Thursday, November 17, 2011

Opioids for Chronic Pain - CSAM Position Paper 2011

On Nov. 5, 2011, at the Canadian Society of Addiction Medicine annual scientific meeting, Dr. Ronald Lim and Dr. Nady el Guebaly presented on CSAM's new position for use of opioids in chronic pain.  I took some notes and compikled this blog based on those simply to share the highlights of the discussion. This is a very hot and controversial topic that affects the majority of physicians in clinical practice.  I was very thankful to see that concerns of patients and clinicians were so well addressed in this complex field.

This position paper was developed in response to
  1. concerns regarding patient and public safety risk from opioids
  2. Rising rate of rx opioid abuse
  3. Rising rates of illict use of rx opioids

NOUGG - National Opiate Use Guideline Group was the research team  set up with physician/epidemiologist, four physician researches, and research librarian to study research to date and bring findings to the National Advisory Comittee
6,580 studies identifed
184 met inclusion criteria
Concerns regarding patients and public safety were raised.
Canada recorded rx opioid consusmption increased by 50%
Canada is current the third largest opioid analgesic consumer per capita
Dhalla 2009 showed that 1095 overdose death in Ontario, 56% had been given opiod prescription within 4 weeks before death
Study of oipiod depent patients, 37% receieved their oidiod from physican prescriptions
Kuehn 2009  noted increase in rx and increase abuse, serious injuries and overdose death
In patients with history of substance abuse
prevalence of aberrant drug related behaviour 11.5%
urine drug screens with illicit drugs 14.5%

Investigation of the evidence of opiod efficacy was best for the following:

diabetic neuropathy
peripheral neuroptahy
postherpetic neuralgia
phantom limb
spinal chord

In other conditions the evidence was mixed or absent:
Fibromyalgia - no randomized trials of strong opiods
of the trials, tramadol, shown best.
small benefits outweighed by increasde adverse affect
neuropathic pain - subjective improvement was noted but not not that significant when compared with  functional status. Patients felt better but didn't appear to 'do' better with the subjective benefit.
Migraine, tension headaches
opioids not indicated

A major recommendations was associated with discontinuing opioids:
-opioids should be tapered and discontinued if patient’s pain remains unresponsive after trial of several differnet opioids.
This was a critical piece of information given the clinical tendency to start opioids and believe they are beneficial when they haven't shown benefit and then leave them in place for fear of addressing the issues of discontinuance.
Further recommendations included the following:
definition of addiction in context of pain treatment should be clarified and concerns should clearly be raised if the following are noted:
1)Continued opioid use despite adverse consequences
2)Loss of control
3)preoccupatins with obtaining opioids despite adequate analgesia
4) denial of a problem
There were very important recommendations regarding physician training in this regard, consensus being that physicians needed specific training and that specific training would go a very long way to reducing concerns re safety and abuse.
Physican prescribing should be appropriately trained  and physicians should ,perform documentend compreshensive training

Further, "medical legal consequences should be muted". If physicians were supposed to prescribe opiates for severe and chronic pain in appropriate situations they should not face overwhelming negative consequences for doing what was best for the patients or else physicians would have no choice, really but to feel that they were getting a mixed message in which 'ommission' would be rewarded but where 'commission' would be punished.

Opioid prescribing for chronic non-cancer pain

M.Kahan, R. Lim, N. el Guebaly Sept 2011

1.Careful patient selection
2.First line opioids - WHO pain ladder
3.Dose titration - should improve function, reduce pain by at least 30% (10 pt), mostly well below the 200 mg morphine oral range
4.Overdose prevention
5.Screen for addiction risk
6.Opioid tapering - lack of response to high dose
  1. Management of high risk addiction
  2. Management of suspected addiction
  3. Treatment options - structure opiodi therapy, opioid agonsits
This will be published in the Can. Journal of Addiction Medicine

The discussion continued with recommendations for Public Health, defunding the 80 mg Oxycontin, and de linking Buprenorphine prescribing from Methadone, being addressed.  The discussion, in fact , was rather exciting suggesting participants not only appreciated the presentation but working themselves in this difficult area had many questions and ideas to share.  It was clinically very elucidating.

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