Opioid Guidelines Research Articles

Pharmacotherapy of Pain in Populations with Serious Illness: Best Practices and Emerging Issues (P9)

1.Improve the ability to offer safe and effective opioid therapy to patients with serious illness by augmenting conventional guidelines with new information about side effect treatment, management of risks associated with drug abuse, and targeted treatment of breakthrough pain.2.Improve the ability to use adjuvant analgesics to manage bone pain, visceral pain, and neuropathic pain syndromes.3.Use NSAIDs more effectively based on an improved understanding of potential risks and benefits. Given the prevalence of pain in the medically ill, specialists in palliative medicine need a strong skill set in pain management. Pharmacotherapy is the mainstay approach and clinical guidelines for the use of three categories of drugs opioids, nonopioids, and so-called adjuvant analgesics are evolving with new research and experience. Opioid guidelines now confirm that morphine is not the drug of choice but one among many, and differences in risk profiles, particularly as this pertains to methadone, influence drug selection. The importance of breakthrough pain is now clear and treatment decisions have been complicated by the appearance of multiple fentanyl preparations, which have the benefit of more rapid onset but uncertain cost-utility relative to conventional drugs. Opioid side effect management is becoming more sophisticated, particularly with the recognition of side effects such as hypogonadism and sleep-disorder breathing, which may not be perceived by clinicians as being opioid-related. The management of risks associated with the abuse potential of opioid drugs is now viewed as a key responsibility, given the increase of prescription drug abuse in the United States. All of these advances in the safe and effective use of opioids are mirrored in changes that have occurred in the use of other analgesic categories. Slow progress toward mechanism-based treatment has highlighted the non-opioid options for pains of varied mechanisms, such as bone pain, visceral pain and neuropathic pain. Drug combination therapy may offer the optimal balance between analgesia and side effects. This session offers an update on the pharmacotherapy of pain in those with serious illness.

Changes in Opioid Prescribing for Washington Workers' Compensation Claimants After Implementation of an Opioid Dosing Guideline for Chronic Noncancer Pain: 2004 to 2010

An opioid overdose epidemic emerged in the United States following increased opioid prescribing for chronic noncancer pain. In 2007, Washington State agencies implemented an opioid dosing guideline on safe prescribing for chronic noncancer pain. The objective of this population-based observational study was to evaluate opioid use and dosing before and after guideline implementation. We identified 161,283 workers aged 18 to 64 years with ≥1 opioid prescriptions in Washington Workers' Compensation, April 1, 2004, to December 31, 2010. Prevalence and incidence rates of opioid use were assessed. We compared pre- and postguideline chronic and high-dose use (≥120 mg/d) among incident users. The mean monthly prevalence of opioid use declined by 25.6% between 2004 (14.4%) and 2010 (10.7%). Fewer incident users went on to chronic opioid therapy in the postguideline period (4.7%; 95% confidence interval [CI], 4.5–5.0%) than in the preguideline period (6.3%; 95% CI, 6.1–6.6%). Compared with preguideline incident users, postguideline incident users were 35% less likely to receive high doses (adjusted odds ratio = .65; 95% CI, .59–.71). Although the extent to which decreases were due to the guidelines is uncertain, to our knowledge, this is the first report of significant decreases in chronic and high-dose prescription opioid use among incident users. PerspectiveEvidence-based strategies for opioid risk management are needed to help abate the epidemic of opioid-related morbidity and mortality. The study findings suggest that opioid dosing guidelines that specify a “yellow flag” dosing threshold may be a useful tool in preventing escalation of doses into ranges associated with increased mortality risk.

Compliance with Opioid Treatment Guidelines for Chronic Non-Cancer Pain (CNCP) in Primary Care at a Veterans Affairs Medical Center (VAMC)

The primary objective of this study was to measure prescribing compliance with the Veterans Affairs/Department of Defense treatment guidelines for chronic non-cancer pain (CNCP) in the primary care setting. We also determined the proportion of subjects who demonstrated aberrant drug-related behaviors (ADRBs) and the patient characteristics associated with them. This is a retrospective chart review. Primary care setting in Veterans Affairs Medical Center. All patients with CNCP between the ages of 18 and 87 years who received opioid prescriptions for 3 or more consecutive months during a 1-year period (July 2009 to August 2010) were eligible for inclusion. A random sample of 800 patients was selected using pharmacy prescription database. Chi-square test was utilized to analyze associations between ADRB and patient characteristics. About half the patients in our sample had a signed opioid pain care agreement (OPCA), and at least one urine drug test (UDT) was obtained. UDT was positive for an illicit drug/unreported opioid in 19.5% of the patients, and negative for the prescribed drug in 25.2% of the sample. About 10% of the sample population had morphine equivalent dose equal to or greater than 200 mg/day. ADRBs were identified in 22.9% of the patients. Younger age, psychiatric comorbidities, history of substance abuse, and high opioid dose were associated with high risk of ADRB, but the presence of OPCA lowered the risk of ADRB. This article studied the prescribing practices of opioids in a primary care setting and can be used to enhance provider education regarding chronic pain guidelines.

P225 The Development Of Evidence Based Guidelines For Opioid Pain Treatment

BackgroundOpioid analgesic-related deaths more than tripled in the US from 1999 through 2006. According to the CDC, 27,000 unintentional drug overdose deaths occurred in the United States in 2007; the...

Changes in Opioid Prescribing for Chronic Pain in Washington State

To conduct a survey of primary care physicians and advanced registered nurse practitioners (ARNPs) in Washington State (WA) focused on changes in practice patterns and use of support tools in the prescription of opioids for the treatment of chronic noncancer pain (CNCP). A convenience sample of primary care providers in WA was obtained from diverse geographic regions and health care organizations. The web-based anonymous survey was conducted in March-August 2011. Among 856 provider respondents, 623 reported treating patients with CNCP and served as the analysis sample. Most providers (72%) reported concern about opioid overdose, addiction, dependence, or diversion. Only 25% indicated concern about regulatory scrutiny. Only a small proportion of providers overall (3.3%) reported that they had stopped prescribing opioids for CNCP, but twice as many ARNPs (5.8%) as physicians (MDs and osteopaths) (2.1%) reported this. A greater proportion of physicians (70.9%) than ARNPs (40.1%) reported familiarity with the Washington State opioid dosing guidelines. Physicians in a large health plan with substantial infrastructure support reported less concern about opioids compared with providers in other settings. Of providers in Spokane (the largest city in Eastern Washington), 45% reported very low capacity to access pain specialty consultation. The vast majority of providers reported a need to access more efficient, innovative means of support and education related to treating patients with CNCP, such as telemedicine consultation. Overall, prescribing providers in WA reported ongoing concerns regarding opioid use for CNCP, but those affiliated with a health care organization with opioid prescribing guidelines and access to pain consultation were less likely to report being concerned about opioid-related problems or to have discontinued prescribing opioids.

Prescription Opioid Guidelines and the Emergency Department

ABSTRACTOn January 10, 2013, Mayor Michael Bloomberg announced a set of recommendations intended to guide opioid analgesic prescribing in New York City emergency departments. The intent and scope of these guidelines are discussed through an interview bu an emergency medicine fellow with an expert in emergency medicine pain management and one of the authors of the guidelines. The guidelines are appended to the commentary.

A multidisciplinary outpatient pain management opioid reduction pilot program

Prescriptions for opioid pain medications have been on the rise in the United States. Sales of opioid analgesics quadrupled between 1999 and 2010 (ASIPP Opioid Guidelines, 2012). Issues regarding misuse, abuse, and dependence have been on the forefront and consequently, regulations and guidelines have been implemented to mitigate risks associated with consuming opioid medications. This study was developed to examine outcomes from a pilot program to reduce patients’ reliance on opioid medications at an academic multidisciplinary outpatient pain management center.

Opioid Epidemic in the United States

Over the past two decades, as the prevalence of chronic pain and health care costs have exploded, an opioid epidemic with adverse consequences has escalated. Efforts to increase opioid use and a campaign touting the alleged undertreatment of pain continue to be significant factors in the escalation. Many arguments in favor of opioids are based solely on traditions, expert opinion, practical experience and uncontrolled anecdotal observations. Over the past 20 years, the liberalization of laws governing the prescribing of opioids for the treatment of chronic non-cancer pain by the state medical boards has led to dramatic increases in opioid use. This has evolved into the present stage, with the introduction of new pain management standards by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in 2000, an increased awareness of the right to pain relief, the support of various organizations supporting the use of opioids in large doses, and finally, aggressive marketing by the pharmaceutical industry. These positions are based on unsound science and blatant misinformation, and accompanied by the dangerous assumptions that opioids are highly effective and safe, and devoid of adverse events when prescribed by physicians. Results of the 2010 National Survey on Drug Use and Health (NSDUH) showed that an estimated 22.6 million, or 8.9% of Americans, aged 12 or older, were current or past month illicit drug users, The survey showed that just behind the 7 million people who had used marijuana, 5.1 million had used pain relievers. It has also been shown that only one in 6 or 17.3% of users of non-therapeutic opioids indicated that they received the drugs through a prescription from one doctor. The escalating use of therapeutic opioids shows hydrocodone topping all prescriptions with 136.7 million prescriptions in 2011, with all narcotic analgesics exceeding 238 million prescriptions. It has also been illustrated that opioid analgesics are now responsible for more deaths than the number of deaths from both suicide and motor vehicle crashes, or deaths from cocaine and heroin combined. A significant relationship exists between sales of opioid pain relievers and deaths. The majority of deaths (60%) occur in patients when they are given prescriptions based on prescribing guidelines by medical boards, with 20% of deaths in low dose opioid therapy of 100 mg of morphine equivalent dose or less per day and 40% in those receiving morphine of over 100 mg per day. In comparison, 40% of deaths occur in individuals abusing the drugs obtained through multiple prescriptions, doctor shopping, and drug diversion. The purpose of this comprehensive review is to describe various aspects of crisis of opioid use in the United States. The obstacles that must be surmounted are primarily inappropriate prescribing patterns, which are largely based on a lack of knowledge, perceived safety, and inaccurate belief of undertreatment of pain. Key words: Opioid abuse, opioid misuse, nonmedical use of psychotherapeutic drugs, nonmedical use of opioids, National Survey on Drug Use and Health, opioid guidelines.

American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain: Part I – Evidence Assessment

Background: Opioid abuse has continued to increase at an alarming rate since the 1990s. As documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration, available evidence suggests a wide variance in chronic opioid therapy of 90 days or longer in chronic non-cancer pain. Part 1 describes evidence assessment. Objectives: The objectives of opioid guidelines as issued by the American Society of Interventional Pain Physicians (ASIPP) are to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to produce consistency in the application of an opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of abuse and drug diversion. The focus of these guidelines is to curtail the abuse of opioids without jeopardizing non-cancer pain management with opioids. Results: 1) There is good evidence that non-medical use of opioids is extensive; one-third of chronic pain patients may not use prescribed opioids as prescribed or may abuse them, and illicit drug use is significantly higher in these patients. 2) There is good evidence that opioid prescriptions are increasing rapidly, as the majority of prescriptions are from non-pain physicians, many patients are on long-acting opioids, and many patients are provided with combinations of long-acting and short-acting opioids. 3) There is good evidence that the increased supply of opioids, use of high dose opioids, doctor shoppers, and patients with multiple comorbid factors contribute to the majority of the fatalities. 4) There is fair evidence that long-acting opioids and a combination of long-acting and shortacting opioids contribute to increasing fatalities and that even low-doses of 40 mg or 50 mg of daily morphine equivalent doses may be responsible for emergency room admissions with overdoses and deaths. 5) There is good evidence that approximately 60% of fatalities originate from opioids prescribed within the guidelines, with approximately 40% of fatalities occurring in 10% of drug abusers. 6) The short-term effectiveness of opioids is fair, whereas the long-term effectiveness of opioids is limited due to a lack of long-term (> 3 months) high quality studies, with fair evidence with no significant difference between long-acting and short-acting opioids. 7) Among the individual drugs, most opioids have fair evidence for short-term and limited evidence for long-term due to a lack of quality studies. 8) The evidence for the effectiveness and safety of chronic opioid therapy in the elderly for chronic non-cancer pain is fair for short-term and limited for long-term due to lack of high quality studies; limited in children and adolescents and patients with comorbid psychological disorders due to lack of quality studies; and the evidence is poor in pregnant women. 9) There is limited evidence for reliability and accuracy of screening tests for opioid abuse due to lack of high quality studies. 10) There is fair evidence to support the identification of patients who are non-compliant or abusing prescription drugs or illicit drugs through urine drug testing and prescription drug monitoring programs, both of which can reduce prescription drug abuse or doctor shopping. Disclaimer: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” Key words: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversion

The Opioid Manager: A point-of-care tool to facilitate the use of the Canadian Opioid Guideline

The Opioid Manager is designed to be used as a point-of-care tool for providers prescribing opioids for chronic noncancer pain. It condenses the key elements from the Canadian Opioid Guideline and can be used as a chart insert. The Opioid Manager has been validated and is available for download from the Guideline's Web site http://nationalpaincentre.mcmaster.ca/opioidmanager/. The Opioid Manager is divided into the following four parts: A) before you write the first script, B) initiation trial, C) maintenance and monitoring, and D) when is it time to decrease the dose or stop the opioid completely? The Opioid Manager has been downloaded by 1,432 users: 47 percent family physicians, 18 percent pharmacists, 13 percent other physicians, and 22 percent miscellaneous. To show how to use the Opioid Manager, the authors created a 10-minute video that is available on the Internet. The Opioid Manager is being translated to French, Spanish, Portuguese, and Farsi.

Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline

Opioid use and dosing for patients with chronic non-cancer pain have dramatically increased over the past decade, resulting in a national epidemic of mortality associated with unintentional overdose, and increased risk of disability among injured workers. We assessed changes in opioid dosing patterns and opioid-related mortality in the Washington State (WA) workers' compensation system following implementation of a specific WA opioid dosing guideline in April, 2007. Using detailed computerized billing data from WA workers' compensation, we report overall prevalence of opioid prescriptions, average morphine-equivalent dose (MED)/day, and proportion of workers on disability compensation receiving opioids and high-dose (≥120 mg/day MED) opioids over the past decade. We also report the trend of unintentional opioid deaths during the same time period. Compared to before 2007, there has been a substantial decline in both the MED/day of long-acting DEA Schedule II opioids (by 27%) and the proportion of workers on doses ≥120 md/day MED (by 35%). There was a 50% decrease from 2009 to 2010 in the number of deaths. The introduction in WA of an opioid dosing guideline appears to be associated temporally with a decline in the mean dose for long-acting opioids, percent of claimants receiving opioid doses ≥120 mg MED per day, and number of opioid-related deaths among injured workers.

Training for General Practitioners in Opioid Prescribing for Chronic Pain Based on Practice Guidelines: A Randomized Pilot and Feasibility Trial

This study is a pilot and feasibility study that compares 2 training experiences to improve appropriate opioid prescribing for chronic pain. Both training conditions included education in relation to opioid guidelines. Following education, 1 condition included training aimed at improving psychological flexibility and the other included training in practical knowledge and skills related to pain management. Eighty-one general practitioners (GPs) took part in the study, each having been randomly assigned to 1 of the training conditions. It proved easy to recruit GPs to the training. Overall, GPs demonstrated increased knowledge of opioid prescribing for chronic pain and decreases in concerns related to prescribing following training. However, there were no changes observed in reported prescribing practices or in secondary measures of well-being. There were also no significant differences between the training conditions, other than a greater increase in intention to use prescribing guidelines in the psychological flexibility condition. Feasibility and acceptability of the training methods were generally rated high. The psychological flexibility condition was rated higher than the comparison condition in terms of interest and satisfaction. Finally, processes of psychological flexibility before and after training significantly correlated with measures of GP well-being, providing partial support for the relevance of these processes as a focus in GP training. Perspective A training intervention for GPs including education on opioid guidelines for chronic pain and psychological flexibility training increased knowledge of prescribing and reduced concerns but did not change prescribing behavior or well-being. The training was highly acceptable to GPs but may have been too short to produce other effects.

Spinal opioids in adult patients with cancer pain: A systematic review: A European Palliative Care Research Collaborative (EPCRC) Opioid Guidelines Project

Background: A systematic review, undertaken according to an initiative to revise European Association for Palliative Care guidelines on the use of opioids for cancer pain, which aimed to analyse analgesic efficacy and side effects of spinal opioids in adult cancer patients previously treated with systemic opioids. Methods: Search strategy elaborated with MeSH terms and words related to cancer, palliative care, pain, spinal route and opioids. PubMed, Embase and Cochrane assessed in Nov 2009. Studies were analysed and classified according to quality of evidence and strength of recommendation. Results: Out of 2939 abstracts, 44 articles were selected (nine randomized controlled trials (RCTs), two non-randomized cohort studies, 28 uncontrolled prospective studies, and five case series). Relief of pain and/or side effects were reported in 42 articles; however, there were few studies of high quality design (RCTs) and these studies had methodological limitations that reduced their quality of evidence to very low. Conclusion: There are few RCTs and these are of very low quality. As a result, they provide weak recommendation for using spinal opioids in adult cancer patients. Further studies are clearly needed.

A systematic review of oxycodone in the management of cancer pain

Background: Oxycodone is often used as an opioid analgesic for moderate to severe cancer-related pain, but its use varies across Europe. This systematic literature review forms the basis of guidelines for oxycodone use within the European Palliative Care Research Collaborative opioid guidelines project conducted on behalf of the European Association for Palliative Care. Objectives: The objective of this study was to identify and assess the quality of evidence for the use of oxycodone for cancer pain in adults. Methods: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals. Studies were included if they reported a clinical outcome relevant to the use of oxycodone in adult patients with moderate to severe cancer pain. Any form and route of oxycodone was included except intrathecal. No direct comparator was required for inclusion and studies were excluded if patients had previously switched from another strong opioid because of intolerable adverse effects or poor efficacy. This is a narrative systematic review, using the GRADE approach to assess the quality of studies and to formulate guidelines. Results: Twenty-nine original studies were identified including a meta-analysis and 14 randomized controlled trials. The identified meta-analysis included three trials comparing oxycodone to morphine and one comparing oxycodone to hydromorphone. Four other randomized trials compared oxycodone with other opioids. The remaining randomized controlled trials compared different routes of administration or formulations of oxycodone. No additional studies that would have been suitable for addition to the meta-analysis were identified. Conclusions: There is no evidence from the included trials of a significant difference in analgesia or adverse effects between oxycodone and morphine or hydromorphone. The evidence was graded as high quality on the basis of a well-conducted meta-analysis, with no limitations likely to affect the outcome, in addition to consistency in the results of the other studies. The research was conducted using participants relevant to cancer and palliative care populations. Oxycodone can be recommended as an alternative to morphine or hydromorphone for cancer-related pain.

A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: A European Palliative Care Research Collaborative opioid guidelines project

Background: Opioid use in patients with renal impairment can lead to increased adverse effects. Opioids differ in their effect in renal impairment in both efficacy and tolerability. This systematic literature review forms the basis of guidelines for opioid use in renal impairment and cancer pain as part of the European Palliative Care Research Collaborative’s opioid guidelines project. Objective: The objective of this study was to identify and assess the quality of evidence for the safe and effective use of opioids for the relief of cancer pain in patients with renal impairment and to produce guidelines. Search strategy: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals. Selection criteria: Studies were included if they reported a clinical outcome relevant to the use of selected opioids in cancer-related pain and renal impairment. The selected opioids were morphine, diamorphine, codeine, dextropropoxyphene, dihydrocodeine, oxycodone, hydromorphone, buprenorphine, tramadol, alfentanil, fentanyl, sufentanil, remifentanil, pethidine and methadone. No direct comparator was required for inclusion. Studies assessing the long-term efficacy of opioids during dialysis were excluded. Data collection and analysis: This is a narrative systematic review and no meta-analysis was performed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the studies and to formulate guidelines. Main results: Fifteen original articles were identified. Eight prospective and seven retrospective clinical studies were identified but no randomized controlled trials. No results were found for diamorphine, codeine, dihydrocodeine, buprenorphine, tramadol, dextropropoxyphene, methadone or remifentanil. Conclusions: All of the studies identified have a significant risk of bias inherent in the study methodology and there is additional significant risk of publication bias. Overall evidence is of very low quality. The direct clinical evidence in cancer-related pain and renal impairment is insufficient to allow formulation of guidelines but is suggestive of significant differences in risk between opioids. Recommendations: Recommendations regarding opioid use in renal impairment and cancer pain are made on the basis of pharmacokinetic data, extrapolation from non-cancer pain studies and from clinical experience. The risk of opioid use in renal impairment is stratified according to the activity of opioid metabolites, potential for accumulation and reports of successful or harmful use. Fentanyl, alfentanil and methadone are identified, with caveats, as the least likely to cause harm when used appropriately. Morphine may be associated with toxicity in patients with renal impairment. Unwanted side effects with morphine may be satisfactorily dealt with by either increasing the dosing interval or reducing the 24 hour dose or by switching to an alternative opioid.

Development of a Quality Improvement Process after Evaluation of Patient Outcomes and Nursing Documentation

The release of new opioid treatment guidelines that were published in February 2009 and the implementation of the REMS (Risk Evaluation Mitigation Strategies) have prompted the development of a compliance quality improvement project. Within the practices there are many patient issues that can arise with opioid prescriptions. In order to ensure patient safety and good practice a compliance monitoring program was developed. Many patient phone calls, lost prescriptions, inappropriate use of medication and other concerns were dealt with on a daily basis. A pilot program was developed to review charts for patient teaching and education. The next step was to develop a one page educational sheet and implement a phone follow-up call to the patient after receiving the prescription. The outcomes that were looked at include the number of phone calls from the patient, lost prescriptions, compliance in taking the medication as directed and any other concerns. In conjunction with this, charts were reviewed for documentation of the elements of Universal Precautions for Pain Management. This program focused on both Physician and Nursing compliance. Improvement Plan and Implementation: During January and February 2010, a teaching/medication guideline sheet was developed to include the following elements: Medication purpose, dosing, side effects, renewals, safe storage, and proper disposal. (see Figure 1) This sheet was given to patients when they received any prescriptions at their visit. For patients that called in for renewals, they received the teaching sheet/guideline when they picked up the prescription. In order to capture the education, the nursing note was revised. (see Figure 2) This allowed better documentation of nurse’s patient teaching about the prescribed medication. A follow-up call was made 5 days after the visit to assess any problems with the medication. (see Figure 3) This process was implemented May 1, 2010. Implemented a plan with our in-house retail pharmacy in which the prescription is sent to the pharmacy by the staff and the patient has the option to pick up the prescription at the pharmacy or the pharmacy would fed-ex the medication to the patient’s home. No scripts are sent to the patient homes. Retrospective Chart Review: A retrospective chart review from July to December 2009 of 250 charts was completed for current nursing practice for documentation of teaching when prescriptions were given. This project was completed at Lehigh Valley Hospital-Muhlenberg Center for Pain Management. In addition, we were tracking the number of phone calls made by the patient after receiving a prescription about any problems or concerns with the medication. Out of the 250 charts-100 patients had received prescriptions for opioid medications. 80 charts had no documentation that the patient had any teaching or instructions in regards to the prescribed medication. 20 charts had adequate documentation of teaching about the prescribed medication. In addition, approximately 55 patient phone calls were recorded with problems or concerns about their prescribed medication. Concurrent chart reviews were completed during February, March, May and June33 random charts for compliance in obtaining an opioid agreement and the use of Urine Drug Screens. The patients were on an opioid from a few months to 7 years. Out of the 33 charts there were 6 charts that had an opioid agreement-many that were obtained but never updated on an annual basis. Out of the 6 that had an opioid agreement there was only 1 UDS completed. Many of the charts were lacking in documentation of risk assessments, benefit of current treatment and the 4A’s. Concurrently, a Standard Operating Procedure was developed for Opioid Prescribing to include opioid agreements, outline responsibilities of the staff (physician and nursing), and urine drug screen guidelines. This SOP was implemented as of July 6, 2010.

Adherence to Clinical Guidelines for Opioid Therapy for Chronic Pain in Patients with Substance Use Disorder

Patients with chronic non-cancer pain (CNCP) have high rates of substance use disorders (SUD). SUD complicates pain treatment and may lead to worse outcomes. However, little information is available describing adherence to opioid treatment guidelines for CNCP generally, or guideline adherence for patients with comorbid SUD. Examine adherence to clinical guidelines for opioid therapy over 12 months, comparing patients with SUD diagnoses made during the prior year to patients without SUD. Cohort study. Administrative data were collected from veterans with CNCP receiving treatment within a Veterans Affairs regional healthcare network who were prescribed chronic opioid therapy in 2008 (n = 5814). Twenty percent of CNCP patients prescribed chronic opioid therapy had a prior-year diagnosis of SUD. Patients with SUD were more likely to have pain diagnoses and psychiatric comorbidities. In adjusted analyses, patients with SUD were more likely than those without SUD to have had a mental health appointment (29.7% versus 17.2%, OR = 1.49, 95% CI = 1.26-1.77) and a urine drug screen (UDS) (47.0% versus 18.2%, OR = 3.53, 95% CI = 3.06-4.06) over 12 months. There were no significant differences between groups on receiving more intensive treatment in primary care (63.4% versus 61.0%), long-acting opioids (26.9% versus 26.0%), prescriptions for antidepressants (88.2% versus 85.8%, among patients with depression), or participating in physical therapy (30.6% versus 28.6%). Only 35% of patients with SUD received substance abuse treatment. CNCP patients with SUD were more likely to have mental health appointments and receive UDS monitoring, but not more likely to participate in other aspects of pain care compared to those without SUD. Given data suggesting patients with comorbid SUD may need more intensive treatment to achieve improvements in pain-related function, SUD patients may be at high risk for poor outcomes.

Feasibility Study of Rapid Opioid Rotation and Titration

Background: Opioid guidelines recommend opioid rotation and switching for patients who do not achieve adequate pain relief or who experience intolerable adverse events (AEs) with their current opioid. However, specific recommendations and protocols for opioid rotation are lacking, making the practice time consuming and difficult for primary care physicians to accomplish independently or coordinate with a pain specialist. Objectives: To assess the safety and feasibility of using 24-hour intravenous patientcontrolled analgesia (IV-PCA) to achieve rapid opioid rotation and titration (RORT). Study design: Open-label pilot study. Setting: Hospital research center. Methods: At admission, patients (aged ≥ 18 years) with treatment-refractory chronic pain who were taking morphine or oxycodone for ≥ 3 months and had pain scores ≥ 4 on a 10- point scale, underwent opioid rotation to oral oxymorphone extended release (ER). They also received IV-PCA oxymorphone for 24 hours as needed. At discharge, the participants were taking oral oxymorphone ER with oxymorphone immediate release (IR) as needed based on their total 24-hour oral plus IV-PCA oxymorphone use. During a 2-week follow-up, their oxymorphone usage was titrated as needed. Main outcome measures were AEs, Patient Global Impression of Change (PGIC), Brief Pain Inventory (0 = no pain/interference, 10 = worst pain/ complete interference), treatment satisfaction, and change in oxymorphone dose. Results: Twelve patients enrolled and completed the 24-hour IV-PCA; 10 completed the 2- week follow-up post–24-hour IV-PCA. PGIC status improved by 12 hours (odds ratio [OR], 0.19, 95% CI, 0.08−0.44; P < 0.001), and both PGIC status and activity scores improved by 24 hours (OR, 0.23, 95% CI, 0.09−0.55; P = 0.001; OR, 0.49, 95% CI, 0.25−0.96; P = 0.04, respectively) and 2 weeks (OR, 0.14, 95% CI, 0.04−0.46; P = 0.001; OR, 0.21, 95% CI, 0.06−0.72; P = 0.01) versus 6 hours. During the 24-hour IV-PCA time period, 6 of 10 patients accomplished ≥ 50% of their overall dose titration. At 2 weeks, 8 of 10 participants were Greatly Satisfied or Somewhat Satisfied with the overall RORT procedure. RORT was well tolerated, with no serious AEs. Limitations: This was a pilot open-label study in a small number of participants. A larger randomized study with long-term follow-up and comparison to traditional protocols is necessary. Conclusions: Preliminary data suggest that RORT can be performed safely and effectively by incorporating IV-PCA during the first 24 hours. Further investigations are needed to determine whether RORT can become an ambulatory treatment intervention in pain practice. Clinicaltrials.gov registration: NCT00580294 Key words: chronic pain, opioid rotation, opioid switching, opioid substitution, opioid conversion, oxymorphone, oxycodone, morphine

S43– Low back interventions and opioid treatment guidelines: Comparison between ACOEM and APS

S43– Low back interventions and opioid treatment guidelines: Comparison between ACOEM and APS

Opioid dependence treatment and guidelines.

In response to the growing incidence of opioid dependence, guidelines have been created, and new treatments are being developed to assist physicians in treating dependence and withdrawal of opioids. To review treatment modalities and guidelines utilized in opioid dependence. Guidelines for the treatment of opioid dependence have been developed by organizations such as the American Society of Interventional Pain Physicians (ASIPP) and the American Psychiatric Association (APA). Current guidelines recommend comprehensive treatment with pharmacological agents such as methadone, buprenorphine, or buprenorphine combined with naloxone as well as psychosocial therapy. These guidelines stress the need for an integrated approach to treatment. Office-based opioid treatment is currently being utilized to treat opioid dependent patients in a physician's office setting with buprenorphine/naloxone replacement therapy as an alternative to entering patients into a methadone clinic. These office-based programs offer a breakthrough in access to care for dependent patients. Physicians need to be aware of and adhere to currently accepted guidelines and recommendations for treating opioid dependent patients, including integrating psychosocial treatments and behavior modification strategies for optimal results. Clinicians must be educated on the new treatment modalities and regulations surrounding the use of these therapies.