2 17 16 Opioid Syllabus

2016-02-17

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2/9/2016

DISCLOSURES

•Hassan R. Mir, MD, MBA, FACS

•Medical/Orthopaedic Publications Editorial/Governing Board

•OTA Newsletter Editor

•OsteoSynthesis, The JOT Online Discussion Forum Editor

•JOT Associate Editor

•JAAOS Consultant Reviewer

•JBJS Consultant Reviewer

•Board Member/Committee Appointments for a Society

•AAOS Diversity Advisory Board and Council on Advocacy Member

•OTA Public Relations Committee

•FOT Nominating and Membership Committees

•Speakers Bureau/Paid Presentations for a Company or Supplier

•Depuy-Synthes

•Paid Consultant for a Company or Supplier

•Smith & Nephew

2/9/2016

Opioid Epidemic

•Americans <5% of World Population

•99% of Global Hydrocodone Supply

•80% of Global Opioid Supply

•Prescription Opioid Overdose Deaths

Tripled in Last Decade

Manchikanti L, Singh Angelie. Therpeutic Opioids: a ten-year perspective on the complexities and complications of the

escalating use, abuse, and nonmedical use of Opioids.

Pain Physician

. 2008;11:S63-S88.

CDC Press Release. Prescription painkiller overdoses at epidemic levels.

Annual Deaths

Opioids > Cocaine + Heroin

Opioids > Suicide or MVC

2/9/2016

Source of Opioids?

Substance Abuse and Mental Health Services Administration (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings.

(Office of Applied Studies, NSDUH Series H-32,

DHHS Publication No. SMA 07-4293). Rockville, MD. www.oas.samhsa.gov/nsduh/2k6nsduh/2k6results.pdf

States Requiring PDMP Use

Kentucky

Massachusetts

New Mexico

New York

Ohio

Tennessee

West Virginia

2/9/2016

Role of Orthopaedic Surgeons?

Orthopedic Surgeons are the 3rd Highest

Prescribers of Opioids

(7.7% of all Rx)

PCPs –28.8%; Internists –14.6%

Orthopedic Surgery & Opioids

•Literature on Worse Clinical Outcomes in:

•Trauma

•Low Back Pain

•Occupational MSK Disorders

•TKA

•Reverse Shoulder Arthroplasty

•Spine Surgery

•More coming…

2/9/2016

Orthopaedic Trauma Patients using Opioids

Preoperatively?

Doctor Shopping Postoperatively?

Doctor Shopping

•Prevalence: 21%

Increased:

–Postop Opioid Rx

–Duration of Postop Opioid Use

–MED per day

2/9/2016

•Single Opioid Provider:

–2 Rx’s

–Duration of 28 days

–26 MED/day (mg)

•Multiple Opioid Providers:

–7 Rx’s

–Duration of 110 days

–43 MED/day (mg)

Doctor Shopping Predictors

•≤High School Education (3.2 X)

•Preoperative Opioid Use (4.5 X)

Recommendations

•Monitor Postoperative Opioid Rx following

Orthopaedic Trauma

•Identify and Prevent Doctor Shopping

•CSMD Utilization

•Particularly for Patients with:

•Lower Level of Education

•History of Preoperative Opioid Use

2/9/2016

Patient Expectations

2/9/2016

Provider Education

2/9/2016

Pain Clinics

•Rapid Rise in Number

•732 in FL

•4 Pain Clinics for every 100,000 People

•Outnumber McDonald’s

•Some Pain Clinics provide Important Services for

Patient Care and Pain Management

•However, “Pill Mills” Prescribe and Dispense

Controlled Substances Outside the Scope of Standard

Medical Practice

PDMPs

•Programs with Positive Early Results

Conclusions

•The US is in an Opioid Epidemic

•Detrimental Effects on Individuals and Society

•Our Patients are At-Risk

•Orthopaedic Surgeons should:

•Recognize Risk Factors

•Set Patient Expectations and Prescribe Responsibly

•Take Control of MSK Pain Management

•Educate Other Providers

2/9/2016

THANK YOU

Hassan R. Mir, MD, MBA, FACS

2/15/2016

Intravenous (IV) Acetaminophen

Effectiveness in Pain Management

of the Geriatric Hip Fracture

Patient

Clifford B. Jones, MD FACS

The CORE Institute

Banner University Medical Center

University of Arizona Orthopaedic Residency Program

Phoenix AZ

Is Scheduled Intravenous Acetaminophen

Effective in the

Pain Management Protocol of

Geriatric Hip Fractures?

Alexander J. Bollinger, M.D. 1,2

Paul D. Butler, M.D. 1,2

Matthew S. Nies, M.D. 2

Debra L. Sietsema, PhD. 2,3

Clifford B. Jones, M.D. 2,3

Terrence J. Endres, M.D. 2,3

American Academy of Orthopaedic Surgeons, Annual Meeting

March 24, 2015

1. Grand Rapids Medical Education Partners

2. Michigan State University CHM

3. Orthopaedic Associates of Michigan

Geriatr Orthop Surg Rehabil. 2015 Sep;6(3):202-8. doi:

10.1177/2151458515588560.

2/15/2016

Purpose

•Hip fractures are a common problem in the

geriatric population, having substantial impact

on the healthcare system

•$30 billion annual cost 1-2

•Often result in functional decline and greater

mortality 2-9

Purpose - con’t

•Post-operative pain control remains difficult in

the elderly population

•Opioid- and NSAID-associated complications

more common 2,10-22

•Intravenous acetaminophen has been shown in

prior studies to be safe and efficacious in major

orthopaedic surgery 20,22-29

What is IV Tylenol

•OFIRMEV® (acetaminophen) injection

•Mallinckrodt Pharmaceuticals

•Administration 650mg q 4 or 1000mg q 6

•70% Higher peak 15-30 min dose

•50% Lower hepatic levels

2/15/2016

Mean Plasma & CSF Concentrations of

IV, PO, & PR Acetaminophen

IV, PO, PR

Costs $

2/15/2016

Hypothesis

•The use of scheduled IV acetaminophen as part of

a perioperative pain-control protocol for patients 65

or older with hip fractures will reduce problems

associated with inadequate pain control, while

simultaneously decreasing complications

associated with opioid analgesic use and reducing

length of hospital stay.

•Start on admission

•Complete POD #2

Methods

•Retrospective chart review from June 1, 2011 -

May 31, 2013

•Group 1: June 1, 2011 - May 31, 2012

» (before initiation of protocol)

•Group 2: June 1, 2012 - May 31, 2013

» (after initiation of protocol)

Methods - con’t

•Inclusion Criteria:

•65 years or older

•Admitted to orthopaedic surgery service

•Underwent operative fixation of “hip” fracture by one

of six surgeons within specified time period

•CPT codes 27235, 27236, 27244, 27245

•AO classification 31-A & 31-B

2/15/2016

Methods - con’t

–Exclusion Criteria:

•Pathologic fracture

•Periprosthetic fracture

•Concomitant orthopaedic injury requiring operative

intervention

•Perioperative death (same hospitalization)

Methods - con't

284 subjects required (142 per cohort) at α=0.05 and β=0.20

Total Fractures Group 1 Group 2

Geriatric Fractures 433 214 219

Subtrochanteric 13 7 6

Non-Ortho Admit 55 24 31

Included Hip Fractures 365 183 182

Exclusions:

Concomitant Injuries 8 3 5

Periprosthetic 8 5 3

Pathologic 8 4 4

Perioperative Death 5 2 3

Total 336 169 167

Methods - con’t

•Statistical Analysis

•Quantitative data were analyzed using the

unpaired t-test, while nominal data were analyzed

using the chi-square test

•Multivariate regression analyses for quantitative

data and logistic regression analysis for nominal

data

•Significance evaluated at p<0.05

2/15/2016

Study Population

*Mean (Range)

Group 1 (n=169) Group 2 (n=167) p-Value

Age (years)* 83.3 (65-101) 81.8 (66-101) 0.08

Gender (number of patients) 0.85

Male 45 (27%) 46 (28%)

Female 124 (73%) 121 (72%)

Fracture (number of patients) 0.33

Femoral Neck 81 (48%) 78 (47%)

Intertrochanteric 88 (52%) 89 (53%)

Surgical Treatment 0.81

Arthroplasty 71 (42%) 68 (41%)

Internal Fixation 98 (58%) 99 (59%)

Body Mass Index* 25.3 (13.4-57.1) 26.3 (16.1-41.5) 0.10

Time from Admission to OR (hours)* 17.1 (1-65) 15.3 (0-56) 0.09

Total Acetaminophen (# doses)* 8.7 (0-35) 9.2 (0-30) 0.48

Oral Acetaminophen (# doses)* 8.5 (0-35) 5.4 (0-27) <0.001

IV Acetaminophen (# doses)* 0.2 (0-12) 3.7 (0-12) <0.001

Results

Group 1 (n=169) Group 2 (n=167) p-Value

Length of Stay (days) <0.001

Mean (Range) 4.4 (1.2-13) 3.8 (1.5-11.4)

Narcotic Use (mg morphine-equivalent) <0.001

Mean (Range) 41.3 (0-189.7) 28.3 (0-204.3)

Daily Narcotic Use (mg/day) 0.05

Mean (Range) 9.6 (0-49.9) 7.8 (0-53.2)

Bowel Motility Agents (# doses) 0.29

Mean (Range) 1.0 (0-10) 0.8 (0-4)

Anti-emetic Agents (# doses) 0.48

Mean (Range) 0.8 (0-11) 0.7 (0-7)

Pain Score (VAS scale) <0.001

Mean (Range) 4.2 (0-9.2) 2.8 (0-7.7)

Missed PT sessions (%) <0.001

Mean (Range) 21.8 (0-66.7) 10.4 (0-100)

Discharge Location (# patients) 0.001

Home 12 (7%) 32 (19%)

Secondary Care Facility 157 (93%) 135 (81%)

Results - con’t

2/15/2016

Results - con’t

2/15/2016

Results - con’t

Intravenous acetaminophen usage both correlated

with and was independently predictive of:

•shorter mean length of hospital stay

•lower mean narcotic usage

•lower mean pain score

•lower percentage of physical therapy sessions

missed

•higher likelihood of discharge to home

2/15/2016

Conclusion

•The utilization of scheduled IV acetaminophen as

part of a standardized pain-management protocol

for geriatric hip fractures resulted in a shortened

length of hospital stay, decreased pain score and

narcotic use, fewer missed physical therapy

sessions, and higher rate of discharge to home.

Future Directions?

•Cost-analysis

•OFIRMEV® ~$40 per 1000 mg dose

•Prospective, randomized trials

•Verified outcome measures

References

1.Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Report. 2010;(29):1-20, 24.

2.Marks R, Allegrante J, Ronald-MacKenzie C, et al. Hip fractures among the elderly: causes, consequences and control. Ageing Research Reviews. 2003;2:57-93.

3.Leibson C, Tosteson A, Gabriel S, et al. Mortality, disability, and nursing home use for persons with and without hip fractur e: a population-based study. Journal of the American Geriatrics

Society. 2002;50:1644-1650.

4.Brainsky A, Glick H, Lydick E, et al. The economic cost of hip fractures in community-dwelling older adults: a prospective study. J Am Geriatr Soc. 1997;45:281-287.

5.Hannan EL, Magaziner J, Wang JJ, et al. Mortality and locomotion 6 months after hospitalization for hip fracture: risk factor s and risk-adjusted hospital outcomes. JAMA. 2001;285:2736-2742.

6.Alegre-Lopez J, Cordero-Guevara J, Alonso-Valdivielso JL, et al. Factors associated with mortality and functional disability after hip fracture: an inception cohort study. Osteoporos Int.

2005;16:729-736.

7.Cooper C, Cole ZA, Holroyd CR, et al. Secular trends in the incidence of hip and other osteoporotic fractures. Osteoporos Int. 2011;22:1277-1288.

8.Hayes W, Myers E, Robinovitch S, et al. Etiology and prevention of age-related hip fractures. Bone. 1996;18:77-86.

9.Schneider E, Guralnik J. The aging of America: Impact on health care costs. JAMA : the journal of the American Medical Associ ation. 1990;263:2335-2340.

10.Morrison RS, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103:303-311.

11.Pasero CL, McCaffery M. Reluctance to order opioids in elders. Am J Nurs. 1997;97:20, 23.

12.Duggleby W, Lander J. Cognitive status and postoperative pain: older adults. J Pain Symptom Manage. 1994;9:19-27.

13.Gustafson Y, Berggren D, Brannstrom B, et al. Acute confusional states in elderly patients treated for femoral neck fracture. J Am Geriatr Soc. 1988;36:525-530.

14.Givens JL, Sanft TB, Marcantonio ER. Functional recovery after hip fracture: the combined effects of depressive symptoms, cognitive impairment, and delirium. J Am Geriatr Soc.

2008;56:1075-1079.

15.Marcantonio ER, Flacker JM, Michaels M, et al. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48:618-624.

2/15/2016

References

16. Lane JM. CORR Insights (R): Does early functional outcome predict 1-year mortality in elderly patients with hip fracture? Clin Orthop Relat Res. 2013;471:2711-013-2995-6. Epub 2013 Apr 19.

17.Koval KJ, Skovron ML, Aharonoff GB, et al. Ambulatory ability after hip fracture. A prospective study in geriatric patients. Clin Orthop Relat Res. 1995;(310):150-159.

18.Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. JAMA : the

journal of the American Medical Association. 1998;279:1877-1882.

19.Cheville A, Chen A, Oster G, et al. A randomized trial of controlled-release oxycodone during inpatient rehabilitation follow ing unilateral total knee arthroplasty. J Bone Joint Surg Am.

2001;83-A:572-576.

20.Koppert W, Frotsch K, Huzurudin N, et al. The effects of paracetamol and parecoxib on kidney function in elderly patients undergoing orthopedic surgery. Anesth Analg. 2006;103:1170-1176.

21.Jahr JS, Breitmeyer JB, Pan C, et al. Safety and efficacy of intravenous acetaminophen in the elderly after major orthoped ic surgery: subset data analysis from 3, randomized, placebo-

controlled trials. Am J Ther. 2012;19:66-75.

22.Smith HS. Perioperative intravenous acetaminophen and NSAIDs. Pain Med. 2011;12:961-981.

23.van der Westhuizen J, Kuo PY, Reed PW, et al. Randomised controlled trial comparing oral and intravenous paracetamol (acetaminophen) plasma levels when given as preoperative

analgesia. Anaesth Intensive Care. 2011;39:242-246.

24.Sinatra RS, Jahr JS, Reynolds LW, et al. Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after

major orthopedic surgery. Anesthesiology. 2005;102:822-831.

25.Lachiewicz PF. The role of intravenous acetaminophen in multimodal pain protocols for perioperative orthopedic patients. Orthopedics. 2013;36:15-19.

26.Looke TD, Kluth CT. Effect of preoperative intravenous methocarbamol and intravenous acetaminophen on opioid use after primary total hip and knee replacement. Orthopedics.

2013;36:25-32.

27.Sinatra RS, Jahr JS, Reynolds L, et al. Intravenous acetaminophen for pain after major orthopedic surgery: an expanded ana lysis. Pain Pract. 2012;12:357-365.

28.Tsang KS, Page J, Mackenney P. Can intravenous paracetamol reduce opioid use in preoperative hip fracture patients? Orthop edics. 2013;36:20-24.

29.Abdulla S, Eckhardt R, Netter U, et al. Efficacy of three IV non-opioid-analgesics on opioid consumption for postoperative pain relief after total thyroidectomy: a randomised, double-blind

trial. Middle East J Anesthesiol. 2012;21:543-552.

Thank You

2/15/2016

Pain Strategies for Practicing

Orthopaedic Surgeons

Joseph R. Hsu, MD

Professor, Orthopaedic Trauma

Limb Lengthening and Deformity Service

Carolinas Medical Center

Disclosures

CDC funding

Prescription Reporting with Immediate Medication

Utilization Mapping (PRIMUM)

Smith & Nephew –speakers bureau

Acumed –consulting

Slide contributions from Michael Ruffolo,

Steven Olson, and Alejandro Marquez-Lara

BLUF: Multi-modal strategy

Short acting opioids

8 weeks maximum

Refer to pain management

if requiring more narcotics

NSAIDs

Non-selective:

Ibuprofen, naproxen, etc.

Selective if GI risk:

Meloxicam (generic)

Gabapentin

Up to 1800 mg/day

effective

Increased evening dose

No sustained-release

opioids

No sedative-hypnotics

Benzos, ambien, etc.

“Primum non nocere”

2/15/2016

Did he say NSAIDS???

What should you fear?

Geusens P, Emans PJ, de Jong JJ, van den Bergh J. NSAIDs and fracture healing.

Curr Opin Rheumatol. 2013 Jul;25(4):524-31.

Ortho influence on pain management

Walter Crawford Kelly,

Jr. (August 25, 1913 –

October 18, 1973)

2/15/2016

Secondary Bone Healing

Schindeler et al, Stem Cell Dev Biology, 2008

Inflammation

Vasodilation

“4Rs”

Chondrocyte

Activity

Osteoblast

Activity

Angiogenesis

Secondary Bone Healing Models

Simon AM., et al., JBMR, 2002

Control Rofecoxib

2/15/2016

Primary Bone Healing Models

NSAIDs do not appear to

have a significant effect on

primary bone healing

Sato S., et al., J. Pharmacology, 1986Martins MV., et al., Braz Dent J, 2005

Significant flaws in clinical

studies condemning NSAIDS

Burd TA, Hughes MS, Anglen JO. Heterotopic ossification prophylaxis with indomethacin

increases the risk of long-bone nonunion. J Bone Joint Surg (Br) 2003;85(5):700-5.

Dodwell ER, Latorre JG, Parisini E, Zwettler E, Chandra D, Mulpuri K, et al. NSAID

exposure and risk of nonunion: a meta-analysis of case-control and cohort studies.

Calcif Tissue Int 2010;87:193-202.

Bhattacharyya T, Levin R, Vrahas MS, Solomon DH. Nonsteroidal antiinflammatory

drugs and nonunion of humeral shaft fractures. Arthritis Rheum 2005;53:364-7.

Jeffcoach DR, Sams VG, Lawson CM, Enderson BL, Smith ST, Kline H, et al.

Nonsteroidal anti-inflammatory drugs’ impact on nonunion and infection rates in

long-bone fractures. J Trauma Acute Care Surg 2014;76:779-83.

Giannoudis PV, MacDonald DA, Matthews SJ, Smith RM, Furlong AJ, De Boer P.

Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal antiinflammatory

drugs. J Bone Joint Surg (Br) 2002;82(5):655-8.

2/15/2016

Case-Control

32 Nonunions of Femoral

Diaphysis vs 67 Comparable

patients

Sample size

Patient recall phone or clinic

NSAID use cause or result of

nonunion?

NSAID Use

62.5% vs 13.4%

22 vs 1 week use

RR = 10.74

Many different techniques:

Different nails, reamed and

unreamed.

JBJS Br, 2000

Slide from Michael Ruffalo, MD

Retrospective Case-

Control of all femur,

tibia, humerus fractures

1,901 Patients

12.1% Received NSAIDS

(short term in hospital)

NSAIDS

17% of patients receiving

NSAIDS had a

complication

OR = 2.17 p < 0.016

No mention of NSAID

use out of hospital

No discussion of

fracture characteristics

Best Trauma Center in

America?

<1% infection in open

fractures

3.2% Infection,

Malunion/Nonunion

Rate

J Trauma Acute Care Surg, 2014

Slide from Michael Ruffalo, MD

Levels of evidence

2/15/2016

van Esch

Ziltener

Dumont

Thaller

Gaston

Dahners

Wheeler

Vuolteenaho

Boursinos

Kurmis

Dodwell

Geusens

Pountos_12

Xian

Bailey

Gajraj

Badolier

Radi

Abdul-Hadi

Cottrell

Pountos_08

Harder

Barry

Adult Studies

Pediatric Studies

Avoid NSAIDs No clear

recommendations

Literature Reviews

NSAIDs Ok

Number of Clinical Studies Cited

Mean: 2.0

Mean: 8.0

Mean: 4.0

2/15/2016

Geusens et al Metabolic Bone Disease 2013

General Review Pountous et al World J of Surg 2012

The prospective series

show less adverse effects

2/15/2016

Overall Meta-Analysis

•Dodwell et al Calcif Tissue Int 2010

Higher Quality Studies

•Dodwell et al Calcif Tissue Int 2010

Higher Dose Ketorolac

•Dodwell et al Calcif Tissue Int 2010

2/15/2016

Evidence Based Review

The balance of evidence

… appears to suggest

that a short-duration

NSAID regimen is a safe

and effective supplement

to other modes of post-

fracture pain control,

without a significantly

increased risk of sequelae

related to disrupted

healing

Non-selective NSAIDs

Less effect on bone healing

Selective still helpful with side-effects of NSAIDs

Gerstenfeld LC, Thiede M, Seibert K, Mielke C, Phippard D, Svagr B, Cullinane

D, Einhorn TA. Differential inhibition of fracture healing by non-selective and

cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs. J Orthop Res.

2003 Jul;21(4):670-5.

Are we OK with Opioid Monotherapy being

the standard for musculoskeltal pain?

Primarily US

Past 15 to 20 years

Industry driven

Multi-billion dollar industry

JCAHO/Joint Commission

2/15/2016

Wake Forest Baptist Medical Center

Fraudulent Marketing:

OxyContin

“with the intent to defraud or mislead,” it marketed and

promoted OxyContin as a drug that was less addictive, less

subject to abuse and less likely to cause other narcotic side

effects than other pain medications.

United States Attorney’s Office Western District of Virginia [news release].

Available at: http://www.dodig.osd.mil/ IGInformation/IGInformationReleases/

prudue_frederick_1.pdf. Accessed September 11, 2008.

2/15/2016

Efficacy no better

Hale ME, Fleischmann R, Salzman R, et al. Efficacy and safety of controlledrelease versus

immediate-release oxycodone: randomized, double-blind evaluation in chronic back pain.

Clin J Pain. 1999;15:179–183.

Kaplan R, Parris WC, Citron MI, et al. Comparison of controlled-release and immediate-

release oxycodone in cancer pain. J Clin Oncol. 1998;16:3230–3237.

Staumbaugh JE, Reder RF, Stambaugh MD, et al. Double-blind, randomized comparison of

the analgesic and pharmacokinetic profiles of controlledand immediate-release oral

oxycodone in cancer pain patients. J Clin Pharmacol. 2001;41:500–506.

Heiskanen T, Kalso E. Controlled-release oxycodone and morphine in cancer related pain.

Pain. 1997;73:37–45.

Mucci-LoRusso P, Berman BS, Silberstein PT, et al. Controlled-release oxycodone compared

with controlledrelease morphine in treatment of cancer pain: a randomized, double-blind,

parallel-group study. Eur J Pain. 1998; 2:239–249.

Bruera E, Belzile M, Pituskin E, et al. Randomized, double-blind, cross-over trial comparing

safety and efficacy of oral controlled-release oxycodone with controlled- release morphine in

patients with cancer pain. J Clin Oncol. 1998;16: 3222–3229.

Big business

Significant payments to pain KOLs, pain

societies, and pain advocacy groups

UW Pain & Policy

Studies Group

$2.5 million paid by

opioid manufacturers

http://www.jsonline.com/watchdog/watchdogreports/119130114.html

http://hcrenewal.blogspot.com/2012/12/the-king-of-pain-recants-pharmaceutical.html

2/15/2016

Pain Management:

Opioid monotherapy vs. multimodal

Opioid monotherapy

Short acting alone

Short and long acting

Multi-modal

Short course, short-

acting opioids

NSAIDS

Gabapentin

What is the evidence behind

opioids for NCP?

2/15/2016

Moderate improvements

pain & physical function

vs. placebo

Comparable to NSAIDs

or TCAs

30% adverse events

Nausea, dizziness

25% discontinued

Disclaimer: most studies

industry funded…

Only short term studies

Disclaimer: most studies

industry funded…

Only short term studies

No difference funtional

outcome

2/15/2016

What about Chronic Non Cancer

Pain (CNCP)?

persons in chronic pain

on opioids reported

decreased pain relief,

functional capacity, and

quality of life vs persons

in chronic pain not on

opioids, adjusting for

severity

Opposite marketing

claims

Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK.

Critical issues on opioids in chronic non-cancer pain: an epidemiological study.

Pain 2006;125:172–179

Are higher doses better?

Liberally escalating

dosage vs. “hold the

line” dosage

No significant

improvement primary

pain and functional

outcome escalating

27% overall discharged

from trial

(misuse/noncompliance)

Naliboff BD, Wu SM, Schieffer B, et al. A randomized

trial of 2 prescription strategies for opioid treatment of

chronic nonmalignant pain. J Pain 2011;12:288–296.

Functional rehab

Yes –taking opioids

No –not taking

Work return and

retention inverse to dose

2/15/2016

All 20 tablets of

naproxen 500mg BID

Randomized (PRN LBP)

Placebo

Cyclobenzaprine 5mg

Oxycodone 5/325

No difference pain

improvement 1 week or

3mos

More adverse events

Surgery always needs opioids, right?

Patient satisfaction: Cultural?

Prospective,

observational

USA vs. Netherlands

Very few opioids in

Netherlands

2/15/2016

What about Satisfaction Scores?

Higher opioid doses post-op

Greater reported pain

Decreased satisfaction with pain relief

Chen L, Vo T, Seefeld L, Malarick C, Houghton M, Ahmed S, Zhang Y, Cohen A, Retamozo C,

St Hilaire K, Zhang V, Mao J.

Lack of correlation between opioid dose adjustment and pain score change in a group of

chronic pain patients. J Pain. 2013; 14:384–392.

Trevino CM, deRoon-Cassini T, Brasel K. Does opiate use in traumatically injured individuals

worsen pain and psychological outcomes? J Pain. 2013;14:424–430.

Gabapentin

Neuropathic component

Complex pain management

Previous opioid use

High dose requirements

Ho KY, Gan TJ, Habib AS. Gabapentin and postoperative pain--a systematic

review of randomized controlled trials. Pain. 2006 Dec 15;126(1-3):91-101.

2/15/2016

Gabapentin

CRPS

Acute pain

Neuropathic pain

Long term doses up to

2400mg/day

Short term doses up to

3600mg/day

Mellick GA, Mellicy LB, Mellick LB: Letter:

Gabapentin in the management of reflex

sympathetic dystrophy. J Pain Symptom

Manage 1995;10:265-266.

Werner MU, Perkins FM, Holte K, Pedersen JL, Kehlet H:

Effects of gabapentin in acute inflammatory pain in humans.

Reg Anesth Pain Med 2001;26:322-328.

Moore RA, Wiffen PJ, Derry S, Toelle T, Rice AS. Gabapentin for chronic

neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2014 Apr

27;4:CD007938.

Gabapentin for Adults with Neuropathic Pain: A Review of the Clinical Efficacy

and Safety [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in

Health; 2015 Apr 14.

NSAIDs Clinical Scenarios

Contraindications

Renal insufficiency

Allergy

Peptic Ulcer Disease

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Clinical Scenarios

ED management

Non-operative

Operative

Peri-operative

Outpatient

Special cases

Nonunion

Osteotomy

Bone transport

Emergency Department

26 y.o.

male

Cost effective?

Rainer TH, Jacobs P, Ng YC, Cheung NK, Tam M, Lam PK, Wong R, Cocks RA. Cost

effectiveness analysis of intravenous ketorolac and morphine for treating pain

after limb injury: double blind randomised controlled trial. BMJ. 2000 Nov

18;321(7271):1247-51.

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Non-operative injuries

Davis TRC, Ackroyd CE. Non-steroidal anti-inflammatories in the treatment of Colles’

fractures. Br J Clin Pract 1988;42(5):184-9.

Craig M, Jeavons R, Probert J, Benger J. Randomised comparison of intravenous

paracetamol and intravenous morphine for acute traumatic limb pain in the

emergency department. Emerg Med J. 2012 Jan;29(1):37-9.

Healed, good function, pain free

Operative

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NSAIDs work after surgery

Derry CJ, Derry S, Moore RA, McQuay HJ.

Single dose oral ibuprofen for acute postoperative pain in adults.

Cochrane Database Syst Rev 2009;(3):CD001548.

Norman PH, Daley MD, Lindsey RW. Preemptive analgesic effects of ketorolac in

ankle fracture surgery. Anesthesiology. 2001 Apr;94(4):599-603.

Kang H, Ha YC, Kim JY, Woo YC, Lee JS, Jang EC. Effectiveness of multimodal

pain management after bipolar hemiarthroplasty for hip fracture: a randomized,

controlled study. J Bone Joint Surg Am. 2013 Feb 20;95(4):291-6.

Maheshwari AV, Boutary M, Yun AG, Sirianni LE, Dorr LD. Multimodal analgesia

without routine parenteral narcotics for total hip arthroplasty. Clin Orthop

Relat Res. 2006 Dec;453:231-8.

Ketorolac (Toradol)

IV Ketorolac trometamol: as effective as

morphine for surgical pain and pain related to

cancer, and it has fewer side effects.



GI haemorrhage risk only slightly higher with

ketorolac than morphine (odds ratio 1.17 (95%

CIs 0.991.13)); risk rises sharply more than five

days or in patients older than 75

Strom BL, Berlin JA, Kinman JL, Spitz PW, Hennessy S, Feldman H, et al.

Parenteral ketorolac and risk of gastrointestinal and operative site bleed

ing. A postmarketing surveillance study. JAMA 1996;275:37682.

Gillis JC, Brogden RN. Ketorolac. A reappraisal of its pharmacodynamic

and pharmacokinetic properties and therapeutic use in pain manage

ment. Drugs 1997;53:13988.

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20 yo contiguous neck,

trochanteric, & subtroch

Operative injuries

Cultural expectations

Equivalent or better outcomes NSAIDs

Hip, ankle, and femur fractures

Lindenhovius AL, Helmerhorst GT, Schnellen AC, Vrahas M, Ring D, Kloen P.

Differences in prescription of narcotic pain medication after operative treatment of

hip and ankle fractures in the United States and The Netherlands. J Trauma. 2009

Jul;67(1):160-4.

Helmerhorst GT, Lindenhovius AL, VrahasM, Ring D, Kloen P. Satisfaction with pain

relief after operative treatment of an ankle fracture. Injury. 2012 Nov;43(11):1958-61.

Carragee EJ, Vittum D, Truong TP, Burton D. Pain control and

cultural norms and expectations after closed femoral shaft fractures.

Am J Orthop (Belle Mead NJ). 1999;28:97–102.

Peri-operative

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Ketorolac

Short acting opioids plus NSAIDs

Own our influence on pain management

Walter Crawford Kelly,

Jr. (August 25, 1913 –

October 18, 1973)

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Martin BC, Fan MY, Edlund MJ, Devries A, Braden JB, Sullivan MD.

Long-term chronic opioid therapy discontinuation rates from the TROUP study.

J Gen Intern Med 2011;26:1450–1457.

Instead of this reaction to NSAIDS…

Weigh the facts

NSAIDs and delayed

bone healing

Clinical Association ≠

causation

Conflicting basic science

Opioids and delayed

bone healing

Clinical Association ≠

causation

Some evidence in basic

science

Opioids and dependence

Causation clear

Opioids and death

Causation clear

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Prescription Reporting with Immediate

Medication Utilization Mapping (PRIMUM)

Principal Investigators: Rachel Seymour, PhD, and Joseph Hsu, MD

Co-investigators: Michael Beuhler, MD; Michael Bosse, MD; Stephen Colucciello,

MD; Michael Gibbs, MD; Steven Jarrett, PharmD; Michael Runyon, MD; Animita

Saha, MD; Brad Watling, MD; Christopher Griggs, MD; Stephen Wyatt, DO; Daniel

Leas, MD; Sharon Schiro, PhD; Meghan Wally, MSPH

•Goals:

1) To identify patients at high risk for misuse, abuse, and diversion of

prescription opioids and benzodiazepines.

2) To provide critical information to the prescriber at the point of care

in order to inform clinical decision-making

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Intervention: Alert System

•Prescriber selects controlled

substance

•EMR searches patient chart for

defined risk factors for

abuse/misuse/diversion

•Provides prescriber with alert

•Prescriber can continue or

discontinue script.

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2/15/2016 73

What can be done?

Become conversant in

the problem

Stop prescribing long

acting

Multi-modal pain

management

Local policy

Utilize PDMP or

implement decision

support

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Useful Tools and Tips on

Opioids

Difficult discussion

Frame as patient safety

Enroll reasonable family

member

If available

Consistent policies and

procedures

Blame the policy

Assess sedation:

Pasero scale

Assess risk with MME Calculator

2/15/2016

CDC Guidelines

12 guidelines, 56 pages

chronic pain (i.e., pain

lasting >3 months or

past the time of normal

tissue healing)

http://www.cdc.gov/drugoverdose/prescribing/guideline.html

New trend?

Blame the courts

“Low T”

Healing, bone mineral density, erectile

dysfunction, libido, etc.

De Maddalena C, Bellini M, Berra M, Meriggiola MC, Aloisi AM. Opioid-induced

hypogonadism: why and how to treat it. Pain Physician. 2012 Jul;15(3 Suppl):ES111-8.

Aloisi AM, Ceccarelli I, Carlucci M, Suman A, Sindaco G, Mameli S, Paci V,

Ravaioli L, Passavanti G, Bachiocco V, Pari G. Hormone replacement therapy in

morphine-induced hypogonadic male chronic pain patients. Reprod Biol Endocrinol. 2011 Feb 18;9:26.

Birthi P, Nagar VR, Nickerson R, Sloan PA. Hypogonadism associated with

long-term opioid therapy: A systematic review. J Opioid Manag. 2015 May-Jun;11(3):255-78.

Rubinstein A, Carpenter DM. Elucidating risk factors for androgen deficiency

associated with daily opioid use. Am J Med. 2014 Dec;127(12):1195-201. doi:

10.1016/j.amjmed.2014.07.015. Epub 2014 Jul 22.

Demarest SP, Gill RS, Adler RA. Opioid endocrinopathy. Endocr Pract. 2015 Feb 1;21(2):190-8.

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Multi-modal strategy

Short acting opioids

8 weeks maximum

Refer to pain management

if requiring more narcotics

NSAIDs

Non-selective:

Ibuprofen, naproxen, etc.

Selective if GI risk:

Meloxicam (generic)

Gabapentin

Up to 1800 mg/day

effective

Increased evening dose

No sustained-release

opioids

No sedative-hypnotics

Benzos, ambien, etc.

“Primum non nocere”

Thank you

2/15/2016 84

Discussion

2 17 16 Opioid Syllabus

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