Hi there. My name is Dr. Kirchen. I'm here and ready to start our noon lecture if everyone's ready. All right, yeah, I think we are. I'm just going to turn the screen over to you, or actually, you're just going to have to hit that green arrow right there if you haven't already done it. Oh, you're already on top of it. All right. Thank you, Dr. Kirchen, for being with us today. Yeah. Hi, everyone. Like I said, my name is Gwynn Kirchen. I should preface my lecture by saying I am not a physiatrist, so I very much appreciate you all letting me join you for our didactic session today. I was made aware of your guys' digital didactics that you have running, which have been phenomenal, and the Pain Fellows at our institution have been kind of made aware and tuning into some of those as they're appropriate to our specialty, and so I reached out to your leadership and asked if there was any way that I could contribute, and one of the topics that they selected was to talk about rational opioid prescribing. This is a talk that I give occasionally at a statewide basis for the continuing education required for our prescribers. It's really going to be kind of highlighted around the CDC recommendations. I know that this may only be applicable to some of you who go out into kind of private practice or whatever it may be when you graduate. We'll all kind of face patients who will be either maintained on opioids or requesting opioid therapy, whether you're running an inpatient rehabilitation program or seeing pain complaints on an outpatient basis. This is likely going to be a part of all of our careers, so we'll spend a little bit of time today about how to do it in a safe way for your patients and the medical legal implications of those decisions, and so we'll kind of get that conversation started. So the goals and objectives of our discussion today is why should we worry about this? What are the risky side effects of opioids? Talk about what the effect of that is on the opioid epidemic, and then just that in our literature there's a lack of evidence for their use in the long term, and then we'll turn to the CDC guidelines and talk about how to safely assess your patient, prescribe the medications if they're appropriate, and risk mitigate the use of those medications. So this is just an infographic that gives an overall summary of the side effects of opioid therapy, and many of these we're kind of well aware of. Here it's pointing to the abdomen, saying that the patients get an ileus and constipation. We're all very well aware of those side effects. One of the ones that is the biggest contributors to morbidity and mortality is the ventilatory depression effect. I had lots of slides about the PCO2 curve and all of that type of stuff that I give to some of my anesthesiology colleagues when I talk to them. I removed some of that because the big important thing is to realize it's the respiratory depressant effect that really leads to a lot of the morbidity and mortality. It results from the effect of the medication at the mu receptor, and there is an increased risk of respiratory depression when a patient is given a large dose, they are at advanced age, they're taking other CNS depressants, or if they have comorbid pathology, particularly of kidney disease in patients treated with morphine. These sorts of things are going to be important later on in the slide when we kind of highlight those patients who are at high risk of opioid therapy, and not shockingly, that's connected to those who are at high risk of respiratory depression from opioid therapy. This is a slide that you may not have exactly seen, but we're kind of all well aware of this national trend that we have, and it's just highlighting that over the last 20 years or so that the rate of overdoses of these substances has really gone up, really other than just methadone, and we'll talk about why that may be in a few slides. This is a meta-analysis coming out of the Annals of Internal Medicine from 2015. I try to, in most of my talks, really highlight literature from kind of medicine, or more overarching specialties, rather than those really kind of nuanced articles that come out of pain medicine and those types of things, because I'm trying to talk about this on a broad spectrum for those of us who will be writing these medicines. And this meta-analysis really shows, if you look at the red box at the conclusion, it says, evidence is insufficient to say that opioids are effective in long-term therapy, but it's clear evidence that in a dose-dependent fashion, there's a risk of serious harm from these medicines. So in that risk-to-benefit balance, risk is clear, benefit is questionable. When you look at the table from that article, you see one of the challenges is that most of these studies were not particularly chronic. They were more on the range of four, six, eight weeks, that type of thing. And in our practices, I'm sure you guys are the same as me, when you are writing opioids for 12 weeks, that barely even feels like chronic. We're so desensitized, because there's so many patients on opioid therapy, and for such long periods of times, we're talking years, maybe decades for some of these patients. And there's no evidence that really greatly highlights their effectiveness. When you look to the right side, you see there's some that show a little bit of pain relief here or there, a little bit of functional improvement here or there, but none of them are particularly strong, and they don't go out to the duration of therapy that we're seeing them used in common clinical practice. Yet, all of these studies clearly highlight that there is a lot of risk associated. So there's an increased risks of patients with addiction and abuse, which is kind of what that CDC slide showed a few slides back, overdose, falls, fractures, cardiovascular events, endocrinologic abnormalities, motor vehicle collisions, and then increased risk of morbidity and mortality with other sedatives, particularly with benzodiazepine. So if you're going to use these medications, we'll talk about how to do it safely. And that's really going to be the focus of our talk, because I see a lot of trainees come in to our clinic, either for the pain fellowship or just as residents, and this is something that I think is really important for people to understand well, so that if you're going to use opioids, you at least do it in the safest way possible for your patients. And also what this slide is kind of pointing out is that the use of opioids is gaining more and more pointed attentions. Physicians have been faced with criminal charges. They've been put under investigation by the DEA, by their personal medical, their like local system. And so if you're going to, when you prescribe these, you need to do it in a safe way, not only for your patient, but also to protect yourself legally and protect your license. So the next kind of big chunk of the talk is going to be taken from the CDC guidelines, which were published in JAMA in 2016, and they broke it down into three major parts, when to initiate or continue opioids, how to choose which opioids to use, dose them and how to follow that, and then how to assess the risk of harms of that chronic opioid use. Now do keep in mind, they did say that this is for non-cancer pain. So when a patient has a cancer diagnosis, it is somewhat different and is not technically falling under these guidelines. Although a lot of what we can learn from these guidelines in our discussion should still be applied to a certain extent for cancer pain, but with a little bit more of a focus on the quality of life when it's for cancer. I would also like to point out a common kind of misconception that I see. For example, if you're seeing a patient for cancer pain, for a pain complaint, evaluate if that pain complaint is metastatic in origin or is non-metastatic and there are other chronic pain complaints. You should still kind of treat those non-metastatic pain complaints in a cancer patient in concordance with the CDC guidelines, because that pain complaint is not cancer related. That's not so much because I feel that cancer patients should suffer. Definitely that's not the case, but that you have to kind of keep in mind that you want to minimize their opioid requirement, decrease the development of tolerance, so that if they do develop cancer pain, that they are responsive yet to opioid therapy. So with that little bit of kind of a soapbox discussion, I'll break into these guidelines. And then I think I can see if any questions come in, so you guys can share those with me as we go. I'm going to see, I just see one from Matt, Matt's my fellow, saying go MCW. So yes, thank you for the MCW shout out and support. Okay, so send a message if you have any other questions and I'll address them as we go. Otherwise we'll have time at the end. So the first section, when to initiate or continue opioids. Remember opioids are not first line and that'll be kind of the first piece we'll talk about here. So this is a screenshot literally from the CDC guidelines. And it just is saying that non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred. Really only go to opioids as a second or third line option when the patient understands the risk and has not had optimal response to the more conservative options first. This is the only slide I'm going to have on that because in my opinion, you know, that's kind of the expertise that we try to really develop in an entire year of a fellowship. Not only how to safely prescribe opioids if they're appropriate, but really what are the other non-opioid pharmacologic or what are the other non-pharmacologic options. And you guys are also developing expertise in a lot of these topics as well. And so, you know, we will kind of skip over this because as we all realize that takes kind of years of practice to develop, but it's a multi-pronged approach. If you ever work with me in my clinic and Matt, my co-fellow or my fellow can kind of speak to it. I often call it a menu and I tell patients we're going to outline a menu of options and then they can choose what they're going to order from it. I don't force anyone to do anything. I don't think that's right. Patients are autonomous in their care. That doesn't mean that I am forced to prescribe opioids either because I am autonomous in what I choose to do and recommend with my medical license. But this is kind of the variety of components that I think need to be treated from multiple angles to get the best improvement in pain and function. Before starting opioids, clearly set treatment goals. Our goals are not going to be a pain score. I'm not using opioids to take you from a pain score of eight to five or whatever that may be. I want you to outline functional goals and we will always revisit this in kind of the lens of function. What is it that you wish to be able to do with opioid therapy that you cannot do now? And I want this in the patient's own words. They need to set their own goals and it may be variable. Maybe they want to be able to grocery shop. Maybe they want to be able to play with their grandkids. Of course, if their goals are unreasonable, like if they say they want to run a marathon and that's clearly unreasonable, we have to discuss that. They need to have reasonable goals. I'm not going to run a marathon and it's not because of chronic pain. It's just because I'm not made to do that. And so that may be the case with your patients as well and you need to kind of clearly discuss that. I like them to set reasonable short-term goals that kind of pace them towards their big picture goal. So if you haven't gone grocery shopping at all because you can't do it, you're not going to go from here to running through the grocery store with one oxycodone in one week. So what are reasonable things? Can you at least park your car and walk up to the door and take the riding cart from there? And then make small stepwise improvements towards what we expect while using the opioids to allow you to do the rehabilitation that you need to get there because if you are deconditioned, the opioids in and of themselves will not make you functional. The opioids help you manage your pain in a way that you can work on strength and function on your own accord. And keep in mind that clinically meaningful improvement is at least 30% improvement in pain or function. We cannot set the expectation that opioids or any of the therapies we do will take your pain away in entirety. Meaningful improvement is 30 to 50%. And so patients need to be made aware of that, otherwise you're just going to be chasing an outcome that is not feasible. And that's in many ways how we end up with these patients on really high opioids is because their expectations may be misconstrued. So there are some objective validated functional assessment tools that I encourage you to look at and consider using in your practice. So not only can you have them state in their own words what their goals may be, but these validated tools allow you to still have some sort of objective data that you can track over time. This is the brief pain inventory developed by the World Health Organization pre-Donald Trump defunding them, I suppose. And it was validated technically in cancer care, but can we utilize that in also non-cancer care as well? And it is available in the short and long form. There's also the form called the PEG, which looks at pain intensity, interference and enjoyment of life and interference with general activity. And that is a really nice, easy tool that can be used to look at pain. Sorry, I just realized I can also put my video up really fancy if anyone wants to see my beautiful office as well. And this is a really easy one for the patients to do. It's only three questions and you can track that over time. I would rather trend these metrics over time than their pain score. And then when I revisit with them at future appointments, see if they have made quantitative improvements in their functional assessment and then also qualitative improvement in regards to what did you set as your pacing goal towards your big picture goal and have we gotten there. So now I can both quantitatively and qualitatively assess what strides they've made in their functional goals to define if they're receiving the benefit that we expect in that risk and benefit. Because of the meta-analysis says we don't have proof of benefit in the long-term, but if the patient specifically has benefit, then perhaps it's reasonable to be using opioids. Before and periodically throughout opioid therapy, continue to revisit the risk and benefits. We've talked about how to assess benefit personalized to the patient, and now we got to talk about the risk. So there's the overarching risks that I introduced in that meta-analysis of falls, fractures, heart attacks, hormone irregularities, but you also need to critically assess the patient's independent risk and be explicit about it. Share with them that on a population-based meta-analysis level, break that down in patient understandable terms that we don't have any evidence that it's helpful, but we do have a lot of evidence of the risk. That risk is dose dependent. Once you get to the equivalent of 50 to 100 morphine equivalents, your risk goes up, and that risk goes up even more significantly when you're at doses of 100 morphine equivalents or more. That was kind of shared in the CDC literature. There's also a VA study that kind of corroborates those findings. Those who overdose were more likely on higher morphine equivalents compared to controls. Those who overdose had an average of around 100 morphine equivalents compared to controls being 50. They found there was a disproportionate risk of overdose in patients who are on methadone, and that's because the pharmacokinetics and the pharmacodynamics of methadone are quite challenging, and so providers who are not comfortable with those nuances of prescribing may set their patients up for risk or patients who self-escalate or take more than they should are putting themselves at risk of methadone overdose. It's probably because we clearly see that methadone disproportionately causes overdose or is seen in those who overdose that providers have somewhat shied away from prescribing it. If you remember that CDC slide I showed you at the beginning, the overall number of methadone overdoses has remained relatively stable even in the context of opioid overdoses climbing. That's probably because more and more people are shying away from prescribing methadone with this focus on overdoses. Again, also an increased overdose risk when you co-prescribe opioids and benzos, and we'll talk about that with greater clarity in a few slides because the CDC gives an entire number in their 1 through 12 of what you should do to safely prescribe opioids just dedicated to this point. The thing that I'd like you to also visit is remember different opioids have different potencies, so you need to take them all back to their morphine equivalents with a conversion tool to define what your patient's morphine regimen is. Be sure to look at what they are actually taking and receiving. In the computer, it may say they take hydrocodone 5q4 hours, but if you look at what they've actually been prescribed, you may see that they're not actually taking it that often. Maybe they only take two of those pills a day, and that's important to know what they are actually actively taking. How do you risk assess the patient for aberrant use of their medication? There are a variety of validated tools as well to quantitatively risk assess your patients. Now, these were validated for patients who are opioid naive that were in consideration of starting opioid therapy. That may happen sometimes in your practice. There's also a lot of times that you may just be inheriting or seeing as a consult a patient who is already on opioid therapy. While these weren't developed for that purpose, they are used for that purpose very often in clinical practice. The two most common are the opioid risk tool and the SOAP. This on your screen right now is opioid risk tool. It's a little bit more challenging to score. The questions are a little bit more obvious, and then you see that scoring rubric at the top of that risk tool. It's kind of seeing if the patient or their family has comorbid diagnoses that put them at risk. I see a question coming through. What is the goal or point of calculating morphine equivalents while prescribing opioids? It's so that you have greater clarity in how much opioid your patient's actually taking because it's hard to realize where they fall in the lines of that risk categorization when they're on different medicines. If they're taking hydromorphone or Dilaudid 4 mg PO, that may sound like not a lot, but you need to convert that to morphine equivalents. The common conversion for that is about three to fourfold. Now that's actually kind of 12 morphine equivalents. Compare that to hydrocodone, where if they're on 5 of hydrocodone, that's 1 to 1 to morphine. That equals 5 morphine equivalents. You want to figure out what they're taking on a typical basis between long-acting and short-acting if they're on both of those medications. Convert that to morphine equivalents so that you can look and see what their risk is because we see that the risk really goes up at around 50 morphine equivalents. That is why some states and the CDC kind of make some recommendations about those upper dosing limits, which we'll talk about in a few slides. That's why. You just need to kind of take into account what they're taking. Then, since all of these guidelines are based on morphine equivalents, you need to convert them to morphine equivalents so you can kind of make the right recommendation for your patient. Hopefully, that kind of answers that question. The opioid risk tool is one option. The next option is SOAP. I prefer this one because the scoring is easier and I think the questions are less obvious. It was first developed as a 24-question long form and then validated in a seven-question and five-question version. So I prefer the five-question version because it has similar enough sensitivity and specificity while being far more user-friendly and you'll have a far greater level of compliance of your patients actually filling it out or your MAs administering it. And then this you can look at to kind of, again, score where their risk profile is. And this is easier to score because it's just you add the numbers up rather than this is for three points if you're a boy, two points if you're a girl or those types of things which makes it more challenging. So these are all options for kind of assessing your patient's risk for aberrant behavior with opioid therapy, which is part of that patient-specific risk profile. The other patient-specific risk profiles are, do they fall into one of those categories at increased risk of respiratory depression? Do they have kidney dysfunction? Do they have pre-existing cardiac disease, pre-existing pulmonary disease or sleep disordered breathing? All of that puts them at increased risk as well. So there's part of those generic risks and benefits, which I highlighted at the start of the talk from that meta-analysis. And then there's this patient-specific risks and benefits. What are the patient's comorbidities putting them at increased risk of respiratory depression? What are their comorbidities that put them at increased risk of aberrant behavior with opioid therapy? And that's what the ORT or SOAP is to help you kind of formally assess. Which tool is on this slide, the previous one? So the first one was the ORT. This is the ORT and this is the SOAP short form, the five question version that's over here on the side, Screener and Opioid Assessment for Patients with Pain. If you Google that, you'll find it. I think some of these are even available on like MedCalc or that sort of thing. But this, you know, you don't need one of those fancy calculators to define because you just kind of add it up. So in our practice, we have had it where we just print these off and they fill it out. Our practice currently uses the ORT because I'm not the boss of everything. I say that kind of tongue in cheek. You know, I try to make jokes. It does, I tell dad jokes, they're not great and it doesn't work out great on the internet. But we'll likely be moving more towards the SOAP. And so that's something maybe write down in your little notebook on your phone for when I go into practice, if I'm gonna do it, maybe consider the PEG scale for functional assessment. That's the easiest one. And then the ORT versus SOAP for assessing the risk tool. There are some private insurance companies in the state of Wisconsin that require us to document scores for both of those categories before they will give us pre-authorization to put them on chronic opioid therapy. So hopefully that answers your question. We'll keep it moving. All right, so consider it like it's a surgical consent and really talk about the risk and benefit, the overarching one seen from the meta-analysis of what we know from chronic opioid therapy and the patient-specific ones based on their medical comorbidities and the risk assessment for aberrant behavior. That's kind of the first risk benefit part. And then also outline in that risk benefit, we call it our opioid agreement in our clinic that they have to sign. It not only highlights like it's a surgical consent, but then it transitions to expectations of behavior on both my side as the prescriber and on their side as the patient. And that kind of highlights how often I expect to see them, do drug screens, my expectations about other substances and the kind of requirement that they engage in their care in some way other than just opioids. I do not trade a you get opioids for an injection. I do not force any patient to get an injection, nor do I, you know, you must take Lyrica, you must take this, that, or something. I, again, highlight a menu of options. I kind of jokingly say, you know, I'm kind of your waitress. Tell me what are you willing to consider on this menu for your care, but it will not just be solo opioid therapy because we clearly know in the literature that chronic pain is best targeted with a functional approach, multimodal, multidisciplinary. So that is that first chunk of the CDC guidelines. So if anybody has any questions about that, please submit them. We are going to move on to the second piece of the CDC guidelines. This is gonna kind of highlight how to choose an opioid, what dose to start at, for how long, and how to safely follow up the patient. So these five pieces are what we're now going to break into and discuss. When you start opioid therapy, you should start with immediate release medications rather than extended release because of the safety profile of them. Our orthopods used to send patients home after total joints with an extended release oxycontin and short release oxycodone. They have gone away from that practice with some of our recommendations, and it's in line with these safety parameters of concerns. We do see that there's an increased risk of non-fatal overdose with extended release opioids, so that's the big reason why the CDC recommends against it, and nothing that clearly shows that extended release is better than immediate release. If you do feel like an extended release medication is recommended, I probably, in my practice, do this most often for cancer pain patients, but of course, it's kind of valid across the board. You should kind of try to choose one that has a predictable pharmacokinetic effect or a predictable pharmacokinetic or pharmacodynamic profile. So of the options, there's methadone. Methadone is long-acting as an inherent property of the drug itself. The other long-acting agents on the market are long-acting based on the way that they are encapsulated, so that's an important thing to differentiate. The encapsulated ones, like MS content or long-acting morphine or oxycontin, which is long-acting oxycodone, there's also some other long-acting hydrocodones on the market in tramadol that are a little bit more, you know, have kind of come around in the last five years or so. Those cannot be cut or crushed because it can be dangerous to them. Now, they make some that are abuse deterrent, where if you crush them and snort them or inject them, they don't give you as big of a high, but I have seen pharmacists and some other prescribers tell a patient, oh, I'm trying to wean you down on your oxycontin, just cut it in half. That's a big fat no, don't do that. Not safe for the patient. Now, that does make it more challenging to titrate up or down on the drug, but you need to be aware of that when you choose what to do for your patient. Methadone has advantages. On the other hand, it comes in a liquid. The tablets can be quartered or halved, and that gives you more flexibility in dosing, whether you're titrating up or weaning down, but you need to be made aware. Again, like I said, pharmacokinetics, pharmacodynamics of that drug are really challenging. It's a challenging medication to initiate. It takes a while for them to get to systemic levels of that medicine. Keep in mind, methadone, its analgesic half-life is about eight hours, so if you're using it for pain, that has to be done on a BID or TID basis. If it's for addiction, it's a daily basis. If you guys have more questions or interest in methadone or buprenorphine for pain management, I also have a lecture that I give for that, that if anybody has interest, I'd be happy to offer as well. So we won't dig into that too much because I have a whole hour that I talk about just about that, but just leave it to say that it's a good drug because it's cheap. It is not too dependent on the kidneys or liver if they have liver or kidney disease, and you can half it or quarter it and it comes in liquid, but that's offset by the fact that it is a really, really complex medicine, so it's generally not a starting medicine for long-acting. You have oxycontin, which is the most potent of them all. MS-contin, which is morphine-based. Remember, morphine has active metabolites that rely upon the kidney to clear. So in the setting of kidney dysfunction, morphine is a bad choice because those active metabolites build up and increase the risk profile of that medicine, of side effects and morbidity and mortality. The CDC also says that only clinicians who are familiar with the transdermal absorption, pharmacokinetics and pharmacodynamics should be using a fentanyl patch. The biggest error I probably see in that regard is just not a clear understanding of how long it takes that fentanyl to reach systemic levels when deciding how to titrate that med. That can take 24 to 72 hours to reach full systemic levels, and so you should not be titrating that medication every day. Long-acting medications, in general, those decisions of how to titrate it should occur over days to weeks, and the fentanyl patch is no exception. I probably see the most errors in this kind of prescribing in the new cancer diagnoses where they escalate opioids quite aggressively, and so I encourage you to go with a bit of caution in that regard. When you start opioids, use the lowest effective dose. Use caution when you increase the dose and reassess the patient-specific benefits and harms when you are choosing to go up on those doses. Be very careful when you're going over 50 morphine equivalents a day, and avoid increasing over 90 or carefully justify it or incorporate a pain medicine specialist. All right, sorry, I clicked ahead too far. So this is where you want to be able to convert those medications to morphine equivalents. Here's a table that gives an example. Parenteral means it's given IV versus oral, meaning it's by mouth. And so morphine, 10 milligrams of IV morphine is equal to 30 of oral morphine, and then you can kind of follow it from there. There's a variety of good online calculators that help you convert everything back to oral morphine equivalents, and then that's how you apply these risk parameters. So the CDC says if you're going to go over 90, you should incorporate a pain specialist. That probably means a pain medicine boarded physician with kind of the knowledge of the complexities of the opioid and pharmacologic management. That doesn't necessarily mean that the pain expert will kind of take over prescribing those medications, but you should at least have their expertise on board as a consultant for the care of your patient. Now, keep in mind, this is about when you are initiating or escalating these doses. There was a letter to the editor of JAMA in the last year talking about these legacy patients who've been maintained on these chronic high-dose opioid regimens, and that many providers are using these CDC guidelines as an argument that they have to cut those patients aggressively or cut them from their practice. You should not just send someone to the streets and cut them from 200 morphine equivalents to zero overnight, and if they maintain function and do well on opioid therapy, it may not mean that they necessarily need to wean to nothing. In my practice, I still don't feel that there is much clinical use for being over 90 morphine equivalents, so I still aggressively try to wean these patients down over a reasonable period of time, and I have very, very, very few patients that I maintain on that high of an opioid regimen. If you are in my practice and you are on opioids, I don't have a lot, that's not a very big group in my kind of practice, but most of those patients are between 30 and 45 morphine equivalents in alignment with these safety parameters that we know for their appropriate risk-benefit balance. You guys have any questions about that, send those in, this is sometimes a slide that generates a lot of questions. Be aware that long-term opioid use often begins with the treatment of acute pain. In my world, I'm talking a lot, lecturing a lot to surgeons about the role of surgery in starting on chronic opioid therapy. You guys will probably see a lot of people with acute injuries who just get three days, five days, a month of opioids, and we use that pretty comfortably without maybe totally being aware of the risk that that puts a patient at of still being on opioid therapy months to years down the line. So that's why the CDC recommends using the least amount possible without a greater quantity than what should be expected to be needed to treat that acute, severe pain. Often, you need no more than seven days. In the state of Wisconsin, if you are trying to write anything longer than three days, it requires a little bit more paperwork, and that's in alignment with these sorts of recommendations and guidelines. Be aware of the gateway effect of acute pain needs. Dental work is a big reason that people get started on opioid therapy, injuries, and other things like that. So I'm gonna go through about two or three slides from some great work out of Michigan by Dr. Chad Brummet. His group found that for patients who receive opioids for acute needs for perioperative pain care, greater than 70% of the opioids that patients are sent home are not used. So prescribers are sending them home with more than they should need, probably to prevent the need for the patients to call in. In some states, that has required the patient to come in to get a physical paper script. In the state of Wisconsin, we've gone to digital prescribing of controlled substances just in December. That, I think, is very good for patient safety and care, because then you're not gonna have people writing more than you think the patient needs, just so that they don't need to come in to the ER to get a refill on the weekend. Now, some other doctors have said, well, if I write them less, will they be less satisfied? Will they rate me lower? Will they need to call me more? Will they need to call in more refills? All of that can lead to a logistic nightmare. What Dr. Brummet's group found was that there was no correlation between the patient satisfaction scores and how many opioids they left with after surgery or a hospitalization, no correlation with how many phone calls the patients left with the group, and no correlation with how many calls in or requests for refills. So if you give a patient less, the patient is kind of a little bit more aware of how they use their medicine and use it probably more in concordance with kind of appropriate opioid use. Their group also found that patients who were not on opioid therapy, who came into their medical system and had surgery, had a six to 10% rate of still being on opioid therapy a year down the road. That probably may initially sound like not a very big volume to you, but think of, in your entire hospital system, how many opioid-naive patients come in and have surgery? Look around the pre-op or the PACU if you ever wander through there and think of 10% of them are still gonna be on opioids a year down the road. That is a huge amount of patients. So with some of this data, Michigan has put together what's called the Michigan Open website. At this part of the lecture, you may be a little bit bored. We've lost about 10 of you. That's fair. Pull out your cell phone, entertain yourself for three to four minutes while I continue to kind of blabber on at you. Open your camera app, and this QRS code will take you to that Michigan Open website. Now, when you guys graduate and go into practice, this may be something that your system is kind of looking at. The Michigan Open group will, for free, put any hospital or company's logo on all of the paperwork and pamphlets that they've developed. You can just email them a JPEG or whatever of your logo, and they will add it on for free and send you this in a PDF. This is an example of a poster that they've created. On their website, they have a handful of educational pamphlets, both for providers and patients, and posters for patient education as well. This is to, again, remind that you talk with your patients if you send them out with opioids as to how to safely dispose of their leftover pills so that they don't hang around for someone to use aberrantly or to divert to unsafe usage. On that website as well, they go over the most common 20 to 30 surgical procedures and how many opioids the average patient needs, and from that, they looked at the distribution and recommended around the 75th percentile of what the typical patient needs as what to send patients home with after surgery. I had someone ask, when I gave this lecture yesterday, to some physiatrists, what should this mean when a patient hits my inpatient rehab after surgery? Well, for all reality's sake, if a patient's got admitted to rehab after your inpatient rehab after an open COLI, it probably reflects that they either were very frail going into surgery or had a very complicated post-operative course, so that's somewhat different. This data is outlining how many opioid tablets a patient needs after they are discharged. That would probably mean after discharge from the hospital, not after discharge from your rehab, so I would outline kind of a goal or consideration that when they hit your rehab floor that you're trying to keep them to maybe only need 15 or so opioids once they're admitted from the hospital floor. That's hard to do if on the hospital they've been really, really highly escalated on their opioids, but by the time they get to rehab, I would encourage you to have good discussions with your patients and your staff that the use of opioids is to help them return to function, and so it should be used in collaboration with their physical therapy or occupational therapy time period, not so much just to be used for them to lay in bed with a pain score of zero, but with a focus on their return to function. So hopefully you will find some nice resources that you can carry forward with you in your practice in the future. This came from the CDC, and it shows the probability of still being on opioid therapy depending on how long your first prescription is at one year for the solid line and three years for the dashed line, and their statisticians found that that rate significantly has an uptick after five days and 30 days of opioid therapy, so it's even within that first refill window. That first refill that a patient calls you to ask for is a really high-risk period. It feels like not that big of a deal, right, to just give them, oh, they've only been on it a month, they can have one more month, we'll see, but actually looking back statistically, that is a really high-risk period. So I tell my patients this. If I do a surgical like stem implant in them, I tell them we will not be refilling your opioids beyond this first initial period because I clearly see that we know from the evidence that that increases your risk of being on opioids one in three years down the line, and that's what I'm trying to treat you to partially prevent, and so I won't refill that opioid after that first script that they get from surgery unless there's pathology that aligns with their continued nociceptive pain that requires opioids, like an infection or a wound issue. Clinicians should reevaluate the harms and benefits within, sorry, I gotta lower my thing here, within one to four weeks of starting opioids or dose escalation, and then reevaluate every three months. Continue to look at the overarching risk and benefits and the patient-specific risk and benefits to decide if it's reasonable to continue medicine or if you should taper or discontinue it. So in my practice, if I start you on an opioid in general, I see you back in one month. If you're on stable doses, you see myself or the nurse practitioner every two months. If we're using riskier medications like methadone or are making bigger conversions, then I see them more often. Sometimes you may consider an opioid rotation if their opioid therapy is starting to lack efficacy. Keep in mind because of incomplete cross-tolerance, you'll want to decrease the dose of your new medicine, so you'll calculate the equivalent perhaps as you rotate from oxycodone to Dilaudid, but then you'll want to decrease that dose by about 50% for their safety. And when I'm doing an opioid rotation, that's also a time period of particular risk for morbidity and mortality. And so that will be a patient that I will see sooner. If it's a very risky conversion, maybe I see you back in one to two weeks. If it's moderate risk, I'll see you back in a month. And then if you're stable on that conversion dose, then again, every two months. Things that you're gonna follow up on. A mnemonic that you may find helpful for me, I don't love this one but maybe it'll help you, it's called the four A's. And what you're looking at is what are the pros and what are the cons. So on the side of the pros, what degree of analgesia or pain relief are they getting? And then the other pro, activity. The other A, that's function. What kind of gains are we making with these opioids in regards to analgesia and activity? This is where I think there's a lot of value in having the both quantitative assessment forms, you can revisit what was your PEG score before, what is it now? That gives you a notion about activity. And then also the patient's qualitative report. And part of that, compare it back to what they had set as their functional goals for therapy and how what progress they're making in that regard. And then on the con side, you're looking at the bad effects. Again for A's, aberrant behavior. Have they self-escalated? Have they taken things illicitly? Have they taken from their friends, bought things off the street, things like that? Are they having aberrant behavior or dysfunctional behavior? We're not giving you opioid therapy so you can more comfortably kind of watch TV all day. I would consider that some degree of aberrant behavior, not enough to kind of meet addiction criteria, but just not the purpose of this therapy. And then adverse side effects. Think back to that first slide I showed you that had that infographic of all of the different side effects. Are any of those things happening? Are you constipated? Do you have altered mental status? Are you feeling slow and fatigued? Are you having any of those side effects to kind of show patient-specific risk? So that is the second chunk. We're going to move on to the third chunk as long as people don't have any questions. These ones are kind of a little more straightforward. Before starting them periodically during opioid therapy, check a urine drug screen. Oh sorry, I think I'm on the wrong one. You should evaluate the risk factors for opioid-related harm. So revisit that opioid risk tool or the SOAP tool. See if things have adjusted and if they have a higher or lower risk of aberrant use at this point. Incorporate strategies to decrease this risk. When you are concerned that a patient is at increased risk of aberrant behavior, document that. Critically assess it and make sure, since you're really concerned about their aberrant behavior, that it is giving them really good benefit that warrants continuing that medicine. If you have any of these concerns, prescribe them naloxone so that they have an opioid antagonist on hand. In the state of Wisconsin, there is a standing order at our pharmacies that anybody can walk into the pharmacy and pick up a script for naloxone. So sometimes I'm educating the family member in the room, like the wife or the daughter, if you are worried about, you know, your family member's opioid use, let's talk about that and be aware that you yourself could even just go to the pharmacy and pick up a Narcan script. In cities where there's a high rate of opioid overdose, like Boston, there are some people who just carry this on their person just so that they can be a first responder in the case of an opioid overdose as well. And that can be obtained if you want to be a person like that. Again, add a standing order at a pharmacy if you feel so inclined. Again, those patients who are at high risk of opioid overdose are those who have a history of overdose, a history of substance use disorder. I would argue that those patients in my practice do not get opioid therapy unless we're treating palliative cancer pain. Those patients, if I am prescribing with those high risks, I would prescribe Narcan because although they may have cancer, they may not want to die of an overdose. They want to be comfortable as they live and palliate their cancer pain. Patients who are on higher doses or have concurrent benzo or CNS depressant use, consider giving them Narcan therapy as well if you're concerned about risk of harms. Now again, who is particularly at those risks of harms? This is the same as that slide of those who have increased risk of respiratory depression from opioid therapy because it's the respiratory depression that gives you morbidity, the bad morbidity like non fatal overdose or mortality, fatal overdose. Who are those patients? Patients who have sleep disordered breathing, sleep apnea, be cautious in pregnancy. It's not that you cannot use opioid therapy but you should do this in conjunction with expertise of an obstetrician. Patients who have renal or hepatic insufficiency, you may need to kind of choose particular opioid therapy options that are less dependent on either of those organs in the metabolism. Patients who are elderly, 65 or older, who have comorbid mood disorders because that puts them at increased risk of aberrant use. It's also possible that they may be using the opioid therapy partially to treat the suffering associated with pain, meaning the mood and anxiety effect. The one thing that chronic studies of opioid therapy have shown, like the SPACE trial, is that the most effective benefit in the long term of opioids is anxiolysis, but of course the risk benefit is not appropriate to use chronic opioid therapy just to treat the anxiety associated with chronic pain states. Those with a history of substance use disorders or a history of overdose, like I said in the last slide. Review the PDMP, the Prescription Drug Monitoring Program. These are different in every state, but you should have an online tool where you can see controlled substances, what pharmacy they were filled at, who prescribed that medication, and when that was prescribed and when that was filled. That gives you greater ability to see what other sort of controlled substances your patient may be taking. In the Milwaukee area where I practice, most of our psychiatry colleagues are not on electronic medical records, so I cannot see what they're prescribing. This is a really good way that I'm able to see if a patient's on anything for anxiety, like a benzodiazepine, because that's probably the subspecialty in our group that writes the most of them, is psychiatry followed then by primary care doctors. The only way that I may know that a patient is getting concurrent benzodiazepines is from review of their PDMP. This is also a way that you can see if they are on codeine as a cough syrup, which again is a controlled substance, if they're getting tramadol from someone, because some people may feel like that's a relatively benign drug, but I still point out that is an opioid and I consider it as such in my practice and they can't be on that if I'm prescribing opioids. This should be reviewed at least every three months per the CDC. In the state of Wisconsin, it has to be reviewed with every opioid prescription that is for a duration in time greater than three days. I feel like it, in my medical opinion, should be reviewed for every single controlled substance prescription because a patient can overdose and is actually at one of the highest risks of overdose when you are starting or changing their medications. So I recommend that you look at that for every prescription. I also recommend when you are admitting a patient to the hospital or to rehab that you look at the PDMP as well as a secondary confirmatory source of what the patient is taking. They may under-represent what they're taking because they don't want you to think something negative about them. They may over-represent what they're taking so that in hopes that you will start an opioid therapy in an escalated dose and send them home with more. So you want to confirm it on both sides of the spectrum that they're not under or over-representing what they take on a chronic basis. You want to then use that as a resource to reach out to other prescribers if that is appropriate to discuss. So for example, if I have a psychiatrist who's giving my patient chronic benzos, I may reach out to them and say, can you safely taper them off of this benzodiazepine over this next month? The patient wants to continue their chronic opioid therapy but I will not do it if they are also on benzos. And so in that scenario, that's the kind of case where I will give the psychiatrist one month to get them off of benzodiazepine therapy. I will use Narcan in that interim period. I will bring them back one month later and again review the PDMP and a drug screen and contact the psychiatrist and make sure they're not on that benzo anymore for the patient's safety. I use that drug screen at the initiation of opioid therapy or when you establish with my clinic and then at least annually. What you're looking for is that the substances that you prescribed are there as you expect. If it's not there, is it because they diverted? Is it because they self-escalated and they ran out? And then you also want to make sure the things that you don't expect to be there are not there. Other illicit substances like marijuana, which is illegal in the state of Wisconsin, so I treat it as such. And because I don't have any great studies that shows the safe use of concurrent marijuana and opioid therapy. And so that is a policy in my group that they can't have marijuana in their system. I'm also looking for other opioids that I did not prescribe. I'm looking for particular metabolites that show that it is heroin. The metabolite that you would be looking for is called 3-MAM. I was just looking at my cheat sheet because I can never remember. That means that it came from heroin, not from anything PO. And then in my group we use very fancy labs that break it down by metabolite and show you even systemic levels of all this. If your group perhaps just does a more inexpensive lab where it just shows yes or no, you should look to see if you have the capability then to send for reflexive testing that breaks it down more clearly. Is the opioid positive because of oxycodone or hydrocodone or that type of thing? Be aware that many lab-created tests are not able to pick up some synthetic opioids. You may need to request a separate screen for oxycodone. I get a UDS annually. More often if I think a patient's on a very risky regimen or that I think that their risk profile personally is high for aberrant use or if I am doing a wean on them to make sure that they are complying with the wean and not getting opioids from other sources. You should remember how I said the CDC has a whole section just about not using opioids with benzos. This is it. You should avoid writing them concurrently whenever possible. It has the highest safety, one of the highest level safety warnings possible with the FDA putting a black box on their concurrent use. In my practice there is no chronic use of benzos and opioids. Now I've had one or two where their mom died and for one month they were on benzos where they got off of benzos over a month before starting opioids with me, that type of thing, but it's not done in a chronic basis. Keep in mind that there are other CNS depressants like sleeping aids that also carry risk, particularly if the patient has other comorbidities that puts them at risk like sleep disordered breathing or elderly age. Patients cannot stop their benzos rapidly because that can lead to death so that it should be done with the support of their benzodiazepine prescriber. This graph comes from the CDC and it just shows the proportion of patients who are on concurrent benzos and opioids of those who overdose. Studies show that that rate is typically about 30% of those who overdose are on concurrent therapy and so that is over represented compared to the patients who are treated with that medication and so that is an increased risk if you are using those concurrently. This is the last one of the 12-point CDC guidelines so we are getting there. Clinicians should offer or arrange for evidence-based treatment for addiction or opioid use disorder if you have those concerns. How do you kind of define those concerns? Well first there's tolerance. Tolerance is not the fault of anyone, it is just the way that the body works. A fixed dose has decreased in effect over time. When a patient is coming to you to report that the opioid therapy is not working as well as it used to, reassess their personalized risks and benefits. It's reasonable to increase that dose to reasonable opioid doses. That means less than 50 milligrams oral morphine equivalent. At this point you could consider a dose an opioid rotation keeping in mind the incomplete cross tolerance so you know come out with what their equivalent dose of that other opioid would be and then decrease it by 50%. Because of incomplete cross tolerance it should be equally efficacious while helping you get further away from those higher doses that are an increased risk. Dependence is when you are physically dependent where if you don't take it you have withdrawal symptoms. Again that's not particularly like the patient's misbehavior, it's just the way the body works. And I use the analogy to try to kind of de-stigmatize this of how I drink coffee. My body is now tolerant and I am even dependent. I'm a crab in the morning until I drink my coffee because I'm physiologically dependent on it now. If I stop using it for a period of time then do a drug holiday and return to caffeine therapy it is efficacious again. And that's the same thing we see with opioid therapy. And then finally there's addiction and that's when you have some degree of misbehavior or life-altering behavior that you accept just to get that medication. I'm partially probably somewhat addicted to caffeine therapy. I went to Starbucks yesterday in the middle of the pandemic because I just wanted a really good latte. So I'll kind of use those stories as a way to break the ice and de-stigmatize it but educate the patients about those risks. And it's when we start to see those addictive behaviors that we really worry and I need to bring in expertise for my addiction colleagues. Now we have a paucity of addiction specialists in our country. Milwaukee is no different. But do try to have a relationship with someone to send your patients if you're prescribing these medications. They may just do talk therapy or psychology. They may recommend medication and consistent therapy. The CDC says if you have major concerns or interest in this you can get your own waiver to prescribe methadone or buprenorphine for addiction. And that can be done but that requires kind of a dedication to learning another entire subspecialty in my opinion beyond just learning about methadone or suboxone. So here's our summary slide again. These are the things that we talked about today. And at this point I'll transition it over to questions. I think kind of the overarching theme is educate yourself in the evidence-based risks and benefits of chronic opioid therapy. Be aware that the risks have a dose-dependent relationship. So someone who takes one Vicodin a month or one Vicodin a day for their polyarthralgias from their you know severe arthritis may be reasonable but that's a very different story as you get to that 50 morphine equivalents or higher. Then also risk assess your patient for their specific risks for harm and their specific benefit from therapy. Use validated tools to assess that like the PEG, the ORT, the soap and circle back to that when you re-evaluate your patients. I don't know if the moderator has any questions that anyone sent in or if anybody has something to find. Hey Dr. Kirshen thank you so much for this talk. Thank you for having me as well. And that is my email if anyone wants to reach out. Perfect. Yes I'm looking at the chat here and here you go. Do you have any specific method for how you do opioid de-escalation? Beautiful question. I get that a lot. So that is dependent on how significant I feel the risk profile is. If my concern is that you know I'm seeing you in the hospital and you just tried to overdose on your opioids, I am going to wean those opioids aggressively over the period of hours to two days. You can decrease a patient's opioid dose by 15% every one to two days and they should not have severe withdrawal. If you are decreasing you can use tizanidine or clonidine as an adjunct to decrease the sympathetic effects of opioid withdrawal which is where they feel miserable. Keep in mind compared to benzodiazepines you won't die from opioid withdrawal but it can be unpleasant. Then there's the patients who've maybe been on opioids for months, years, months or years or decades that you're trying to de-escalate. Those patients I will decrease more slowly. And then again I decrease by about 10 to 15% at a time, maybe every week, every month, every two months, depending on the reason why I'm trying to get them off a bit. If it's just a lack of efficacy but it's not particularly unsafe maybe we decrease every month. If it's because it's a mix of unsafe and lack of efficacy then I'll probably decrease you every five to seven days so we get you off entirely in about a one to two month prescription. If they're on long-acting and short-acting as you're trying to wean them down, I try to assess which one of those I am more worried about in regards to risk and then I will wean that one first. If it's kind of equivocal that they're equally risky and equally lack of efficacy then I will somewhat empower the patient to choose. Keep in mind when you're weaning a long-acting medicine that you may be somewhat dose limited by what form what it is available in your formulary. MS content only comes in certain doses, oxycontin only comes in certain doses, so you may need to kind of make yourself aware of that and go from there. For example, if I have a patient on like MS content 30 BID then often I will go from 30 BID I'll do one dose of 15 and one dose of 30 for a week. Then we'll do 15 BID for a week then we'll drop one dose of the day and then they get the other 15 and so that's how we work it down. If I'm decreasing a long-acting I don't tend to decrease all two or three doses of the day at one point if I'm trying to do it more slowly I'll drop one maybe every week or every month depending really how slowly we're taking it. Then like I said you can support their withdrawal side effects with tizanidine or clonidine because they both have a sympathetic blockade effect. Studies show that those who succeed the most with weaning opioid therapy are those who are self-selecting to wean their opioids. Now that doesn't mean that I will wait for a patient to come to me to say that they want to wean their opioids if I feel that the risk-benefit is not appropriate in my medical opinion. I'll try to educate them to get them on board. If it's appropriate I'll try to find ways for them to choose and have some autonomy in this process like letting them decide which medication they want to drop first or that type of thing. Then I always offer them to establish with my pain psychology group because if at least they are not self-selecting for their wean outcomes are better at least if they have psychology support and so those are kind of the different ways that I help with that. If I'm trying to do a drug holiday prior to surgery or something I'd like to have them off for one to two months. I also do a drug holiday if for a patient if they're going to have advanced interventional procedure with myself like a stim or a pump trial I want them to have a drug holiday and wean entirely off before that. So hopefully that kind of addresses your question let me know if there's anything else in that regard and hopefully Matt he just said thank you to everyone can kind of corroborate that this is how we try to practice at here at the Medical College. I don't think there's any more questions coming in thank you so much for your time. Once again thank you so much to the AAP for you guys in your dedication to digital learning here in these challenging times and being open to someone of my background coming to lecture to you guys about something slightly different. Be safe everyone thank you. Thank you absolutely and you can find the schedule including tomorrow's lecture with the zoom link and any recording of any of the past lectures at that link on your screen right there let me share it and otherwise we'll see you guys tomorrow for another day of AAP didactics. All right have a good one everyone.

rational opioid prescribing

CDC guidelines

medical specialties

side effects of opioids

opioid epidemic

long-term use of opioids

treatment goals

risks and benefits of opioid therapy

Prescription Drug Monitoring Program

evidence-based treatment