opioid harm reduction

Opioid Harm Reduction Strategies

Paul C. Coelho, MDBoard Certified PM&R

Subspecialty Certified Pain Medicine

Sunday, August 30, 15

Table Of Contents

1. General Principles

2. Reducing Harms to High Dose Patients

3. Preventing Harms to Opioid Naive Patients


General Principles

1. Avoid doses > 120MED for CNP2. Avoid Methadone3. Avoid co-prescribing Benzo’s/ sedatives and opioids.4. Prescribe nasal naloxone to loved ones of pts on high dosages


High Dose (>120MED)Patients

1. Identify the high risk patients.

2. Explain to the patients that their dose has become dangerously

high and it will need to change.

3. Prescribe nasal naloxone and train a loved one in the

patient’s household on administration.

4. If the MED is < 240 offer the patient a 6mo taper.

5. If the MED is > 240 consider a taper or conversion to

buprenorphine for PAIN.


Example 1: Teresa

68y/o retired missionary with diffuse OA. Lives in Mennonite Village. Uses Oxycodone-APAP 10/325, six per day (MED 80). No aberrant behavior.


Example 1: Teresa

1. Teresa reports the medications give her comfort.

2. She was started on them years ago by a doctor long since retired.

3. Leave Teresa alone. She is not who we are worried about for the purposes of this talk.


Example 2: Cleatus

68y/o retired millwright with failed back syndrome. Lives with spouse Rx’d MS04 ER 60mg QID (MED 240). No aberrant behavior.


Example 2: Cleatus

1. Call Cleatus & Mabel into clinic to explain that new literature has suggests that Cleatus’ dose has become unsafe and it will need to change.

2. Rx nasal naloxone and train Mabel in it’s administration.

3. Offer a 15mg/mo taper over 8mo to 120MED.


Example 3: Loretta

52y/o disabled woman with FMS and chronic Hep C, on Transplant List @ OHSU. Medications include a Fentanyl patch 100ucg/hr Q48, Soma 350mg QID, and Xanax .5mg QID. Has an OMMP card. (MED 360)


Example 3: Loretta1. Call Loretta and her adult daughter/care-giver

into clinic to explain that new literature has suggests that Loretta’s dose has become unsafe and it will need to change.

2. Consider an addiction medicine consult given the complex PMH, Hep C, & Transplant status.

3. Rx nasal naloxone and train Frisbee - her daughter- in it’s administration.

4. Load with Gabapentin over 1mo to 1200mg/day5. Convert from alprazolam to clonazepam - 1:1

conversion and begin a 6mo taper. Consider non-addictive alternatives for anxiety (citalopram).


Example 3: Loretta

6. Stop the Soma - it is an addictive barbiturate - and offer a conventional muscle relaxant.7. Consider a conversion to Buprenophine for pain : Induction, stabilization, maintenance.7a. Or offer a 12ucg/mo taper to 50ucg/hr.8. Explain that our clinic policy is either THC or opioids but not both and let her choose.


Addiction Services In Oregon By County

Drug & Alcohol Services by County: http://www.oregon.gov/oha/amh/publications/provider-directory.pdf


http://www.oregon.gov/oha/amh/publications/provider-directory.pdf






Nasal Naloxone

1. SB 384 legalized for lay administration in 2013.

2. Stock in your pharmacies.3. Some patients must pay out of

pocket ($25.00.)4. http://www.prescribetoprevent.org/

wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf


http://www.prescribetoprevent.org/wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf








Buprenorphine

1. Schedule III opioid.2. Morphine Equivalence 30:1.3. FDA approved for pain - Butrans & addiction - Suboxone.4. Ceiling effect for respiratory

suppression.5. Follow the QTc.6. Contra-indications: coprescribing

benzo’s, sedatives,or alcohol use.


Pain or Fear of Withdrawal?


It’s Easier Not to Start Opioids, Than to Stop Em.


It’s Easier Not to Start Opioids, Than to Stop.


More than ½ of patients receiving opioids for 90d

remain on opioids for years.


1/3rd Of Patients Treated in Addiction Clinics Come

From Pain Clinics


Oregon Ranks #1 in the Nation in Prescription

Opioid Abuse


Top Oregon Counties for Opioid Prescriptions

0

52.5000

105.0000

157.5000

210.0000

Josep

hine

Dougla

s

Sher

man

Linco

ln

Clatso

pLin

nLa

ne

Tillamoo

k

Marion Po

lk

County


Prescription Opioid Deaths In Oregon 2000-2011


Prescribed Opioid Addiction Tx By Age


Age of Opioid ODD


Prescription Opioid Deaths & Addiction Treatment

Parallel Opioid Prescribing


Special Thanks To:

• Andrew Kolodny, MD, Chief Medical OfficerPhoenix House

• Jim Shames, MD, Medical Director Jackson County, OR Health & Human Services

• Andrew Mendenhall, MD, Medical DirectorHazelden, Beaverton, OR


Thank You

www.supportprop.org


opioid harm reduction

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