Pain Management 09 21 2016 CDC Guidelines 3 of Opioid Use

Author: Project ECHO Nevada

Morning thank you for joining us this morning I hope everybody's doing well. Before we get going on the presentation I put together which is the third and final installment of the CDC guidelines, does anybody have any cases or a topic of discussion that they'd like to start with? Okay, what we'll do is we'll start with the slides and as we go if anybody has any questions concerns or worries or wants to stop and go over something, feel free to stop us at any moment. So like I said we've done the CDC guidelines kind of a general overview and then we've gone more in depth and this is the third installment third and final installment about the in-depth serious about what CDC has recommended. My contact information if anybody has any questions, concerns, or worries, or just wants to reach out to me with a situation they got for help I'm always more than willing to be there for you and help you out. As we've talked about recently you know as prescription drug use or misuse and abuse as at high or uh an American epidemic and what we've seen over the last, since the change of paradigms in the 1990s what we've seen is that opioid deaths have uh steadily increased with opioid sales and there for you know we are in an epidemic that we're trying to curb. And so in March of 2016 the CDC published guidelines for prescribing opioids for chronic pain.

And what we've seen is that opioid prescribing rates have increased more with family practice general practice and internal medicine physicians in 2007 from 2007-2012 and nearly half of all dispensed opioid prescriptions come from a primary care physician. So what the CDC's looked to do is put out recommendations to provide guidelines to primary care providers for prescribing opiates for non cancer palliative or end-of-life care. And the recommendations have been grouped into three areas of consideration, one was determining when to initiate or continue opiates for chronic pain. And that was our first in-depth presentation so if you want to go online and look at that we have those recommendations. Two we've got you know we've talked about the opioid selection, dosage, duration, follow-up, and discontinuation we did that last month.

And today what we're going to do is look at topic number three which is assessing risk and addressing harms of opioid use. So starting with that the first recommendation that the CDC makes is that before starting or periodically during continuation of opioid therapy providers should evaluate risk factors for opioid related harms. Providers should incorporate into the pain management plan strategies to mitigate risk including consideration offering naloxone when factors that increase the risk for opioid overdose such as history of overdose, history of substance abuse, use disorder, or a high opioid dosage which is greater than 50 MME in a 24-hour And the reasoning behind these is that that certain risk factors are likely to increase the susceptibility to opioid associated harms and warrant incorporation of additional strategies into the management plan to mitigate the risk And if you look at the risk factors that they specifically discuss, one talked about sleep disordered breathing if you look at this in detail thy were talking about even if they haven't been diagnosed with obstructive sleep apnea obese patients kind of fall into this category. Two was pregnant women and that includes you know women who have already delivered and are breastfeeding.

Three was renal or hepatic insufficiency reason for that is that if the patients are unable to metabolize the medications appropriately it may increase their concentration in their system which leaves them more susceptible to an adverse event. Four was patients greater than 65 years of age reasoning behind this is our pharmacy you know interaction with other medications that they're on, two was decreased renal herpetic functional as we get older. Three was mental health conditions or sorry the next one, five is mental health conditions. Six was substance use disorder history, so when we see these patients we want to make sure from the get go we a get a good background on if they have a substance use or abuse history. And last but not least was a prior non fatal overdose. I think uh studies have shown that if a patient has a prior fatal overdose they're susceptible to having an adverse event again.

Pain Management 09 21 2016 CDC Guidelines 3 of Opioid Use

Any questions on these risk factors? Does anyone out there think that they missed any risk factors that they should have considered? Mike any input from you or.. Think that's pretty good? No I think it covers a lot of that I would add under sleep-disordered breathing I think after an individual's on opiates you can I think central sleep apnea is another condition following that one but many of the patients that I see with chronic pain have sleep-disordered breathing, it has a major role so then the opiates then just complicate things as well. Well you always wonder about patients who have chronic pain if there's an underlying sleep disorder that is related or causing their chronic pain so a lot of times that's a nice evaluation that a patient should have less chronic pain and make sure that's not I had a number of patients whose irritability and fatigue changes dramatically with just addressing the sleep problem separate from their pain problem. So it's always a good idea to sleep. Definitely Let me add one thing real quick the prior nonfatal overdose the reason for that is when a person is into the overdose level of using, when they stop using and overdose is a pretty traumatic experience so they could stop using for three months six months a year cycles back, they're using the same amount if not more. But the only thing they screwed up is their tolerance. So that's why that's even a more important uh marker to look for. Yeah and I see that all the time in my clinic I actually had a patient yesterday who uh you know I'd seen years previous return to me about two three months ago and was on MS contin 300 milligrams three times a day with a couple break through and you know her and I had a pretty clear discussion about how we'd all look at alternatives to treat her pain you know.

We talked about strategies to reduce her over the next several months and get her within the CDC guidelines and you know saw her in July and next thing you know she doesn't show no shows in August so you think ah she doesn't like my strategies she's probably went back to who ever was prescribing to her before. But run a board pharmacy and it was negative, nothing shows up. So she she returns yesterday sounds like she had some type of incident or fall on August 10th. The work up at the hospital was negative but she was found you know this fall that occured on August 10th um friends find her on August 16th, take her to the hospital. So she laid around for 6 days with no recollection of anything had occurred uh and she returned to me yesterday and she's on literally nothing and she's like well it's time to you know restart my medications right where we were.

And I'm like you know I think I'll give you like two 5 milligram percocets a day you know. Yeah Yeah because I think there's that fallacy that they just think well I used to be able to take this so therefore should be able to return right to that dose with no problem. But my goodness if I would have put her on 100 milligrams three times a day of MS contin I probably would have killed her. So but the patients don't really understand that situation. I have to I have to admit you know in our clinic these are probably risk factors that we should add to our intake forms. So that when we see patients initially this is something that is asked or checked off so we can you know delve deeper into these issues. Very rarely do we outright ask patients about these situations you know when I review prior medical records usually I'll know if they have renal or hepatic sufficiency and obstructive sleep apnea, uh and we do have a question on our intake form about being pregnant but as far as going in-depth in mental health conditions, not really.

We have a few questions asking about substance use disorder and we have no questions whatsoever on our intake forms about you know if they've had a prior non fatal overdose. So bottom line what this recommendation is the provider should assess to these risk factors periodically. Just because you assess them at one time period doesn't mean that the patients can't develop these over time. Um factors that vary more frequently over time require more frequent follow up. So if you know say a patient doesn't have any of these risk factors six months later they've develop some of them.

Say you were giving them enough medications to last two three months at a time at that point you should probably reconsider how often you see them, especially after you become aware of the risk factor you should probably start seeing them you know every 30 days for a period of time. And then any patient that has a risk factor providers should consider offering naloxone when prescribing opiates um since these patients are at increased risk. So they said um situations again naloxone is increased risk factors, history of prior overdose, patients who are taking benzodiazepines and last but not least patients who take over 50 MME in a 24-hour period. Um I just want to throw this out there is anybody currently in their clinic prescribing naloxone to patients? Yeah we got one, did you, was it the CDC guidelines that encourage you to do this or were you doing it previous? Um I was doing it previous just for some of my patients who are on a lot and they live in remote areas that don't have any medical care right now. Let me ask you did uh, do you do a patient education to the patient and to a family member when you initially give it to them? I have had only a couple of times where I've been able to talk to family in person at the clinic because they travelled to see me um four hours away so they don't often have anyone with them. But I will try to talk to the family members on the phone and I have a handout that talks about the naloxone treatment.

The problem I've had is some of them can't afford the copay. Correct So that's been tough. Um and I, you know that is one complaint that I hear from a lot of providers is that one: there's a prior authorization process to get the naloxone. And for two insurance won't cover it, or three it's cost prohibitive. I think the governor's summit you know that occurred last month I think that's one of the areas that was brought up to the governor and I think they're trying to get it so that it's almost going to be free at the pharmacy but I don't know if that will ever, they're trying to make it more readily available that so that patients can get it even without providers prescribing. Yeah that's actually taken um it was supposed to have taken effect October 1st of last year, but they ended up went to a little bit more time to actually work out the language on it. And supposedly it was signed and ready to go when the summit took place at the end of August, yeah end of August. And so at anytime now it should be ready to the language says that pharmacists can now furnish naloxone without a provider's prescription.

Okay good yeah I've even heard of one situation where HHP insurance had their pharmacy andtherapeutics meeting and um they outright passed that they won't cover naloxone because their theory is, is that well if you think it's a problem they shouldn't be on opiates in the first place, and that it's not their problem to cover it. (laughing) So Something to add with the naloxone make sure that you have enough uh sometimes one is not enough and what you're going to do is you're going to blast off those immune receptors, put the person into withdrawal maybe be able to resuscitate them. Sometimes it takes two shots.

The short acting it only lasts only lasts 20 minutes to a half hour at max Yeah education is really imperative especially, I work with the addiction so I know where I'm coming from, the treatment site of some people when they want to get as high as they possibly can well have that in their back pocket thinking I can really hit it and if I do start to go into overdose hit me with this. It's just a realistic danger that we have out there. So be aware with the amount of uh what they have in the system that would be correlated to the amount that they need if they're truly going to be resuscitated.

Like Chris is saying it's time sensitive too so they still need follow up care. And I have to agree I mean in our clinic we've talked about adopting this but we have not because we're afraid that it promotes bad behavior. You can use this drug now that can reverse it so why don't you go home and push the limits, like I feel like it's a you know it's going to promote you know bad behavior on the patients behalf. (inaudible) Yeah correct In some thought processes it does because that is the thought process of the person using, struggling with addiction. They want to not only avoid pain or withdrawals if they want to get as high as they possibly can.

And you know the other I guess on the flip side I've heard one patient tell me, that was a former Dr. Rand patient that he doubled her meds I mean like literally gave her twice as much between one visit and another without her even asking uh and left the room and then came back in and said Oh my god you know I just realized I giving you so much but you better take this with you and gave her a prescription of naloxone and I guess that scared the patient you know so bad that she, like I need to get out of here I didn't even ask for an increase he doubled my meds and on top of it he comes back in frantically like oh you better take this just in case. Wow So I thought that was kind of interesting so maybe, maybe you know when you try to talk to patients about the dose they're on and you know that they're high risk it seems to me that a lot of patients kind of look at me like ooh-hoo you know like whatever you know I've been taking this forever and I don't think they understand that it is risky and maybe giving that prescription puts it into perspective for them. You know I've thought about that too but.. A lot of times if you have somebody who's accountable with them and they're trying to avoid anything, it's getting a team effort and so it's not a one-on-one situation it's you and your support person who have access to this then they can be aware. There's a couple of strategies that you can use to try to lessen the risk and then also the education is imperative especially how to apply it. (laughing) Alright any providers out there that have had a patient who's been given naloxone that's had to use it? Okay, I wasn't sure if you've seen many situations where patients have been given it and they actually use it or.. No I just hear from EMTs and people I've couple of times after they used it the that's another thing how do you react when the person comes off of it are they sleepy and disoriented, are they coming out swinging.

Yeah are they, there's all different kinds of things that now that you've created this now there's follow up and so it's the whole claim that tape all the way through. Has the person been out has their brain been lacking oxygen for a certain amount of time? So now we have somebody who might be even in a vegetative state when they're revived so there's all kind of complications that go into an overdose and education, being aware of it just gives you more ammunition on what to do or who to hand it off to if you get into one of the situations. So if they're like four hours from a hospital and they use it are they going to be able to revive them and actually you know is there going to be enough time? They'd have to have four hours worth or enough to get them that four hours to the hospital.

But I'm assuming if you, they should the emergency you know if they contact somebody probably somebody within a half hour so if you give them two doses seems reasonable that you can at least keep them alive until you know EMS gets there and EMS at that point would the probably have enough to contain them to get them somewhere else does your business You're right That's the standard practice is to, and its taking the EMS response time into account and the EMS providers have whatever they need the number of doses that they need in order to get to the hospital. So if the, if it's four hours from the home to the hospital then they'll have approximately 8-10 doses on hand for any one overdose patient. Okay So the next recommendation that the CDC makes is providers should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the patients receiving high opioid dosage or dangerous combinations that put him or her at risk of overdose. Providers should review PDMP or the you know the database when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months.

And so the reasoning behind this is that you know even though there is no clinical studies showing the effectiveness of the PDMP on outcomes related to overdose, addiction, abuse, or misuse. What the PDMP does is it contains information on factors that could be related to an overdose. That is one reason, patients receiving scripts for multiple providers and or receiving high total dosage of opioids. So the PDMP is useful and seeing what other controlled substance a patient might be receiving from other providers that could result in a dangerous combination. So I think the main one that I look for is the combination of opioids combined with benzodiazepines You know previously in our clinic we had a policy or and we still do, that we do not prescribe benzos and when we pull the PDMP you know before their visit every month I would just make sure they weren't getting opioids from a another prescriber. But now that this guideline has come out we actually take into account you know if they are seeing a psychiatrist and getting benzos.

I'm discussing it with a patient that it puts them at a higher risk and two, I'm actually reaching out to the prescribing doctor and asking if there's alternatives besides besides benzos being on. So if they're on it for anxiety you know could we try an SSRI or SMRI combined with CBT instead of using chronic benzos, and in some cases the provider agrees with this and you know tells me that they'll taper em off the benzodiazepines over the next 3-6 months so I can continue the opioid therapy for the patient. Some situations the patients may decide to stop the pain medication so, because they think they need the benzo and so those situations then I'm in control of weaning them off the opioids. But previously I kind of just you know I said oh they're under another professionals care that's fine but I think it you know there needs to be some coordination of care especially since this this guideline's been published. The other thing that I like about the PDMP is on the intake form it blows me away on how many patients well put you know hydrocodone 10, 325 10 a day and then I run their PDMP and it shows that they've been getting you know no more than 90 every 30 days. And you know when you go in and start talking to the patient, the patient will be like yeah I'm taking 10 a day and then I'm like wait a second I see you get this script for 90 you know perfectly every 30 days at most that's three a day how can you be taking 10 and then you know the truth kind of comes out. So I think you know patients are going to tell you on the intake forms what they want and not what they're actually taking and so the PDMP is actually a good way to actually see what patients are currently taking or what they're receiving. So the bottom line you know providers should access the PDMP when starting opioid therapy and periodically, you know um experts couldn't agree on how often you know periodically would be but they finally recommended it every so often, about every 3 months.

In our clinic we do it every visit because that's what we do, if I was a primary care physician I'm trying to address other problems it would be difficult to check it every month but in our clinic since that's all we do we check in on every single visit. And I believe state law states that you have to check it when you're initiating or doing a prescription greater than seven days or if you change their dose is that correct? Anybody else have input on it? I think that is the state law. The other thing that I'd caution you on is you gotta remember is that the PDMP at times is not going to include out-of-state prescriptions. Sometimes the VA does not report to the PDMP I think they're changing that though.

And I've seen situations where Indian Health doesn't so if I have a patient that comes to be from Indian Health a lot of times I will call the pharmacy to see if they're on. Or patients who mention to me that they are a VA a patient and they go there for care I will call the pharmacy to see make sure that they're not receiving something from there. I've actually had a patient who came to me via work comp, on a side note mentioned he was going to the VA um but you know acted like he was on medications, I called and found out that he had gotten 560 pills just the day before at the pharmacy.

And come to find out I think we sent him to pain psychology and it turned out, I think Mike actually saw him, this was a couple years ago and found out that he was giving half those pills to his wife. So that relationship didn't last very long. CDC also recommends Oh yea question Um so I noticed you didn't put on there the methadone clinic I find it interesting that they don't report that either. Yea so that's a great point I don't know if that is for you know privacy or HIPPA or I'm not sure why the center of behavioral health doesn't report to the PDMP as well it in drug screens you know we'll see patients positive for methadone and they will then be questioned about it at follow-up which they previously never mentioned before, it'll come out that they were going to the methadone clinic before they saw us, so that is actually an excellent point too.

We saw a patient at our clinic yesterday that was a Dr. Rand patient who came in, was supposedly going there you know it took him between the time Dr. Rand got arrested between when we saw him yesterday. The PDMP was negative patient said they had you know behavior of or center of behavioral health we actually just got a refuse to prescribing them last week, got a drug screen saw him back yesterday to go over the results to confirm that they're on methadone and we also had him sign a waiver that we could call their counselor at the center of behavioral health and make sure there wasn't any issues. And in this situation it turned out the patient was compliant had been showing up everyday they had no abnormal drug screen so at that point we, you know make it easier on the patient we took over their methadone we maintain it, you know they're on around 60 MME and we're just going to maintain it so that instead of them coming in everyday we'd see him once a month. But yeah does anybody know why their reason why they don't report? Next question Yea, another question? I don't know, I was just curious if you knew why or if that was going to change because that seems ridiculous I feel like we should know that information.

I completely agree and I'm not sure why they don't have to report to the PDMP I can try to look into it see if I can get that answer for you though. That would be awesome thank you. Hey no problem Uh, the other thing that I thought was interesting is if you do come across a doctor shopper, they're saying that you shouldn't use the PDPM data to dismiss patients. And they're saying that by doing so you may adversely affect the patient safety and this could represent patient abandonment. Traditionally in our clinic if we catch a patient doctor shopping usually we would terminate care but a lot of times that leads to hostility and kind of a hostile situation in the office. And we've kind of changed it over time that we will react to the situation so if it's a patient who's been good you've been checking PDMPs for years and all of a sudden you know they pop positive for on the report for like 20 vicodin and they admit to it, and say - Oh I had a dental procedure I don't think about calling you. A lot of times we'll give them forgiveness but if it's a situation where you see a patient one day the next day they get 120 from somebody else you know previously in the past we would probably fire them. What we've done now though is try to instead of making it a hostile situation we kind of react to the situation where we say well oh my, you know I'm sorry I can't prescribe to you any further you know always use kind of the government to blame that seems to take the blame off of ourselves and deescalate the situation and usually give them a tapering dose.

And usually what we find at that point is that the patient will terminate us. And so they'll find another provider that will continue to prescribe to them. But I think what they're trying to say is that these are golden opportunities for you to intervene in that patient's life and may have a chance to make a huge difference in outcome here.

So if you can have the time to educate them on how that was wrong, how you think they may need help offer them help and if they get help then you may have a chance to save that person's savethat person's life, and so I think that's why they're saying that you shouldn't use that to dismiss patients. Any questions on that? You could even use that as an opportunity to ask them you know what that's about. Correct Why would they be getting 150 more after they just talk to you and see if you can elicit some response from them that could perhaps lead to some insight or identify the problem.

Yeah and I've got situations where you know I go out of my way to try to get these people help and you know I tell you it is very rare that they actually take my advice. They you know will end up just taking the path of least resistance and you know to them they don't think they have a problem and the path of least resistance is to just find somebody else who will continue to prescribe to them. What's nice is I think the whole Dr.

Rand situation and the publication of the CDC guidelines it seems like you know it's not as easy for them to find other providers now and so I'm wondering if this whole situation that came down you know offering patients help the more patients will take it because they'll find out there isn't a path of least resistance. Um and f you're curious just for individual state law regarding the PDMPs you can access this website for more information but it would have any state that you'd be curious about what their the rules and regulations that they require with PDMPs. The next recommendation that CDC has is when prescribing opioids for chronic pain providers should use urine drug screen testing before starting opioid therapy, consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. And the reasoning is that concurrent use of opioids with other opioid medications, benzodiazepines, or heroin can increase the patient's risk for overdose. And that urine drug screens provide information about drug use that is not reported by the patient. I don't know if that's true all our patients are honest aren't they and they tell us what's going on? It's interesting to see the results on the drug screens and you know asking openly to patients you know I used to I think that earlier in my career I was uncomfortable with going over the results with them. And I would almost give them a bailout like as I would bring it up, but now usually I just slap a report across and say hey what's going on and leave it open-ended and just lean back in my chair and the story I get after that is usually pretty incredible and usually good dinner conversation to make people laugh when I'm out on weekends.

Um the other thing that you need to know is that urine drug screens can assist providers in identifying when they're not using their medications i.e. Diverting them. So if you're giving a person four to you know six percocet a day and they test negative then you know that they're most likely diverting them or they're abusing them and they've been out of them several days before they saw you Um but you need to know that urine drug screens do not provide accurate information about how much or what those opioids or other drugs a patient took prior to seeing you. You know I'm curious Dr. Patterson what percent of your patients have a prescription, you do a test on and they're not using them is that a low frequency or? So well I can give you national data so there was in the pain medicine journal about a year or two ago they publish your drug urine drug screen results across the country and what they found out is that 65% of drug screens in pain clinics were abnormal 65% and I'll say how I found this out is I was, the urine drug screening company that I was doing, they gave me a quarterly report and they handed it to me and were 60% abnormal. And I was like well goodness you know the DEA ever walked in here and they wanted to know like how thorough I was on drug screening I'd hand him this report I would be embarrassed like completely embarrassed. What I ended up doing is I actually you know but they were like congratulations you're better than the national average.

Uh what I ended up doing is I actually looked into the data and what I found out as our numbers were skewed by new patients, meaning that patients who we were adopting their care, majority of those were abnormal and patients who are in our system that we're educating they were more in the normal range. So I went back to the drug screening company and I said hey I want two accounts. I want one account that's for new patients only and I want a second account for my follow-ups and what we have found is that our new patient accounts are just like the national average we're 65-70% abnormal. But our follow ups we've gotten it down to 28% and I'll tell you what that usually the ones that are that are abnormal at that point are usually patients who we've been having problems with or two, patients who came on a lot of short-acting um you know taking you know greater than 10 pills a day that we transition to a long-acting and cut their short-acting down to no more than one or two a day. And in those situations if the long acting is doing it's job they probably don't need the short acting and so it may or may not be in their system a day or two before we see them.

And in those situations we wonder if our compliance is even better than 28% because I doubt you know if we're giving somebody a long-acting and it's in their system and if it's doing the job I doubt they're selling that extra 30 you know hydrocodone or percocet. So I'd encourage you if I mean if you guys are doing, using a drug screening company and you guys are keeping track of that data. You may want to consider getting two accounts, one for patients you adopt and two for your existing patients to see if patients are being more compliant. One thing about drug screens too especially if you're looking at people in addiction uh is to do them consistently because you're creating a behavior. And if the people know that they're going to be drug screened people who are using will use that sometimes to say I can't and justify not using to themselves or their friends.

People who aren't using in an addiction kind of sense don't care, so it doesn't harm them at all but it might be that catalyst to keep the person from misusing or diverting which is uh really interesting too, so I'm making a little bit of extra money and or supplying their friends. And what's interesting is I've seen situations where you know I was telling mid-levels that we hire or bring in that if a person's an addict they can't help themselves that they're going to test positive on a drug screen you know even no matter how often you test whenever you test them is that they're addicted, they can't stop the behavior and you're going to catch em. Because I mean they know they're going to come in they know they may have to give a random drug screen and I think if they can't stop that use a couple days before you know that they can't because they're addicted. And so just knowing that doing you know doing random drug screens you may think that it may get, and it may change some behavior in some patients but a lot of times with people who are truly addicted and can't help themselves, there are so many who use. Now with the drug screens the urine is important because you can get the actual numbers.

Getting so you can create that baseline and if that's the situation we'd expect the numbers to stay consistent or go down a little bit. Correct If they continue to go up or you use the dip, dip just is positive so it's telling you really nothing, that would just be more of a deterrent where the urine will actually give you the numbers so you canwork with the patient keeping a consistent, or those numbers in the area where you think it's optimal optimally therapeutic benefit. Correct The other thing that we were just talking about is you know is that your directions to be you know misinterpreted and so they're saying that you need to know how to account for metabolites or the lack of metabolites in a drug screen. So has anybody ever heard of pill shaving? So say a patient comes to your office they're diverting drugs what they'll end up doing is they'll have a nail file in their pocket with one of the pills that you sold them the month before. When they go in the bathroom they'll take their urine which is completely negative because they're not taking the pills they'll pee in the cup and then they'll take the nail file and they'll file off some shavings of the pill into the into the sample and what you'll see is on the results is that they'll test positive for the parent compound with no metabolites. And so therefore you know the patient's not taking the drugs they actually falsified that drug screen on the spot. So you need to be able to account for the lack of metabolites or what metabolites would be positive in a drug screen. The other thing I've seen is that providers you need to know what's on your panel.

Um meaning that a couple years ago I was talking to somebody in the community and they're talking about the increasing heroin usage and they said - Oh I'm sure you've seen a lot of heroin in your drug screens and I you know looked back and I saw zero over the last six months. And then I the drug screening company provided a lunch for us one day and I started talking to them about and said Oh your checking for the heroin metabolite and they said no, you're supposed to tip us off when we're supposed to check for it I said wow. And so what they showed me is that reports where there was a high morphine level and so patients who tested, you know say they're on oxycodone, had a very high morphine level um we were supposed to, and their PDMP was negative for morphine, we were supposed to assume they're using heroin and ask the company to run for the heroin metabolite. Interesting enough we went back and looked at the last six months because the drug screening company you know saves urine for a period of time and I think ours is for six months. And we actually had them rerun about 15 samples and they all tested positive for heroin. And those are patients who I'd given the benefit of the doubt and actually a couple of them I clearly remember where empirical seeing me so they must have you known the six acetyl morphine um literally is only in our system for several hours so literally those patients used heroin and showed up at my clinic within a couple hours for those urine drug screens to test positive. And so that was a lesson to me that you know I needed to be more aware of what was on my panel and what I was testing for.

Can you address a question I've had patients that I've seen say well I just had a poppy seed muffin before I took the test and that became positive is there any validity to that? Yes there is and um what you'll see is it's a very low morphine level. So they'll barely it'll barely go test positive over the cut off. So the patient is at very low morphine level and you'll look at the cutoff and it's barely above it and they do give you that history than you've got to give them the benefit of the doubt. Unless you see other metabolites associated with morphine in the drug screen then you got to assume maybe something else. But yes that I have seen in situations. Outside of poppy seeds and muffins are there any other substances that may be contaminated it that.

I think that's it And a lot of times patients you know they, the only other situation I've heard is you know is patients test positive for illicit methamphetamine, that if for some reason they're ingesting Vic's VapoRub that make us positive for the illicit form of methamphetamine. So you just need good question if they've been using Vicks VapoRub, putting it up their nose or something and coming to see you. But that's pretty rare because usually they can tell between the L and D isomer so if a patient tries to tell you - Oh that's my amphetamine I'm taking you know that's not true cause amphetamines that are legal will test with the L isomer not the D isomer. Yes question So I have this patient who he tested positive for methamphetamine (inaudible) but um he he's always been very honest me and he's adamant that he's not using meth and so is there any other medications besides the Vic's VapoRub that can test positive for methamphetamine? Vic's is the only one Vic's is the only drug that I'm aware of that can cause that. Here's what I encourage you to do and the drug screening companies will do this for you the urine drug screening companies.

So I've had situations where patients are adamant that's some diet supplement or something else are taking. And what I tell them to do is bring that medication into me I turn that over to the urine drug screen company and they will run that pill, they will dissolve that pill into a liquid solution and they'll run that through the LCMS with their previous urine. Oh okay See if it matches up if it matches up then you can exonerate your patient if it doesn't match up then guess what, they've got some explaining to do. Yeah he um thankfully I don't prescribe his pain medication so I'm kind of out of it. But he came in just so upset like I swear I'm not using meth! So I don't I guess, I sent him to another pain management provider and I guess he can take it up him but that's a good suggestion Yeah no there's some situations that I will actually call the pharmacist or the uh the head technologist at the urine drug screening company and I'll discuss the results with them and say hey the patient's telling me this, is that true? And you know there's been a couple times where they'll exonerate the patient or other times will say that doesn't make any sense, why don't you you know get one of those pills and I'll run it against their urine and see if the results come out consistent. And you know every time that we've done that it's never checked out. So if you get yourself in a situation I'd encourage you to do that.

Which company do you guys use for your drug screens? I use NV labs they're located right here in town. We use the same one they do a good job do you have any, I'll actually ask you that later. No you can go ahead So we were looking into Quest do you know anything about the difference between using Quest labs and NV labs? Because we have a hard time interfacing with our EMRs so we've had issues with getting the results from NV labs. Whereas we have the interface with Quest already. So I don't know if you have any experience with that. No, I've had no experience with Quest I'd just make sure that they're gonna do the exact same panel if you like NV labs and the results they give you but you just havin problems and you do switch, I would just make sure that they're going to give you the exact same panel that you're doing before. Okay perfect thanks The other thing that they said is that if you're going to test patients um don't test for things if it's not going to change the management strategy. And they specifically talk about this in the CDC guidelines in the one area that they bring up that is THC So if a patient's using marijuana but it's not going to change your management strategy then you shouldn't test for it, I thought that was interesting.

Because I've seen marijuana as a gateway drug and therefore I should test for it plus it's illegal in the United States and I found it interesting that the federal government was telling me not to test for it if if it's not going to change management. As an addiction specialist (laughing) you need to know what's in the persons system and today the marijuana is completely different than it was 20 years ago. 20 years ago we didn't have treatment for marijuana, now it's one of the number one reasons for treatment for adolescents in Nevada.

So we have to find out are they taking dabs are they, taking hash, or are they taking flower or what you have to find out what's the THC level, you have to find out are they taking edibles, you have to find out how is that going to interact with the other drugs that they're taking. Just because it's legislatively being past it's not medical. I have a whole thing on marijuana (laughing) As a physician you need to know what's in that person's body you need to know how you can optimally help them and with marijuana right now, when you go to a budtender they're telling you anything that you want to hear to sell whatever they're selling.

And a lot of times they're guessing on the THC level so the person's on an active metabolite or THC and they're driving and they have a benzo, if they get pulled over they're getting multiple charges on multiple drugs. It's your responsibility to know what's in that person system, so I would highly recommend you put THC on your panels and a lot of them the five panel drug screens will have THC. Correct Uh the other thing that they were saying about is that you know drug screens you know some patients may feel like there's a stigmatization and they're saying that if you're going to do drug screens that you should be consistent, treat all patients the same to destigmatized the situation. And two, you shouldn't use the drug screen results once again determining care, it's that moment of education. So you know routine use or standardized policies in your clinical practice may just destigmatized their use. And the bottom line is that urine drug screens should be utilized prior to starting opioids for chronic pain.

They should be utilized periodically for chronic pain you know they recommend. They couldn't come to a consensus but they recommend about every three months, or they said annually. Um in our clinic you know we have them roll dice which is random and we'll get three to four a years and so we're technically getting to drug screen every 3-4 months. And they recommend that you test urine over saliva and that is because the window to catch the metabolites of the drug in the system is much smaller in saliva versus the urine. Just as I was saying before you should be familiar with the drugs included in your drug screening testing panels and you should understand all or how to interpret and understand the results. And do not test for substances for which it will not affect your your management. And urine drug screen testing is intended to improve a patients safety. If you do have unexpected results then you need to look at how you're going to manage this.

One are you going to taper or discontinue the opiates based off the results that you see. Um do you need to bring the patient in more frequently? So we have situations where you know patients test positive for a drug um you know it's another controlled substance that they probably got a friend or a family member you know we may start seeing them every week with a mandatory drug screen for a period of time. Once you know they start having clean drug screens then maybe we'll see them every other week, if those are consistently good then we'll see them every month.

I can't tell you how many patients that we will try to see them on a weekly basis they know they're being seen on a weekly basis. I'm only giving them a week's worth of meds at a time and they still test positive for other substances. And I think it comes back to my statement earlier if you're an addict you can't stop the behavior even if you're seeing them you know once a week and only give them you know a short term amount of medications make it to those points. But consider you know more frequent reevaluation. Um patients who test positive for other substances considered naloxone. And bottom line you know if it's a situation you don't seem that you can handle you should refer out for treatment of substance abuse disorder.

And once again they recommend that you do not terminate patients based on the urine drug screen results, that may constitute patient abandonment and lead to adverse consequences for the patients safety. These are, this is your moment to intervene in their life and hopefully make a difference for a better outcome. The nice thing is that providers should avoid prescribing opioid pain medications when they receive benzodiazepines whenever possible. So as we all know opioids and benzos both cause central nervous system depression, concurrent use puts patients at greater risk of a fatal overdose.

And basically the use of benzos quadruples the risk compared to using opioids alone. So it drastically increases their risk of having an adverse event or a accidental overdose. Question Yeah I had read once that benzodiazepines from a pharmacological standpoint they're very similar to alcohol.

Correct Is it essentially like prescribing alcohol to someone for anxiety or.. So when a patient gets an alcohol detox they actually put them on benzodiazepines on a certain dose to prevent side effects and then they wean them off the benzos when they're in acute withdrawal. So yes they do mimic alcohol. Yeah I've got a number of patients that have opiates benzodiazepines and they use alcohol on top of that. Yeah Sounds like a smart combination (laughing) So bottom line providers should avoid prescribing opiates for patients receiving benzos whenever possible Um you know they recommended that it's safer and more practical to taper the opioids if they've been on long-term benzodiazepines. If you do, if the patient thinks that they need the pain medications and you're going to taper the benzos you need to do it gradually.

Just remember that abrupt discontinuation of benzos can lead to rebound anxiety, hallucinations, seizures, delirium, tremens, and death even though that's very rare. You know opioid detoxification or taper rarely leads to death. And if you look at a tapering schedule benodiazepines they recommend decreasing the dose by 20% every 1-2 weeks. Opioids if you do that, you can do a rapid taper you can do it over a 2-3 week period of time. But if you want to be you know make it more comfortable for your patient they recommend doing 10% a week. And there's better compliance with tapering when you get cognitive behavioral therapy involved during the taper.

So you should probably set them up with somebody to see on a weekly basis while you're tapering them to make sure that the anxiety and other complications that may arise can be treated. The next recommendation is that providers should offer or arrange evidence-based treatment usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies for patients with opioid use disorder. An opioid use disorder is a problematic pattern of opioid use leading to clinically significant impairment or distress manifested by at least two defined criteria occurring within a year. So these are your patients that maybe have two different drug screens within a year show up impaired you know wants abnormal drug screens at different times during the year or say they've got an abnormal PDMP drug screen or abnormal behavior. So these are these are characteristics you're looking for. The contextual evidence review shows that opioid agonist or partial agonist treatment with methadone maintenance therapy or buprenorphine in combination with psychosocial is more effective in preventing relapse than detoxification alone.

And that makes a lot of sense, I think the issue here is insurance coverage. A lot of patients don't have coverage for you know cognitive behavioral therapy in combination and that becomes a sticky issue. So a lot of the times you have to do medication management only. Bottome line you want to assess your patients for opioid use disorders based on patient's concerns, behaviors PDMP data and/or urine drug screen results. If it's not clear to you if a patient has a substance use disorder you should refer them out to a treatment specialist to further assess if they have the disorder.

And for patients who meet the criteria of opioid use disorder you want to offer or arrange medication assisted treatments in combination with behavioral therapies um and once again consider offering them naloxone since they're at risk. In patients with problematic opioid use that did not meet the criteria for opioid use disorder you should consider tapering or discontinue their opiates if you're unable to to taper then you should probably once again offer them opioid agonist therapy. And bottom line again you should not dismiss patients based off of a substance use disorder, as this may constitute abandonment and it may adversely affect patient safety. Once again this is your moment intervene and hopefully get the patient help and save a life. Question, discussion Anything we missed or any of you guys would like to discuss about your patients? Alright, did we know what our topic is next month Chris? Off the top of my head no. Sorry off the top of our head we don't know what next month's topic is it maybe sleep or... We're checking right now but anybody have any questions, concerns, worries..

Just a quick question is there a way to go back and watch the two previous opioid meetings that you guys had? Yes so if you go to the ECHO website and go to the pain management section I believe we have the prior two presentations published, correct? The powerpoints are up already the videos are on another website, happy to send them to you if you send me an email this is Chris Marchand. Is that Rachel, okay. Yeah thank you. Is it Rachel Muhlenberg Yeah we'll Chris will send you the links. Uh next month we have 12 steps to proper opiates prescribing. Okay so since we've covered the opioid prescribing guidelines that CDC recommends next next month we're going to do the 12 steps to proper opioid prescribing.

Any other questions? Well hey thank you for joining us I always appreciate it hopefully you guys have a good clinic today and a good month and we look forward to seeing you guys all next month. Thanks! Thank you.

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