Chronic Opiate Therapy

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Chronic Opiate Therapy

• Benjamin Meeks, FNP

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Agenda

• History of Opiate Therapy
• Risks of Opiate Therapy
• Benefits of Opiate Therapy
• Guidelines for Opiate Therapy
• Case Studies

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Give strong drink to those who are about to
perish

• - Solomon

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Modern History

• Portenoy and Foley 1986
• Study of 38 chronic pain patients
• 4 7 years duration
• 66 maintained on 40mg to 60mg morhpine

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Modern History

• 1989 Weissman and Haddox introduce concept of
  pseudoaddiction
• 1995 Introduction of time released oxycodone
• Titrate to effect or side effect

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Modern History

• 97 increase in opioid sales from 1997 to 2010
• 2010 Misuse or abuse of pharmaceuticals overtakes
  alcohol in reason for ED visits
• Drug overdose deaths increase 250 2000 2010
  
  
• 15.1 increase in American population over the
  age of 65 from 2000 - 2010
• Estimated 116 million American with chronic pain

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Ethical Imperatives

• Treat your patients pain.
• Do no harm by contributing to abuse and diversion.

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Risks of Opiate Therapy

• Constipation/Urinary Retention 41
• Tolerance
• Hypogonadism 11
• Addiction
• Death
• Falls/Accidents

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Tolerance

• Reversible physiologic response to the persistent
  presence of opiate agonists leading to
  diminishing therapeutic effect
• Mechanism not fully understood
• Poorly studied

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Addiction

• Addiction/Medication Misuse
• Addiction rates vary by study 5 to 41 of
  chronic pain patients
• 20 of general population reports non-medical
  use of opiates
• Aberrant behaviors in 11.5 to 24
• Aberrant behaviors/Addiction appear greater in
  those aged lt56 years, smokers and unemployed

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Falls/Accidents

• Exposure to opiates increased fall risk by 38
• Greater than 50mg morphine equivalent doubled
  risk of falls
• More common with new opioid prescription
• Greatest in 18 29 year old age group

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What risks does my patient have?
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Benefits of Opiate Therapy

• Pain Control
• Improved Social Function
• Improved Mental Health
• Improved Physical Function

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Benefits of Opiate Therapy

• Meta-analysis of 28 studies with chronic
  nonmalignant pain demonstrated improvements in
  pain and function studies only up to five weeks
• Very little long term evidence no studies longer
  than 2 years, many not controlled
• No long term studies demonstrate strong evidence
  for opiate therapy
• No evidence showing benefit of long acting versus
  short acting opiates

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Guidelines ASIPP 2012

• Comprehensive Assessment
• Pain Condition
• Medical History
• Physical Exam
• Psychosocial History
• Functional Status
• Sleep
• Psychological Evaluation
• Prescription Monitoring Program
• Urine Drug Screening

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Case Study

• 65 year old married white male, 510, 275 lbs,
  disabled coal miner, 1 ppd smoker, denies alcohol
  usage, reports chronic worsening back pain
  without extremity pain, medical history
  significant for O2 dependent COPD, HTN, diabetes
  and mild kidney disease, lives with wife and
  teenage grandchild, no current medications for
  pain, no recent radiology
• Do you prescribe opiates for this patient?

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Case Study

• 40 year old co-habitating white male, 510, 250
  lbs, disabled construction worker, 2 ppd smoker,
  denies alcohol usage, reports five year history
  of worsening back pain without extremity pain,
  medical history significant for COPD, lives with
  girlfriend, failing over the counter NSAIDS/APAP,
  MRI reveals multilevel disc degeneration and
  faect arhtropathy without foraminal stenosis.
• Do you prescribe opiates for this patient?

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Case Study

• 30 year old married female, 55, 140lbs,
  non-smoker, employed as elementary school teacher
  6 week history of worsening low back and right
  leg pain began after lifting a box of books,
  numbness right lateral foot, not improving with
  physical therapy, missing work due to pain, sleep
  is disturbed due to pain, MRI demonstrates right
  L4-5 herniation, lives with husband and 2
  children ages 4 and 6. Ibuprofen 800 TID not
  helpful and causing GI upset.
• Do you prescribe opiates for this patient?

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Summary

• Long term opiate therapy has medically proven
  significant life altering risks
• Long term opiate therapy has not been as yet
  proven in the research to improve function, mood
  and reduce pain over a period of years
• Consider risks, benefits and potential duration
  fo therapy before writing the first prescription
  for opiates