Oral and Intrathecal Opioids: Rational Approaches and Realistic Expectations

Outcomes

Learners completing this activity report improved abilities in:

• Communicating with, and educating their patients
• Weigh risk vs. benefit for patients when choosing opioid analgesic regimen
• Implementing proper evaluation and risk assessment practices for long-term opioid therapy
• Tapering opioids when appropriate

Learning Objectives

As a result of participating in this activity, learners will be better able to:

• Integrate opioid analgesics into a pain treatment plan individualized to the needs of the patient
• Manage patient expectations and interactions with regards to opioid prescribing and tapering
• Assess the success of opioid therapy for each patient
• Mitigate iatrogenic opioid dependence or abuse

Activity Description 

Best practices for chronic pain management agree on specific recommendations for mitigating opioid-related risk through risk assessment, including screening for risks (e.g., depression, active or prior history of SUDs, family history of SUD, childhood trauma) prior to initiating opioids; medication dosing thresholds; consideration of drug-drug interactions, with specific medications and drug-disease interactions; risk assessment and mitigation (e.g., patient-provider treatment agreements); drug screening/testing; prescription drug monitoring programs; and access to nonpharmacologic
treatments.

Because there are opioid receptors on the spinal cord and at specific areas of the brain, significantly smaller doses of opioids in the spinal fluid can provide significant analgesia at much lower doses than oral opioids. Implanted intrathecal pumps with catheters in the spinal fluid can supply medication continuously, and they have been used for both cancer and noncancer pain. The largest trial ever performed in cancer patients demonstrated improved pain control with fewer side effects and a trend toward improved life expectancy with implantable pumps. However, there are significant side effects, including delayed respiratory depression, granuloma formation, and opioid-induced hypogonadism.

It is vital to consider a risk-benefit analysis to provide the best possible patient-centered outcome while mitigating unnecessary opioid exposure. Reevaluation of patients is critical in this setting because the use of medications to control acute pain should be for the shortest time necessary while also ensuring that the patient is able to mobilize and restore function.

Outline

1. Examine changes in attitudes, beliefs, laws and prescribing practices for opioids in recent years
2. Identify key pharmacological aspects of oral and intrathecal opioids
3. Explore the role of opioids in the overall treatment of chronic pain
4. Evaluate the definitions of success and failure for chronic opioid therapy
5. Propose next steps when opioid therapy is a failure

Overview

• Changing attitudes, beliefs and prescribing practices in recent years
• Pharmacology of opioids – oral, transdermal and intrathecal
• Is there a scientific approach to dosing?
• The role of pharmacogenomics
• Intrathecal panel based recommended dosing
• Role of opioids in the larger scheme of pain treatment
• Definitions of success and failure
• Calling out failure and proposing subsequent actions
• Importance of physician/patient relationships

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS]  about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Patient Care [ACGME/ABMS]  Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Provide Patient-centered Care [IOM]  Identify, respect, and care about patients’ differences, values, preferences and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health
• Interpersonal and Communication Skills [ACGME/ABMS]  Effective information exchange and teaming with patients, their families, and other health professionals
  
• Professionalism [ACGME/ABMS]  As manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • 1.5: Explain how cultural, institutional, societal, and regulatory influences affect assessment and management of pain

• 2. Pain assessment and measurement: How is pain recognized?
  • 2.1: Use valid and reliable tools for measuring pain and associated symptoms to assess and reassess related outcomes as appropriate for the clinical context and population
  • 2.2: Describe patient, provider, and system factors that can facilitate or interfere with effective pain assessment and management
  • 2.3. Assess patient preferences and values to determine pain-related goals and priorities
  • 2.4: Demonstrate empathic and compassionate communication during pain assessment

• 3. Management of pain: How is pain relieved?
  • 3.1: Demonstrate the inclusion of patient and others, as appropriate, in the education and shared decision-making process for pain care
  • 3.2: Identify pain treatment options that can be accessed in a comprehensive pain management plan
  • 3.4: Develop a pain treatment plan based on benefits and risks of available treatments
  • 3.5: Monitor effects of pain management approaches to adjust the plan of care as needed
  • 3.6: Differentiate physical dependence, substance use disorder, misuse, tolerance, addiction, and nonadherence

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Speaker] Richard Rosenquist discloses the following financial relationships: Consulting: Mainstay Medical

Neither the peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

All relevant financial relationships have been mitigated. Materials were peer-reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• Strickler, G. K., Kreiner, P. W., Halpin, J. F., Doyle, E., & Paulozzi, L. J. (2020). Opioid Prescribing Behaviors—Prescription Behavior Surveillance System, 11 States, 2010–2016. MMWR Surveillance Summaries, 69(1), 1.
  
• Silva, M. J., & Kelly, Z. (2020). The Escalation of the Opioid Epidemic Due to COVID-19 and Resulting Lessons About Treatment Alternatives. American Journal of Managed Care, 26(7), 202-204.
• Kral, L. A., Jackson, K., & Uritsky, T. J. (2015). A practical guide to tapering opioids. Mental Health Clinician, 5(3), 102-108.
• AMA Opioid Task Force (2020) Progress Report: Physicians' progress toward ending the nation's drug overdose and death epidemic. https://www.ama-assn.org/syste...
• Mackey, S. (2014). National pain strategy task force: the strategic plan for the IOM pain report. Pain Medicine, 15(7), 1070-1071.
• IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.
• Krebs, E. E., Gravely, A., Nugent, S., Jensen, A. C., DeRonne, B., Goldsmith, E. S., ... & Noorbaloochi, S. (2018). Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA, 319(9), 872-882.
• Brummett, C. M., Waljee, J. F., Goesling, J., Moser, S., Lin, P., Englesbe, M. J., ... & Nallamothu, B. K. (2017). New persistent opioid use after minor and major surgical procedures in US adults. JAMA surgery, 152(6), e170504-e170504.
• Klueh, M. P., Hu, H. M., Howard, R. A., Vu, J. V., Harbaugh, C. M., Lagisetty, P. A., ... & Lee, J. S. (2018). Transitions of care for postoperative opioid prescribing in previously opioid-naive patients in the USA: a retrospective review. Journal of General Internal Medicine, 33(10), 1685-1691.
• Lu, L. (2015). The impact of genetic variation on sensitivity to opioid analgesics in patients with postoperative pain: a systematic review and meta-analysis. Pain Physician, 18, 131-152.
• Ruano, G., & Kost, J. A. (2018). Fundamental considerations for genetically-guided pain management with opioids based on CYP2D6 and OPRM1 polymorphisms. Pain Physician, 21(6), E611-E621.
• Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., ... & Deyo, R. A. (2015). 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. Annals of Internal Medicine, 162(4), 276-286.
• Wang, J. K., Nauss, L. A., & Thomas, J. E. (1979). Pain relief by intrathecally applied morphine in man. Anesthesiology: The Journal of the American Society of Anesthesiologists, 50(2), 149-151.
• Deer, T. R., Pope, J. E., Hayek, S. M., Bux, A., Buchser, E., Eldabe, S., ... & Doleys, D. M. (2017). The Polyanalgesic Consensus Conference (PACC): recommendations on intrathecal drug infusion systems best practices and guidelines. Neuromodulation: Technology at the Neural Interface, 20(2), 96-132.
• Deer, T. R., Pope, J. E., Hanes, M. C., & McDowell, G. C. (2019). Intrathecal therapy for chronic pain: a review of morphine and ziconotide as firstline options. Pain Medicine, 20(4), 784-798.
• Webster, L. R., & Webster, R. M. (2005). Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Medicine, 6(6), 432-442.
• Butler, S. F., Fernandez, K., Benoit, C., Budman, S. H., & Jamison, R. N. (2008). Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). The Journal of Pain, 9(4), 360-372.
• MacPherson EL. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. Bethesda, MD: American Society of Health System Pharmacists; 2010.
• HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose [news release]. HHS Press Office; December 19, 2018
• Henry, S. G., Paterniti, D. A., Feng, B., Iosif, A. M., Kravitz, R. L., Weinberg, G., ... & Verba, S. (2019). Patients’ experience with opioid tapering: A conceptual model with recommendations for clinicians. The Journal of Pain, 20(2), 181-191.