Pain Management & Opioids - RxFiles

1 pain Management & OpioidsAddressing Important Challenges and Introducing a Chronic pain & Opioids Mini-Book TWO WORTHY GOALSRETHINKING OUR StewardshipThe Risk of Over-Reaction FALL 2017 pain Management is often a challenge and even more so in the context of the current concerns around Opioids . Two decades ago, the prevailing priority was around pain Management . Today, the pendulum for many has swung towards patient safety. Both are worthy goals! Sometimes these goals seem to compete and be at odds. Our goal is to pursue a balanced of the current opioid crisis is driven by organized crime and illicit manufacturing. However, it is also important to consider fully the potential safety issues around prescription Opioids .

2 There is a lot to be learned from recent evidence and our collective clinical experience. Chronic pain is complex, as is a potential role for Opioids . Opioids offer a net benefit for some, but harm for others. Coordinated strategies and prescribing safeguards will hopefully help protect both patient and society. It sometimes seems that for every crisis, we create an equal and opposite crisis to deal with it. In the case of the opioid crisis there is the risk that an opioid may not be prescribed adequately when it is indicated, such as during initial Management of acute injury. Sometimes this is the result of media and societal pressure. Sometimes it is the result of perceived pressure from policy makers and regulating bodies.

3 Sometimes, it is just the result of frustration with the extra hassle. In addition, if patients on high doses are forced to discontinue or taper too rapidly, they may seek illicit Opioids to deal with the withdrawal, putting themselves at even greater risk. The recent 2017 opioid Prescribing Guideline for Chronic Non-cancer pain (CNCP), provides 10 recommendations for Opioids in There are challenges with any attempt to summarize and seek simplicity. Thus attention to the detail, the strength of the recommendation and the qualifying remarks will be essential in getting the whole picture. To address some of these challenges, our upcoming academic detailing sessions and supporting materials, such as the RxFiles pain Mini-Book, will try to explore the evidence, clarify a few misunderstandings and discuss potential best practice approaches around Opioids and pain .

4 The illicit manufacturing and distribution of Opioids , although a major part of the larger opioid crisis , is largely beyond the scope of this s ensure Opioids , are necessary, safe and See the RxFiles pain Mini-BookDISCLAIMER: The content of this newsletter represents the research, experience and opinions of the authors and not those of the Board or Administration of Saskatoon Health Region (SHR). Neither the authors nor Saskatoon Health Region nor any other party who has been involved in the preparation or publication of this work warrants or represents that the information contained herein is accurate or complete, and they are not responsible for any errors or omissions or for the result obtained from the use of such information.

5 Any use of the newsletter will imply acknowledgment of this disclaimer and release any responsibility of SHR, its employees, servants or agents. Readers are encouraged to confirm the information contained herein with other sources. Additional information and references online at Copyright 2017 RxFiles , Saskatoon Health Region (SHR) Loren D Regier BSP, BARxFiles - pain Mini-Book Update on pain Management & Opioids in CNCP Chronic pain Treatment Medications & Comparisons Page pain Medication Trial Dosages, Regimen Options & Costs Chronic pain Treatment Chart Comparison of Benefits & Harms Supplementary Notes (evidence to support colour chart) 2 3 4 2017 Canadian Guideline for opioid therapy and CNCP Key Points and Recommendations (Summary) Questions Surrounding the Recent Canadian opioid Guidelines the opioid epidemic overblown to the point of preventing some patients from getting good pain Management ?

6 Tools or resources are available in SK for non-pharmacological interventions? What can I offer to someone who lacks financial assistance to access such interventions? might an opioid trial look like, practically? is the current evidence on how well Opioids may work over the long-term in CNCP? can I measure functional improvement? if a patient does not improve with an opioid trial, but does not want to come off? has the maximum daily opioid dose, for new opioid patients, been reduced to 50 MED/d (suggested) and 90 MED/d (recommended)? patients with CNCP & psychiatric or substance use disorders be considered for opioid treatment? the guidelines require that patients, currently on much higher opioid doses, will be able to get down to the new lower maximum daily MEDs?

7 Caution Regarding PRN Opioids & Dose Escalation In CNCP 14 16 16 16 17 17 17 17 18 18 18 opioid Prescribing Charts & Tools opioid Comparison Chart pain Approaches Chart: Acute vs Palliative vs CNCP Prescribing Opioids Safely Chart Informed Consent / Agreement Form sample ( RxFiles ) Brief pain Inventory (BPI) - Patient assessment tool Navigating Opioids for Chronic pain - Patient tool, dose related harm19 20 21 24 26 28 Tapering Opioids Tools to Increase the Chance of Success Background Evidence & Considerations opioid Tapering Chart & Template ( RxFiles ) opioid Tapering Information for Patients (CDN Guideline) - Link: (english).

8 Pdf 29 30 34 RxFiles Newsletter / Discussion Guide Fall 2017 pain Management & Opioids Addressing Important Challenges 37 Additional Support Documents & Links RxFiles -PainLinks for Those Living with pain : - RxFiles opioid & pain Resource Links: Other -CFPC - CNCP Resources: -Clinic Policy (Sample): PRESCRIBING Of MOOD-ALTERING DRUGS, Opioids & Other CONTROLLED SUBSTANCES: -Fentanyl Patch Exchange Tool: - Management of Chronic Non-Cancer pain Tools ( ) -Medical Marijauna / Cannabinoid Links: Coming soon. opioid Manager & Appendix (2017 CNCP Guideline tool Revision coming soon) -Documentation tool - available at the following: ; ; 2017 painsafetyaaPAIN Management AND opioid PRESCRIBING OVERVIEW OF PRACTICAL TIPS FOR SAFE AND EFFECTIVE PRACTICE 2) In those unresponsive to non- opioid therapy , one may consider an opioid trialQ Opioids have a potential role in patients with inadequate pain relief who have trialed non-drug and drug Discuss with the patient, the potential for benefit ( pain and function), versus harm ( addiction, overdose, fatal overdose, potential side effects) and other practical issues.

9 See the RxFiles CNCP Treatment Colour Chart & supplementary Given 1000 patients with chronic pain treated over 6 months with opioid therapy compared to continuing previous care:1 - pain : 112 more patients would have a pain reduction of 1/10 on a visual analog scale (over 3-6 mos) - Function: 102 more patients would have a small but important improvement in function (over 1-6 mos)Q The 2017 Canadian CNCP opioid Guidelines recommend against an opioid trial in patients with an active*strong recommendation or a history**weak recommendation of substance use disorder or an active psychiatric disorder**weak recommendation. - These patient populations were excluded from opioid trials showing benefits in CNCP, and observational data suggests a higher risk of harm ( addiction, overdose) compared to those without these disorders.

10 1) Individualize & optimize non- opioid therapy Q See the RxFiles CNCP Treatment Colour Chart & supplementary notes. This chart is intended to provide ideas for treatment with considerations of relevant evidence, experience & Q Non-pharmacological interventions are essential to long-term success in CNCP. Individualization of a plan is important due to availability, motivation and practicality limitations. Financial coverage will be a barrier for some people. We have provided suggestions and links to support tools/services where available (national, provincial & local).