use for mild, acute or “break through pain”
◦ NOT for opioid naïve patients
◦ Long and unpredictable ½ life
◦ Multiple drug interactions
◦ QT prolongation
 ECG before starting and when doses >200mg/day
 Switching from another opioid: 70-90% reduction of
equianalgesic dose
Morbidity & Mortality Weekly Report. 2012;61(26):493-497. © 2012 Centers for
Disease Control and Prevention (CDC)

Transdermal system
◦ Onset of action: 12-18 hours, used Q 48 or 72 hrs
◦ Chronic, stable pain only
◦ Elimination after patch removal: 13-22 hrs
◦ Fever can result in up to 30% ↑ in drug levels
⊘ Heating pad or hot tub
◦ Not best option for catechetic pt weighing <50kg;
unpredictable absorption +/or elimination

Opioid Rotation: Change in opioid drug with the

Indications for Opioid Rotation:
goal of improving outcomes
◦
◦
◦
◦

Occurrence of intolerable adverse effects
Poor analgesia despite aggressive dose titration
Change in clinical status
Financial or drug availability consideration
Deciding Next Specific Opioid:
◦ Past experience with different opioids,
sensitivities, efficacy, etc.
Fine, G. Opioid Rotation: Definition and Indications. Pain Management Today eNewsletter series. American Pain
Foundation. , Quadrant HealthCom Inc. ; 2010: (1): 9. http://newsletter.qhc.com/JFP/JFP_pain032411.htm

Opioid Rotation Guidelines:
◦ Calculate equianalgesic dose of new opioid
◦ Identify automatic dose reduction of 25-50% lower than
calculated equianalgesic dose
 50% reduction if high current opioid dose, elderly, nonwhite, or frail
 25% reduction if patient not above
◦ Strategy to frequently assess initial response and titrate new
dose
◦ Supplemental “rescue” dose for prn: calculate 5-15% and
administer at appropriate interval
Fine, G. Opioid Rotation: Definition and Indications. Pain Management Today eNewsletter series. American Pain Foundation. , Quadrant HealthCom Inc. ; 2010: (1): 9.
http://newsletter.qhc.com/JFP/JFP_pain032411.htm
Standard
Opioid-PO
Opioid Parenteral
Hydrocodone 30mg
NA
Hydromorphone 7.5mg
Hydromorphone 1.5mg
Oxycodone 20mg
Methadone: Consult
Expert
Morphine 30mg
Morphine 10mg
American Pain Society (APS). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer
Pain, 6th edition. 2008. Glenview, IL 60025.
51 year old white female patient with chronic pain due to
MVA
Current Medications:
MS Contin 30mg TID
Hydrocodone/APAP 5/500 1-2 tabs qid prn
(patient states she take 6 tabs/day)
Atenolol 50mg qday
Senokot-S 1 tab bid
MD asks you to convert this patient to oxycodone due to
recent increased itching and ineffective control of pain.
1) Conversion:
Total oxycodone equivalent/day:
90mg morphine + 30mg hydrocodone
90mg morphine
=
30mg hydrocodone =
60mg oxycodone
+ 20mg oxycodone
80mg (total oxycodone dose)
2) Should we suggest the total oxycodone dose or
reduce?
2) Reduction of Dose:
Total oxycodone equivalent/day: 80mg
80mg x 0.25 = 20 mg so reducing by 25% the total
daily dose would be 60mg oxycodone
3) How do we want to give the oxycodone 60mg?
Slow versus immediate release?
3) How do we want to give the oxycodone 60mg?
◦
Oxycontin 15mg TID plus oxycodone 510mg tid prn (start with 5mg)
◦
Patient would be taking 45mg + 15-30mg =
60-75mg
◦
Could switch morphine to oxycodone, keep on
hydrocodone prn dose for first few days,
reassess then switch to oxycodone
Other considerations:
1.
What other medications may this patient benefit
from?
2.
How would you have established this?
3.
Does patient need high dose of opioid?
4.
Has patient tried other modes of therapy such as
stretching (Physical therapy involvement),
massage, TENS unit or cognitive behavioral
therapy (non-drug methods)?

Essential to identify if:
◦
◦
◦
◦

Patient successful
Patient might benefit more with restructuring of treatment
Need treatment for addiction
Benefits outweighed by harm
Frequency of monitoring:
◦
Patient on stable doses

◦
Every 3-6 months
After initiation of therapy, changes in opioid doses, with a
prior addictive disorder, psychiatric conditions, unstable
social environments

Weekly basis may be necessary
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic
Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine
Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.

Should include:
◦ Assessment and documentation of pain severity and
functional ability
◦ Progression towards achieving therapeutic goals
◦ Presence of adverse effects
◦ Clinical assessment and detailed documentation for
aberrant drug related behaviors, substance use and
psychological issues
 If suspect above may need to implement:
 Pill counts
 Urine drug screening
 Family member/caregiver interviews
 Use of prescription monitoring plans
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid
Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids
Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.



Most predictable factor for drug abuse, misuse, or
other aberrant drug related behavior:
◦ Personal or family history of alcohol or drug abuse
Other factors associated with aberrant drug related
behaviors:
◦ Younger age
◦ Presence of psychiatric conditions
Opioid therapy in these patients requires intense
structured monitoring and management by
professionals with expertise in both addiction
medicine and pain management ***DOCUMENT***
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid
Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids
Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
 Assessment
◦
◦
◦
Tools Available:
Webster's Opioid Risk Tool (ORT)
DIRE Tool
Screener and Opioid Assessment for Patients in Pain
(SOAPP®)
Current Opioid Misuse Measure (COMM )
Prescription Drug Use Questionnaire (PDUQ)
Screening Tool for Addiction Risk (STAR)
Screening Instrument for Substance Abuse Potential
(SISAP)
◦ Pain Medicine Questionnaire (PMQ)
◦
◦
◦
◦
TM
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of
Chronic Pain Guidelines. Fifth Edition, November 2011.
Pseudoaddiction to Opioids:
A)
B)
C)
A drug seeking behavior occurring in
patients who are receiving inadequate
pain control
State of adaptation in which exposure to a
drug decreases its effect over time
Characterized by behaviors that include
impaired control over drug use and
continuation despite harm to self or
others
Repeated Opioid Dose Escalations:


When repeatedly occur, evaluate for potential causes:
◦ Assess for treatment control (pseudoaddiction?)
◦ Possible marker for substance abuse disorder or
diversion
Theoretically no maximum or ceiling
◦ High dose definition = >200mg po morphine/day


AAP Opioid Consensus Panel
Some studies suggest higher doses of opioids lead to:
◦ Hyperalgesia
◦ Neuroendocrinologic dysfunction
◦ Possible immune suppression
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain:
an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
Weaning/Tapering Off Opioids:

Institute when:
◦
◦
◦

Patient engages in serious or repeated
aberrant drug-related behaviors or diversion
Experience of intolerable side effects
Making no progress towards meeting therapeutic goals
Approaches to Weaning Opioid:
◦
◦
◦
Slow: 10% dose reduction per week
Rapid: 25-50% reduction every few days
Slower rate may help reduce unpleasant symptoms of
opioid withdrawal
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic
Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain
Medicine Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
Diagnosing Addiction in Patients Taking Opioids:


Evidence of compulsive drug use, characterized by:
◦ Unsanctioned dose escalation
◦ Continued dosing despite significant side effects
◦ Use to treat for symptoms not targeted by therapy
◦ Use during periods of no symptoms
Evidence of one or more associated behaviors:
◦ Manipulation of MDs or medical system to obtain
additional opioids
◦ Acquisition of drugs from other medical sources
or non-medical sources
◦ Drug hoarding or sales
◦ Unapproved use of other drugs (alchohol or other)
Hojsted, J, Sjogren, P. Addiction to Opioids in Chronic Pain Patients: A Literature Review. European Journal of
Pain. 2007;11:490-518.


Consider for patient not well known and/or higher
risk of misuse
Example of components of opioid agreement:
◦ Specified the conditions under which opioids would
or would not be prescribed
◦ Patient responsibilities
 Only receive opioids from Dr. ________
 Will not give medications to anyone else
 If my prescription runs out early for any reason;
have to wait until next prescription is due.
Example of an Opioid Management Agreement:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1
829426/figure/Fig1




Random urine drug screening performed if
recommended by the physician to monitor
adherence and possible use of illicit substances.
Patients informed that the agreement would be
discontinued if patient responsibilities were not
met.
Responsibilities of the physician and/or clinic staff
included providing monthly prescriptions on the
due date, monitoring the effects of therapy,
and providing ongoing care.
Patient signs agreement

Pharmacies licensed by the MN Board of Pharmacy and other
dispensing facilities are required to report the dispensing of
controlled substances listed in the state’s Schedules II-IV.
◦ Data is submitted electronically.



Patient controlled substance prescription history is available to
prescribers and pharmacists
Available 24/7, 365 days a year, with information such as:
◦ Quantity and dosage of controlled substance dispensed,
◦ Pharmacy that dispensed the prescription
◦ In some cases, the practitioner
Assists in checking for potential drug interactions, patterns of
misuse, potential diversion or abuse and generally to assist in
determining the appropriateness in dispensing.
For pharmacist access:
http://pmp.pharmacy.state.mn.us/pharmacist-rxsentryaccess-form.html

Rational Use
1. Reassure patients prescribed opioids or benzos
are taking as directed, evidenced by positive
results
2. Make sure not being misused


Stockpiling or selling to unauthorized others
Evidenced by negative results
3. Detect presence of illicit non-prescribed drugs

Heroin, cocaine, non-prescribed opioids, etc.
Tenore, P. Advanced Urine Toxicology Testing. Journal of Addictive Diseases, 2010;29:436448.

Two types of tests used:
1. Immunoassay
◦
◦
◦
◦
◦
Classify drug as present or absent
Any response above the cutoff is deemed positive
Any response below the cutoff is negative
Subject to cross-reactivity
Some detect specific drugs, while others classes,
i.e. opioids
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California
Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Immunoassay Pearls:



Human urine has a creatinine concentration greater
than 20 mg/dL.
In the clinical setting it is important that 300 ng/mL
or less be used for initial screening of opiates (Food
stuff and poppy seed can make +); Confirm with
laboratory test
Opiate Class; lower sensitivity to hydromorphone ,
hydrocodone, oxycodone , oxymorphone, fentanyl,
meperidine, and methadone
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California
Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford,
CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Immunoassay Pearls (continued):




Amphetamine/methamphetamine are highly
crossreactive
◦ may detect other ephedrine and pseudoephedrine
◦ Further testing may be required by a more specific
method, i.e. GC
Opiate class: morphine and codeine
Ability of opiate immunoassays to detect semisynthetic/
synthetic opioids varies among assays because of
differing cross-reactivity patterns.
Specific immunoassay tests for some semisynthetic/
synthetic opioids may be available (eg, oxycodone,
methadone).
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care . Stanford, CT: California Academy of
Family Physicians, PharmaCom Group, Inc; 2010.
2. GC/MS (Laboratory Testing)
Generally, a more definitive laboratory-based
procedure
 Identify specific drugs; may be needed:
(1) Specifically confirm the presence of a given
drug; i.e. morphine is the opiate causing the + IA
response
(2) to identify drugs not included in an
immunoassay test
(3) when results are contested.

Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care.
Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Examples of cross-reacting compounds for
certain immunoassays
Interfering drug
Quinolone antibiotics
Trazodone
Venlafaxine
Quetiapine
Efavirenz
Promethazine
Dextromethorphan
Proton pump inhibitors
Immunoassay affected
Opiates
Fentanyl
Phencyclidine
Methadone
THC
Amphetamine
Phencyclidine
THC
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient
Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Approximate windows of detection
of drugs in urine
Detection time
Drug in urine
Amphetamines
Up to 3 days
THC (Single use)
1 to 3 days
(Chronic use)
Up to 30 days
Cocaine use
2 to 4 days
Opiates (morphine, codeine)
2 to 3 days
Methadone
Up to 3 days
EDDP (methadone metabolite)
Up to 6 days
Benzodiazepines
Days to weeks
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care.
Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.

Consult lab regarding anything unexpected

Schedule appointment to discuss with patient
◦ Be positive and supportive


Use to strengthen the healthcare
professional-patient relationship
Support positive behavior change

FDA recommendations for disposal
◦ Locate medication take back program in community
◦ Example: Dakota County Sherriff’s Office has a drop
box at the Burnseville Police Department and the
Hastings Sherriff’s Office where people can drop off
their prescriptions anonymously
◦ Many drop box locations in Hennepin county:
http://www.hennepin.us/medicine
Hennepin County Drop Box Example:
http://www.hennepin.us/medicine

FDA recommendations for disposal
◦ If no medication take back program
 Mix medications with unpalatable substance
 Place mixture in container such as sealed bag
 Throw container in household trash
◦ Exception: List of meds recommended to dispose
by flushing
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/B
uyingUsingMedicineSafely/EnsuringSafeUseofMedicine/Safe
DisposalofMedicines/ucm186187.htm

FDA recommended for flushing (examples):
◦
◦
◦
◦
◦
◦
◦

Fentanyl (SL tabs, film, lozenge, patch)
Morphine
Meperidine
Hydromorphone
Methadone
Oxycodone
Tapentadol
Others listed on FDA updated website:
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/Buyin
gUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDispos
alofMedicines/ucm186187.htm


Federal controlled substance laws and rules
prohibit a pharmacy from receiving
controlled substances from anyone who is
not a registrant of the US DEA.
Pharmacists are not allowed to accept
controlled substances from patients or
members of the public.




Assessment of pain is key every time you see a patient
Opioids can be part of a comprehensive pain
management approach for a non-cancer chronic pain
patient; document all assessment and communication
regarding opioids each office visit
Ensure pain is being treated appropriately with a
multimodal approach using the best medications and
therapy for the individual patient
Utilize expertise of other non-pharmacy professionals
for additional therapy to synergistically treat pain
Guidelines:
Assessment and management of chronic pain. 2005 Nov (revised 2011 Nov). NGC:008967
Institute for Clinical Systems Improvement - Nonprofit Organization.
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