Opioid Prescribing, CDC

View the Opioid Prescribing modules offered by CDC:

Options for reviewing the modules include:

1. View slides
2. Listen to transcript,
3. Read the transcript
4. View the webcast (if compatible)

I recommend that you view the slides while listening to the transcript (A&B).  You will have to advance the slides per your estimate of when the slide should change based on the presenter’s content.

For the paper,

1. Summarize of the main concepts for each of the modules reviewed.
2. Identify a conclusion or plan for opioid prescribing as an APRN.
3. The paper is to be 1000-1200 words, excluding title page and references. Use APA format.

Expectations

• Length: The paper is to be 1000-1200 words, excluding title page and references.

  CDC’s Guideline for Prescribing Opioids for Chronic Pain is intended to improve communication between providers and

  patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain

  treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose.

  The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

  Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

  Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

  Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

  DETERMINING WHEN TO INITIATE OR CONTINUE OPIOIDS FOR CHRONIC PAIN

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  CLINICAL REMINDERS

  • Opioids are not first-line or routine therapy for chronic pain

  • Establish and measure goals for pain and function

  • Discuss benefits and risks and availability of nonopioid therapies with patient

  IMPROVING PRACTICE THROUGH RECOMMENDATIONS

  LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html

  GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN

  When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.

  When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.

  Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

  Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

  OPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, AND DISCONTINUATION

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  ASSESSING RISK AND ADDRESSING HARMS OF OPIOID USE

  Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.

  Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

  When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

  Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.

  Clinicians should offer or arrange evidence-based treatment (usually medication- assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

  CLINICAL REMINDERS

  • Use immediate-release opioids when starting

  • Start low and go slow • When opioids are needed for

  acute pain, prescribe no more than needed

  • Do not prescribe ER/LA opioids for acute pain

  • Follow-up and re-evaluate risk of harm; reduce dose or taper and discontinue if needed

  CLINICAL REMINDERS

  • Evaluate risk factors for opioid-related harms

  • Check PDMP for high dosages and prescriptions from other providers

  • Use urine drug testing to identify prescribed substances and undisclosed use

  • Avoid concurrent benzodiazepine and opioid prescribing

  • Arrange treatment for opioid use disorder if needed

  LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html

• Format: APA Style

  Assessing Benefits and

  Harms of Opioid Therapy

  for Chronic Pain

  Clinician Outreach and

  Communication Activity

  (COCA) Call

  August 3, 2016

  Office of Public Health Preparedness and Response

  Division of Emergency Operations

  Accreditation Statements CME: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical

  Education (ACCME®) to provide continuing medical education for physicians. The Centers for Disease Control and Prevention

  designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit

  commensurate with the extent of their participation in the activity.

  CNE: The Centers for Disease Control and Prevention is accredited as a provider of Continuing Nursing Education by the

  American Nurses Credentialing Center’s Commission on Accreditation. This activity provides 1.0 contact hour.

  IACET CEU: The Centers for Disease Control and Prevention is authorized by IACET to offer 1.0 CEU’s for this program.

  CECH: Sponsored by the Centers for Disease Control and Prevention, a designated provider of continuing education contact

  hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is

  designed for Certified Health Education Specialists (CHES) and/or Master Certified Health Education Specialists (MCHES) to

  receive up to 1.0 total Category I continuing education contact hours. Maximum advanced level continuing education contact

  hours available are 0. CDC provider number 98614.

  CPE: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Pharmacy Education as

  a provider of continuing pharmacy education. This program is a designated event for pharmacists to receive 0.1 CEUs in

  pharmacy education. The Universal Activity Number is 0387-0000-16-150-L04-P and enduring 0387-0000-16-150-H04-P course

  category. Course Category: This activity has been designated as knowledge-based. Once credit is claimed, an unofficial

  statement of credit is immediately available on TCEOnline. Official credit will be uploaded within 60 days on the NABP/CPE

  Monitor

  AAVSB/RACE: This program was reviewed and approved by the AAVSB RACE program for 1.0 hours of continuing education

  in the jurisdictions which recognize AAVSB RACE approval. Please contact the AAVSB RACE Program at race@aavsb.org if

  you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession.

  CPH: The Centers for Disease Control and Prevention is a pre-approved provider of Certified in Public Health (CPH)

  recertification credits and is authorized to offer 1 CPH recertification credit for this program.

  Continuing Education Disclaimer CDC, our planners, presenters, and their spouses/partners wish to

  disclose they have no financial interests or other relationships with

  the manufacturers of commercial products, suppliers of commercial

  services, or commercial supporters, with the exception of Dr. Mark

  Sullivan and Dr. Jane Ballantyne. They would like to

  disclose that their employer, the University of Washington, received

  a contract payment from the Centers for Disease Control and

  Prevention. Dr. Sullivan would like to disclose that he is consulting

  with Chrono Therapeutics concerning development and testing of an

  opioid taper device.

  Planners have reviewed content to ensure there is no bias.

  This presentation will not include any discussion of the unlabeled

  use of a product or products under investigational use.

  Objectives At the conclusion of this session, the participant will be

  able to:

   Describe the evidence for the benefits and harms of opioid

  therapy for chronic pain outside of active cancer treatment,

  palliative, and end-of-life care.

   Review methods for setting goals for pain management with

  patients.

   Summarize factors that increase risk for harm and how to

  assess for such factors.

   Review methods for assessing patients’ pain and function, and

  for conducting appropriate follow-up.

  Save-the-Dates

  Mark your calendar for the upcoming opioid prescribing call

  Call

  No.

  Date Topic

  1 June 22 Guideline for Prescribing Opioids for

  Chronic Pain

  2 July 27 Non-Opioid Treatments

  3 August 3 Assessing Benefits and Harms of

  Opioid Therapy

  4 August 17 Dosing and Titration of Opioids

  TODAY’S PRESENTER

  Deborah Dowell, MD, MPH Senior Medical Advisor

  National Center for Injury Prevention and Control

  Centers for Disease Control and Prevention

  TODAY’S PRESENTER

  Mark Sullivan, MD, PhD Professor, Psychiatry and Behavioral Sciences

  Anesthesiology and Pain Medicine

  Bioethics and Humanities

  University of Washington

  TODAY’S PRESENTER

  Jane Ballantyne, MD, FRCA Professor, Anesthesiology and Pain Medicine

  Director, Pain Fellowship

  University of Washington

  Disclaimer

  The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the

  Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry

  National Center for Injury Prevention and Control

  CDC Guideline for Prescribing Opioids for Chronic Pain:

  Assessing Benefits and Harms of Opioid Therapy

  Deborah Dowell, MD, MPH

  August 3, 2016

  CDC Guideline Published in the Morbidity and Mortality Weekly Report (MMWR)

  CDC Guideline for Prescribing Opioids for Chronic Pain – United States 2016

  JAMA: The Journal of American Medical Association

  Deborah Dowell, Tamara Haegerich, and Roger Chou

  CDC Guideline for Prescribing Opioids for Chronic Pain— United States, 2016

  Published online March 15, 2016

  Difficult to predict benefits and harms of long- term opioid use in individual patients

  • Unclear whether there are long-term benefits

  • Short-term benefits

  – Small to moderate for pain – Inconsistent for function

  • Serious risks include opioid use disorder and overdose

  • Risk assessment instruments do not consistently predict opioid abuse or misuse

  Opioids not first-line or routine therapy for chronic pain

  • Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.

  • Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

  • If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

  (Recommendation category: A; Evidence type: 3)

  Establish and measure progress toward goals

  • Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks.

  • Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

  (Recommendation category: A; Evidence type: 4)

  Before starting long-term opioids for chronic pain

  1. Determine whether expected benefits for both pain and function are anticipated to outweigh risks to the patient

  2. Establish treatment goals*

  3. Set criteria for stopping or continuing opioids 4. Have an “exit strategy” for discontinuing therapy

  *For patients already receiving opioids, establish goals for continued treatment

  Assessing likely benefits of opioid therapy for individual patients

  • Consider diagnosis (insufficient evidence for long-term benefits in headache, fibromyalgia, nonspecific back pain)

  • Consider patient goals

  – Opioids might reduce pain in the short term

  – Opioids might reduce intermittent exacerbations of pain

  – Opioids might not reduce pain effectively long term

  – Opioids unlikely to eliminate pain

  – No demonstrated long-term improvement in function

  Evaluate and address risks for opioid-related harms

  • Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms.

  • Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (>50 MME/day), or concurrent benzodiazepine use, are present.

  (Recommendation category: A; Evidence type: 4)

  Assessing for mental health conditions

  • Treatment for depression may decrease overdose risk when opioids are used

  • Assess for anxiety, PTSD, and depression using validated tools, e.g.,

  – Generalized Anxiety Disorder (GAD)-7

  – Patient Health Questionnaire (PHQ)-9

  – PHQ-4

  Assessing for substance use disorder

  • Ask patients about their drug and alcohol use

  – Single screening questions can be used, e.g., “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

  – Validated screening tools can also be used, e.g.,

  • Drug Abuse Screening Test (DAST)

  • Alcohol Use Disorders Identification Test (AUDIT)

  • Use PDMP data and urine drug testing to assess for concurrent substance use

  Establishing treatment goals

  • Include goals for both pain and function

  – Improvement in physical function not always realistic

  (e.g., catastrophic spinal injury)

  – Function can include emotional and social dimensions

  • Set realistic, meaningful functional goals

  (e.g., walk around block)

  • Set goals for objective improvement

  • Use validated instruments such as the PEG* Assessment Scale

  – Clinically meaningful improvement: >30% improvement

  * Pain average, interference with Enjoyment of life, and interference with General activity (PEG) Assessment Scale

  3-item (PEG) Assessment Scale

  1. What number best describes your pain on average in the past week? (from 0=no pain to 10=pain as bad as you can imagine)

  2. What number best describes how, during the past week, pain has interfered with your enjoyment of life? (from 0=does not interfere to 10=completely interferes)

  3. What number best describes how, during the past week, pain has interfered with your general activity? (from 0=does not interfere to 10=completely interferes)

  PEG = Pain average, interference with Enjoyment of life,

  and interference with General activity

  Re-evaluate benefits and harms of opioids, and continue therapy only as a deliberate decision

  • Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation.

  • Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently.

  • If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

  (Recommendation category: A; Evidence type: 4)

  How often to evaluate patients to assess benefits and harms of long-term opioid use?

  • Within 1 – 4 weeks of starting or increasing dosage

  – Within 1 week when

  • Starting or increasing ER/LA opioids

  • Total daily opioid dosage >50 MME/day

  – Within 3 days when starting or increasing methadone

  • Regularly reassess at least every 3 months

  • Reassess patients exposed to greater risk more frequently

  – Depression or other mental health conditions

  – History of substance use disorder or overdose

  – Taking ≥50 MME/day or other CNS depressants

  Before continuing long-term opioids for chronic pain, ask

  • Do opioids continue to meet treatment goals?

  – Progress toward individual patient goals?

  – Sustained, meaningful improvement in pain and function?

  • Are there adverse events or early warning signs?

  – Over-sedation or overdose risk (if yes, taper dose)

  – Signs of opioid use disorder (if yes, treat or refer)

  • Do benefits continue to outweigh risks?

  • Can dosage can be reduced?

  • Can opioids can be discontinued?

  Connect With Us

  Find more information on drug overdose and the Guideline: • www.cdc.gov/drugoverdose

  • www.cdc.gov/drugoverdose/prescribing/guideline

  Are you on Twitter?

  • Follow @DebHouryCDC and @CDCInjury for useful information and important Guideline updates.

  Find out more about Injury Center social media: • www.cdc.gov/injury/socialmedia

  CDC GUIDELINE FOR PRESCRIBING OPIOIDS

  FOR CHRONIC PAIN

  ASSESSING BENEFITS AND HARMS OF OPIOID THERAPY

  MARK SULLIVAN, MD, PHD

  Psychiatry and behavioral sciences

  Anesthesiology and pain medicine

  Bioethics and humanities

  Jane Ballantyne, MD, FRCA Professor, Anesthesiology and Pain Medicine

  Director, UW Pain Fellowship

  University of Washington, Seattle WA

  CDC Gu ide l i ne fo r P rescr ib ing Op io ids

  fo r Ch ron i c Pa in

  Mark Sullivan, MD, PHD Professor, Psychiatry and Behavioral Sciences

  Anesthesiology and Pain Medicine

  Bioethics and Humanities

  University of Washington, Seattle WA

  Jane Ballantyne, MD, FRCA Professor, Anesthesiology and Pain Medicine

  Director, Pain Fellowship

  University of Washington, Seattle WA

  ASSESSING BENEFITS AND HARMS

  OF OPIOID THERAPY

  • Ms. Christie is a 46 year old woman who has had fibromyalgia for the past three years. She was sent by her primary care provider to a rheumatologist who diagnosed fibromyalgia after a physical exam and an extensive series of blood tests.

  • Her primary care provider treated her with gabapentin 300mg qAM and 600mg qHS with moderately good results. She continued to have moderate 5/10 pain, but she was able to continue her job as a receptionist and her role as wife and mother to two high-school students.

  CASE: 46 YR OLD WOMAN WITH FM

  Opioids not first-line or routine therapy for chronic pain

  • Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.

  • Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

  • If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

  (Recommendation category: A; Evidence type: 3)

  • “Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms.”

  • Chou R et al Annals Intern Med 2015; 162:276-86

  NATIONAL INSTITUTES OF HEALTH

  PATHWAYS TO PREVENTION WORKSHOP

  • Opioid analgesics are commonly used for the treatment of fibromyalgia (FM) despite multiple treatment guidelines that recommend against the use of long-term opioid therapy

  • American Pain Society and the American Academy of Pain Medicine

  • American Academy of Neurology • European League Against Rheumatism • Canadian Pain Society and the Canadian

  Rheumatology Association • British Pain Society

  OPIOID TREATMENT OF FIBROMYALGIA

  • Cochrane 2014 review concludes there is “no evidence at all” of oxycodone efficacy for fibromyalgia

  • Tramadol may be effective in the treatment of FM but it is a weak opioid receptor agonist, and its efficacy in FM is likely related to its action as a serotonin-norepinephrine reuptake inhibitor.

  OPIOID TREATMENT OF FIBROMYALGIA

  • Three months before today’s visit, Ms. Christie was

  rear-ended when stopped at a stoplight. She

  suffered a significant exacerbation of her

  fibromyalgia. She reported severe 8/10 pain in the

  ED immediately after the crash. She had no

  fractures, but was diagnosed with neck and back

  sprain. At that time she was prescribed oxycodone

  5mg every 4 hours as needed for pain.

  • She continued to complain of severe 7/10

  widespread pain despite taking 20mg oxycodone

  when she saw her primary care provider 2 weeks

  after the crash. Furthermore, she said that she

  was no longer able to do her job or fulfill her

  responsibilities at home.

  CASE: 46 YEAR OLD WOMAN WITH FM

  Establish and measure progress toward goals

  • Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks.

  • Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

  (Recommendation category: A; Evidence type: 4)

  She asked her primary care provider to increase her oxycodone dose to improve her pain and function level. Her primary care provider wanted to help her keep her job, so he wrote for oxycodone ER 20mg twice a day. When he checked in with her a week later, she reported feeling better and was getting back to work.

  CASE: 46 YR OLD WOMAN WITH FM

  • It is best to establish goals before embarking on a course of long-term opioid therapy, including criteria of success and failure www.coperems.org

  • Focus on achievement of life goals. Do not accept the goal of “no pain” or the goal of “less pain” in isolation from life goals

  • If patient resists, ask “ how would your life be different if you had significantly less pain?” Then explain that this is the life you will aim for together, which may or may not involve significant pain reduction.

  ESTABLISHING GOALS FOR OPIOID

  THERAPY FOR CHRONIC PAIN

  http://www.coperems.org/

  • Measuring pain intensity alone is not adequate

  • wrong goals • wrong patients • wrong understanding

  • Need multidimensional assessment • Function, both physical and role, personal

  activity • Sleep, depression, anxiety • Is life moving forward again? • http://paintracker.uwmedicine.org

  MEASURING PROGRESS

  IN CHRONIC PAIN CARE

  http://paintracker.uwmedicine.org/

  Re-evaluate benefits and harms of opioids, and continue therapy only as a deliberate decision

  • Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation.

  • Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently.

  • If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

  (Recommendation category: A; Evidence type: 4)

  • Short-term and long-term opioid therapy are different therapies, even if same meds used

  • Short-term response (weeks-months) does not predict long-term response (months-years)

  • Patients themselves tend to overestimate the benefit of therapy based on experiences with starting and stopping opioid therapy

  • Pay attention to patients’ report of current level of pain and function, but don’t be distracted by claims that “I would be much worse without these opioids”

  MEASURING PROGRESS IN RESPONSE TO

  LONG-TERM OPIOID THERAPY

  Evaluate and address risks for opioid-related harms

  • Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms.

  • Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (>50 MME/day), or concurrent benzodiazepine use, are present.

  (Recommendation category: A; Evidence type: 4)

  • Medication regimen

  • Opioid dose

  • Long-acting or extended-release opioids

  • Concurrent sedative use

  • Patient characteristics

  • Current or past substance use disorders (tobacco)

  • Inadequately treated mental health disorders (PTSD)

  • Young age

  • Previous opioid overdose

  TWO SOURCES OF RISK

  FOR LONG-TERM OPIOID THERAPY

  • Decreased function/return to work (cohorts)

  • Hyperalgesia

  • Tolerance (invisible?)

  • Dependence (lifelong?)

  • Misuse (due to above)

  • Abuse (25%) and addiction (10%)

  RISKS OF LONG-TERM OPIOID THERAPY

  TO PATIENTS

  • Hypogonadism (infertility, low libido)

  • Masked psychiatric disorder (PTSD)

  • Induced depression (duration > dose)

  • Overdose, death, emergency department visits

  (>700,000 in 2012)

  • Motor vehicle crashes (OR=1.2-1.5)

  • Falls, fractures, sedation, delirium

  RISKS OF LONG-TERM OPIOID THERAPY

  TO PATIENTS

  • Abuse

  o 12th graders: 10% 2010  6% 2014

  • Accidental overdose, death

  oHeroin deaths doubled 2010 – 2012

  • Addiction

  RISKS OF LONG-TERM OPIOID THERAPY

  TO FAMILY AND FRIENDS

  • Initially managed on gabapentin, began opioids

  in emergency department after motor vehicle

  crash

  • These were continued because of reports of

  continued severe pain and dysfunction

  • Opioid therapy slipped from short-term to long-

  term without explicit examination of goals, risks

  and benefits of long-term opioid therapy

  BACK TO MS. CHRISTIE

  46 Y/O FEMALE WITH FIBROMYALGIA

  • Ms. Christie should not have been given more than 3-7 days of opioids for her back strain from motor vehicle crash

  • When she saw her primary care provider 2 weeks later, her opioid therapy was now treating her FM, not her back strain from motor vehicle crash

  • Her report of improvement a week after her primary care provider doubled her OxyContin dose, is not sounds promising, but is not a good indicator of her likelihood of benefit from long- term therapy

  BACK TO MS. CHRISTIE

  46 Y/O FEMALE WITH FIBROMYALGIA

  • Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014 Apr 16;311(15):1547-55. doi: 10.1001/jama.2014.3266. Review.

  PubMed PMID: 24737367.

  • Goldenberg DL, Clauw DJ, Palmer RE, Clair AG. Opioid Use in Fibromyalgia: A Cautionary Tale. Mayo Clin Proc. 2016

  May;91(5):640-8. Review. PubMed PMID: 26975749.

  • Ngian GS, Guymer EK, Littlejohn GO. The use of opioids in fibromyalgia, Int J Rheum Dis. 2011;14:6-11.

  • Painter JT, Crofford LJ. Chronic opioid use in fibromyalgia syndrome: a clinical review. J Clin Rheumatol 2013; 19(2):72-77.

  • Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J

  Pain. 2009;10(2):113-130.

  • Franklin GM. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology.

  2014; 83(14):1277-1284.

  • Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence based recommendations for the management of

  fibromyalgia syndrome. Ann Rheum Dis. 2008;67(4):536-541.

  • Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012 Canadian guidelines for the diagnosis and management of

  fibromyalgia syndrome: executive summary. Pain Res Manag. 2013;18(3):119-126.

  • Lee J, Ellis B, Price C, Baranowski AP. Chronic widespread pain, including fibromyalgia: a pathway for care developed by

  the British Pain Society. Br J Anaesth. 2014;112(1):16-24.

  • Gaskell H, Moore RA, Derry S, Stannard C. Oxycodone for neuropathic pain and fibromyalgia in adults. Cochrane Database

  Syst Rev. 2014 Jun 23;(6):CD010692. doi: 10.1002/14651858.CD010692.pub2. Review. PubMed PMID: 24956205.

  • Bennett RM, Kamin M, Karim R, Rosenthal N. Tramadol and acetaminophen combination tablets in the treatment of

  fibromyalgia pain: a double-blind, randomized, placebo-controlled study. Am J Med. 2003;114(7):537-545.

  • Biasi G, Manca S, Manganelli S, Marcolongo R. Tramadol in the fibromyalgia syndrome: a controlled clinical trial versus

  placebo. Int J Clin Pharmacol Res. 1998;18(1):13-19.

  • Russell IJ, Kamin M, Bennett RM, Schnitzer TJ, Green JA, Katz WA. Efficacy of tramadol in treatment of pain in

  fibromyalgia. J Clin Rheumatol. 2000;6(5):250-257.

  FIBROMYALGIA REFERENCES

  Sullivan MD, Gaster B, Russo JE, Bowlby L, Rocco N, Sinex N, Livovich J,

  Jasti H, Arnold RM, Randomized Trial of Web-based Training about Opioid

  Therapy for Chronic Pain, Clin J Pain, 2010; 26:512-7.

  Donovan AK, Wood GJ, Rubio DM, Day HD, Spagnoletti CL. Faculty

  Communication Knowledge, Attitudes, and Skills Around Chronic Non-Malignant

  Pain Improve with Online Training. Pain Med. 2016 Apr 1. pii: pnw029. [Epub

  ahead of print] PubMed PMID: 27036413.

  Ballantyne J, Sullivan MD, Chronic pain intensity: wrong metric?, New Engl J

  Med, 2015, 373:2098-99, PMID: 26605926

  Sullivan MD, Ballantyne J, Must we reduce pain intensity to treat chronic pain?,

  Pain, 2016; 157:65-9. PMID: 26307855

  Ballantyne JC, Sullivan MD, Kolodny A, Opioid dependence versus addiction: a

  distinction without a difference?, Arch Intern Med, 2012; 13:1-2.

  Sullivan MD, Howe CI, Opioid Therapy for Chronic Pain in the US: promises and

  perils, Pain, 2013; 154 Suppl 1:S94-100. doi: 10.1016/j.pain.2013.09.009.

  OTHER REFERENCES

  To Ask a Question

   Using the Webinar System

   “Click” the Q&A tab at the top left of the webinar tool bar

   “Click” in the white space

   “Type” your question

   “Click” ask

   On the Phone

   Press Star (*) 1 to enter the queue

   State your name

   Listen for the operator to call your name

   State your organization and then ask your question

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  Centers for Disease Control and Prevention

  Atlanta, Georgia

  http://emergency.cdc.gov/coca

  http://emergency.cdc.gov/coca

  Today’s webinar will be archived

  When: A few days after the live call

  What: All call recordings (audio, webinar, and

  transcript)

  Where: On the COCA Call webpage

  http://emergency.cdc.gov/coca/calls/2016/callinfo_080316.asp

  51

  http://emergency.cdc.gov/coca/calls/2016/callinfo_080316.asp

  Continuing Education for COCA Calls

  All continuing education (CME, CNE, CEU, CECH, ACPE, CPH, and

  AAVSB/RACE) for COCA Calls are issued online through the CDC Training

  & Continuing Education Online system (http://www.cdc.gov/TCEOnline/).

  Those who participated in today’s COCA Call and who wish to receive

  continuing education should complete the online evaluation by

  September 2, 2016 with the course code WC2286. Those who will

  participate in the on demand activity and wish to receive continuing

  education should complete the online evaluation between September 3 ,

  2016 and August 2, 2018 will use course code WD2286.

  Continuing education certificates can be printed immediately upon

  completion of your online evaluation. A cumulative transcript of all

  CDC/ATSDR CE’s obtained through the CDC Training & Continuing

  Education Online System will be maintained for each user.

  http://www.cdc.gov/TCEOnline/

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  http://emergency.cdc.gov/coca

  http://emergency.cdc.gov/coca

  Save-the-Dates

  Mark your calendar for the upcoming opioid prescribing call

  Call

  No.

  Date Topic

  1 June 22 Guideline for Prescribing Opioids for

  Chronic Pain

  2 July 27 Non-Opioid Treatments

  3 August 3 Assessing Benefits and Harms of

  Opioid Therapy

  4 August 17 Dosing and Titration of Opioids

  Upcoming COCA Call

  registration is not required

  Updated Interim Zika Clinical Guidance for Pregnant

  Women and Data on Contraceptive Use to Decrease

  Zika-affected Pregnancies

   Date: Tuesday, August 9, 2016

   Time: 2:00 – 3:00 pm (Eastern)

   Presenters:

   Dr. Charlan D. Kroelinger – CDC

   Dr. Erin Berry-Bibee – CDC

   Dr. Titilope Oduyebo – CDC http://emergency.cdc.gov/coca

  http://emergency.cdc.gov/coca

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