YAFI Online Programming // Disease State Management and Drug Therapy

Rational Opioid Use

Continuous Learning after the CDC Guideline

Educational Objectives

After participating in this activity pharmacists will be able to:

  • Discuss the continuing need to follow pain management guidelines judiciously to mitigate epidemic opioid overdose
  • Outline the CDC’s recommendations from the 2016 Guideline for Prescribing Opioids for Chronic Pain and lessons learned since their release
  • Discuss talking points and approaches to work with prescribers and ensure patient safety when opioids are prescribed
  • List patient counseling points regarding the safe use of opioids
  • Identify factors that put patients at highest risk of overdose who may need rescue medication

After participating in this activity pharmacy technicians will be able to:

  • Describe the principles behind careful pain management
  • List common mechanisms used to safeguard opioid use
  • Recognize when to refer patients to the pharmacist for issues related to pain management or risk of overdose

Session Offered

Release Date: March 15, 2019

Expiration Date: March 15, 2022

Course Fee

Free

Session Codes

19YC04-ABC36 Pharmacist

19YC04-CBA24 Pharmacy Technician

Accreditation Hours

2.0 hours of CE

Abstract

Daily (chronic) pain is common among adults living in the United States. It is often treated with opioids despite the lack of evidence for long-term benefit. Given the opioid overdose epidemic in the US, the Centers for Disease Control and Prevention has created an evidence- and expert-opinion-based guideline for prescribing opioids for chronic pain. The overall guideline has been developed to help identify the risks and benefits of opioid therapy and improve long-term safety. Included are 12 recommendations on determining when to use opioids for chronic pain; optimal prescribing (selection, dosage, duration, followup, discontinuation); and assessing risks and addressing harms of opioid therapy. The pharmacy team, both pharmacists and pharmacy technicians, have an important role in counseling patients about safe use of opioids. The team can also work with prescribers to ensure their optimal and safe use in patients with chronic pain. Identification of factors putting patients at high risk for opioid overdose and methods to minimize those risks are provided.

Accreditation Statements

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Pharmacists and pharmacy technicians are eligible to participate in this application-based activity and will receive up to 0.2 CEU (2 contact hours) for completing the activity, passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor on- line system and your participation will be recorded with CPE Monitor within 72 hours of submission

ACPE UAN:
0009-0000-19-004-H01-P
0009-0000-19-004-H01-T

Grant funding: Daiichi Sankyo, Inc.

Cost: Free

Initial Release Date: March 15, 2019
Expiration Date: March 15, 2022

To obtain CPE credit, visit the UConn Online CE Center

Use your NABP E-profile ID and the session code 19YC04-ABC36 for pharmacists or 19YC04-CBA24 for pharmacy technicians to access the online quiz and evaluation.

First- time users must pre-register in the Online CE Center. Test results will be displayed immediately and your participation will be recorded with CPE Mon- itor within 72 hours of completing the requirements.

For questions concerning the online CPE activities, email joanne.nault@uconn.edu

Faculty

Lisa M. Holle, PharmD, BCOP, FHOPA, is an Associate Clinical Professor, Department of Pharmacy Practice, University Of Connecticut School of Pharmacy, Storrs, CT and Associate Professor, Department of Medicine, University of Connecticut School of Medicine, Farmington, CT.

Faculty Disclosure

Dr. Holle has no actual or potential conflicts of interest associated with this article.

Disclosure of Discussions of Off-label and Investigational Drug Use

This activity may contain discussion of off label/unapproved use of drugs. The content and views presented in this educational program are those of the faculty and do not necessarily represent those of the University of Connecticut School of Pharmacy. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Content

Introduction

Approximately 20% of adults (50 million) in the United States suffer from daily (chronic) pain, and another 8% (20 million) have reported severe pain (i.e., pain that frequently limits life or work activities).1 This pain is often severe enough to cause worsening health, increased use of healthcare resources, and disability. Results of randomized clinical trials of opioids for treatment of pain have shown their effectiveness when used in the short term (12 weeks or fewer).2 However, the benefit of long-term use (more than three months) is limited.3 Despite this data, prescribers often use opioids to treat chronic pain, with one in five adults with noncancer-related pain prescribed opioids.4 In fact, the rate of prescribing opioids for pain nearly quadrupled from 1999 to 2014.5 At the same time, prescription opioid deaths from both illicit opioids and misuse of prescription opioids tripled, resulting in the opioid overdose epidemic.6

In the midst of this opioid overdose epidemic, the Centers for Disease Control and Prevention (CDC) created a guideline for prescribing opioids for chronic pain in adult patients with chronic pain treated in an outpatient setting (Table 1).7 Other pain-related guidelines are available and should be used for patients with cancer or palliative chronic pain and patients with acute pain treated by specialists like emergency clinicians or surgeons.8-11 Since this guideline’s publication, the opioid prescribing rate, including high dosage opioid prescriptions, is decreasing, yet drug overdose deaths reached an all-time high in the latest report analyzing data through 2016. Thus, understanding appropriate opioid use and prescribing continues to be a hot topic and one in which pharmacy teams should be well versed. This article provides the pharmacy team with a guideline overview, updates related to opioids, and tools they need to apply it to their practice.

 

References

Full List of References

1. Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67:1001–1006

2. Guideline for the use of chronic opioid therapy in chronic noncancer pain: evidence review. American Pain Society and American Academy of Pain Medicine. http://americanpainsociety.org/uploads/education/guidelines/chronic-opioid-therapy-cncp.pdf. Accessed March 2, 2019.

3. Chou R, Deyo R, Devine B, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Evidence Report/Technology Assessment No. 218. Agency for Healthcare Research and Quality. https://effectivehealthcare.ahrq.gov/topics/chronic-pain-opioidtreatment/research. Accessed March 2, 2019

4. Daubresse M, Chang H, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000–2010. Med Care. 2013;51(10):870-878.

5. Centers for Disease Control and Prevention. Vital Signs: Overdoses of Prescription Opioid Pain Relievers---United States, 1999—2008. MMWR. 2011;60(43);1487–1492.

6. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioidinvolved overdose deaths–United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445-1452.

7. Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain–United States, 2016. JAMA. 2016;315(15):1624–1645.

8. Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34(27):3325-3345.

9. National Comprehensive Cancer Network. Adult Cancer Pain. Version 1.2019. https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf.
Accessed February 27, 2019.

10. Chou R, Gordon DB, de Leon-Casasola O, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157.

11. Motov S, Strayer R, Hayes BD, et al. The treatment of acute pain in the emergency department: A white paper position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2018;54:731-736.

12. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162(4):276-286.

13. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376.

14. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014;4:CD007912.

15. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;3:CD000335.

16. Chamberlin KW, Holle LM. Management of common pain conditions encountered by pharmacists: osteoarthritis; low back pain; fibromyalgia; sprains, strains, contusions; and generalized headaches. Drug Topics. 2013;157(8):48-60.

17. Centers for Disease Control. Nonopioid treatments for chronic pain. https://www.cdc.gov/drugoverdose/pdf/nonopioid_treatmentsa.pdf. Accessed February 27, 2019.

18. Centers for Disease Control. Training for providers. Available at: https://www.cdc.gov/drugoverdose/training/index.html. Accessed February 27, 2019.

19. Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med. 2009;24(6):733-738.

20. Ostelo RW, Deyo RA, Stratford P, et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976). 2008;33(1):90-94.

21. Pham T. Pharmacology and therapeutics of pain medications: Part 2. Drug Topics. 2013;157(6):52-62.

22. Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015;175(4):608-615.

23. US Department of Veterans Affairs. VA/DoD clinical practice guidelines: management of opioid therapy (OT) for chronic pain. Washington, DC: US Department of Veterans Affairs; 2010. http://www.healthquality.va.gov/guidelines/Pain/cot. https://effectivehealthcare.ahrq.gov/topics/chronic-pain-opioidtreatment/research.

24. Washington State Agency Medical Directors’ Group. AMDG 2015 interagency guideline on prescribing opioids for pain. Olympia, WA: Washington State Agency Medical Directors’ Group; 2015. http://www.agencymeddirectors.wa.gov/guidelines.asp. Accessed March 2, 2019.

25. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc. 2015;90(6):828-842.

26. Department of Veterans Affairs/Department of Defense. Tapering and discontinuing opioids. http://www.healthquality.va.gov/guidelines/Pain/cot/OpioidTaperingFactSheet23May2013v1.pdf. Accessed March 10, 2019.

27. CDC. Pocket guide: tapering opioids for chronic pain. https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf. Accessed March 10, 2019.

28. Kral LA. Opioid tapering: safely discontinuing opioid analgesics. http://www.nhms.org/sites/default/files/Pdfs/Safely_Tapering_Opioids.pdf. Accessed March 10, 2019.

29. US Department Health and Human Services. US Food & Drug Administration. Statement by FDA Commissioner Scott Gottlieb, M.D., on new steps to advance the development of evidencebased, indication-specific guidelines to help guide appropriate prescribing of opioid analgesics. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm617908.htm?utm_campaign=08222018_Statement_New %20FDA%20steps% 20to%20advance%20evidencebased%20opioid%20prescribing%20guidelines&utm_medium=email&utm_source=Eloqua. Accessed February 27, 2019.

30. Fenthem S. Missouri governor calls for ‘long-overdue’ drug monitoring database to curb opioid abuse. Available at: https://news.stlpublicradio.org/post/missouri-governor-callslong-overdue-drug-monitoring-database-curb-opioidabuse#stream/0. Accessed March 2, 2019.

31. State of Connecticut Department of Consumer Protection. Prescription monitoring program. https://portal.ct.gov/DCP/Prescription-MonitoringProgram/Prescription-Monitoring-Program. Accessed March 2,2019.

32. Kale M. Urine drug tests: ordering and interpretation. Am Fam Physician. 2019;99:33-39.

33. Paquin AM, Zimmerman K, Rudolph JL. Risk versus risk: a review of benzodiazepine reduction in older adults. Expert Opin Drug Saf. 2014;13(7):919-934.

34. American Psychiatric Association. Opioid use disorder diagnostic criteria. Diagnostic and Statistical Manual of Mental Disorders (DSM-V). https://www.asam.org/docs/default-source/educationdocs/dsm-5-dx-oud-8-28-2017.pdf?sfvrsn=70540c2_2. Accessed March 2, 2019.

35. Substance Abuse and Mental Health Services Administration (SAMHSA). Find help and treatment. https://www.samhsa.gov/find-help. Accessed March 2, 2019.

36. Prescribe to Prevent: prescribe naloxone, save a life. http://prescribetoprevent.org/. Accessed March 2, 2019.

37. Opioid overdose prevention programs providing naloxone to laypersons–United States, 2014. Morb Mortal Weekly Rep; 2015;64(23):631-635.

38. State of Connecticut Department of Consumer Protection. Opioid overdose prevention/naloxone (Narcan) initiative. http://www.ct.gov/dmhas/cwp/view.asp?a=2902&q=509650. Accessed March 2, 2019.

39. Singer JA. Stop calling it an opioid crisis–it’s a heroin and fentanyl crisis. Cato at Liberty: 2018 January 9. https://www.cato.org/blog/stop-calling-it-opioid-crisis-its-heroinfentanyl-crisis. Accessed March 2, 2019.

40. Barrett J. DEA reduces opioid manufacturing for 2017. Pharm Times. 2016. https://www.pharmacytimes.com/news/deareduces-opioid-manufacturing-for-2017. Accessed March 2, 2019.

41. United States Drug Enforcement Administration. DEA proposes reduction to amount of controlled substances to be manufactured in 2018. https://www.dea.gov/pressreleases/2017/08/04/dea-proposes-reduction-amountcontrolled-substances-be-manufactured-2018. Accessed March 2, 2019.

42. North Carolina Medical Board. Professional resurces. https://www.ncmedboard.org/resourcesinformation/professional-resources/laws-rules-positionstatements/positionstatements/Policy_for_the_use_of_opiates_for_the_treatment_of_pain. Accessed March 2, 2019.

43. Kroenke K, Alford DP, Argoff C, et al. Challenges with implementing the Centers for Disease Control and Prevention Opioid Guideline: a consensus panel report. Pain Med. 2019:1-12.

44. Provenzano DA, Kamal KM, Giannetti V. Evaluation of primary care physician chronic pain management practice patterns. Pain Physician. 2018;21:E593-E602.

45. Centers for Medicare and Medicaid Services. 2019 Medicare Part D Opioid Policies: Information for Pharmacies. https://www.pharmacist.com/sites/default/files/audience/CMSPartDOpioid%20Pharmacy%20Tip%20Sheet_20181206_508.pdf. Accessed March 2, 2019.

46. Centers for Medicare and Medicaid Services. Medicare Part D Prescription Opioid Policies for 2019. Available at: https://www.pharmacist.com/sites/default/files/audience/CMSPartDOpioid%20Pharmacy%20Webinar_20181206_508.pdf. Accessed March 2, 2019.

47. Darnall BD, Ziadni MS, Stieg RL, et al. Patient-centered prescription opioid tapering in community out-patients with chronic pain. JAMA Intern Med 2018;178(5):707–708.

48. Ensuring appropriate opioid management in a community pharmacy setting. Pharm Lett. 2016;course 214. http://pharmacist.therapeuticresearch.com/Content/Segments/PRL/2016/May/Ensuring-Appropriate-Opioid-Management-in-aCommunity-Pharmacy-Setting-9661. Accessed March 2, 2019.

49. Goodman CW, Brett AS. Gabapentin and pregabalin for pain – is increased prescribing a cause for concern? N Engl J Med. 2017;377:411-414.