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.