katy trinkley, pharmdangie thompson, pharmd. opioid risks and risk prevention strategies ...
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Chronic Pain Medications: Introduction
Katy Trinkley, PharmD Angie Thompson, PharmD
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Outline
Opioid risks and risk prevention strategies
Medication treatment by pain type
Fundamental principles of opioid therapy
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Opioid risks
Opioid prescribing is on the rise
Benefit of opioids after 1 year
Opioid dose is directly related to mortality
Ann Intern Med. 2015; 162:276 Arch Intern Med. 2011;171:686
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Opioid risks
Opioid prescribing is on the rise
Benefit of opioids after 1 yearNo evidence!
Opioid dose is directly related to mortality
Ann Intern Med. 2015; 162:276 Arch Intern Med. 2011;171:686
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Risk prevention strategies
Opioids Avoid Minimize Prolong initiation
Only indicated when safer alternatives are exhausted
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Pain types
Nat Rev Drug Discov. 2010;9:589
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Pain types
Nat Rev Drug Discov. 2010;9:589
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Guided prescribing by pain type
Visceral Highly variable by specific condition
Neuropathic or fibromyalgia Many opioid alternatives
Nociceptive Some opioid alternatives
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Guided prescribing
Neuropathic or fibromyalgia pain Topicals
Lidocaine cream/patch, capsaicin Gabapentin SNRI
Venlafaxine, duloxetine TCA
Nortriptyline Pregabalin
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Guided prescribing
Nociceptive pain Acetaminophen
4 grams/d Topicals
Lidocaine cream/patch, diclofenac gel, capsaicin SNRI for low back pain NSAIDs
Aspirin, naproxen Tramadol IR/ER Opioids
Ann Intern Med. 2015;163:JC10. Circulation. 2007; 115:1634. BMJ. 2011;342:c7086
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Opioid principles
Goals of therapy Selection of opioid Initiation Monitoring Titration Breakthrough pain
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Goals of therapy
Dependent on type of pain Discussion of patient and provider expectations Set realistic goals
Acute pain – rapid pain relief Chronic pain – improve or maintain level of day to day
functioning, overall well being, relationships, reduce drug dependency
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Selection of opioid
Route of administrationConstant pain vs. intermittent painRenal/hepatic functionPrevious exposure to opioids
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Initiation of opioids
Short term trial No evidence supporting one opioid over another No evidence supporting short acting vs. long acting
Generally considered safer to use short-acting opioids for initial therapy
Choice of opioid, starting dose, and titration schedule will be very patient specific
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Initiation of opioids
In general start with: Typical starting dose Immediate release formulations Insufficient evidence to recommend around the
clock or scheduled opioids Titrate up slowly▪ Especially true for geriatric patients
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Monitoring patient on opioids
Monitor for effectiveness and adverse effects 4 A’s ▪ Analgesia▪ Activity ▪ Aberrant drug behavior▪ Adverse effects
Assessment frequency will vary based on patient’s pain
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Titration of opioids
Dose decreases: Slow titration : 10% per week Rapid titration: 25-50% every few days
Dose increases: 20-50% increases in daily dose Equivalent to “breakthrough” dosing needed if on sustained
release products Transition to equivalent dose of sustained released
product, once pain control is achieved Maintain immediate release product for breakthrough pain Goal: Maximize sustained release/minimize immediate release
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Breakthrough pain
Brief, transitory, exacerbation of moderate to severe pain while on stable doses of long acting opioid therapy or around the clock parenteral therapy
May be due to underlying condition or new/unrelated pain Typically treated with as need immediate release opioid
therapy 10-20% of total daily opioid dose
Rescue doses for breakthrough pain should be dosed frequently Outpatient setting: Every 4-6 hours is typical
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Titration based on rescue dosing
If using rescue doses consistently, consider titrating long acting opioids
Recalculate dose of rescue therapy every time dose of long acting opioids is adjusted
Typically use same drug for both rescue and long acting therapy
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Max opioid doses
In theory, there is no maximum ceiling dose for opioid therapy
Best evidence indicates 120 mg/day of morphine or morphine equivalent Maximum studied doses in randomized controlled trials
Higher doses may indicate substance abuse/diversion and/or need for opioid rotation or taper
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Questions