harm reduction
TRANSCRIPT
Opioid Harm Reduction Strategies
Paul C. Coelho, MD Board Certified PM&R
Subspecialty Certified Pain Medicine
Table Of Contents
1. Reducing Harms to High Dose Patients
2. Preventing Harms to Opioid Naive Patients
High Dose (>120MED) Patients
1. Identify the high risk patients.
2. Explain to the patients that their dose has become dangerously
high and it will need to change.
3. Prescribe nasal naloxone and train a loved one in the
patient’s household on administration.
4. If the MED is < 240 offer the patient a 6mo taper.
5. If the MED is > 240 consider a taper or conversion to
buprenorphine for PAIN.
Example 1: Cleatus
68y/o retired millwright with failed back syndrome. Lives with spouse Rx’d MS04 ER 60mg QID. No aberrant behavior.
Example 1: Cleatus
1. Call Cleatus & Mabel into clinic to explain that new literature has suggests that Cleatus’ dose has become unsafe and it will need to change.
2. Rx nasal naloxone and train Mabel in it’s administration.
3. Offer a 15mg/mo taper over 6mo to 120MED.
Example 2: Loretta
52y/o disabled woman with FMS and chronic Hep C, on Transplant List @ OHSU. Medications include a Fentanyl patch 100ucg/hr Q48, Soma 350mg QID, and Xanax .5mg QID. Has an OMMP card. (MED 360)
Example 2: Loretta1. Call Loretta and her adult daughter/care-giver
into clinic to explain that new literature has suggests that Loretta’s dose has become unsafe and it will need to change.
2. Consider an addiction medicine consult given the complex PMH, Hep C, & Transplant status.
3. Rx nasal naloxone and train Frisbee - her daughter- in it’s administration.
4. Load with Gabapentin over 1mo to 1200mg/day 5. Convert from alprazolam to clonazepam - 1:1
conversion and begin a 6mo taper. Consider non-addictive alternatives for anxiety (citalopram).
Example 2: Loretta
6. Stop the Soma - it is an addictive barbiturate - and offer a conventional muscle relaxant. 7. Consider a conversion to Buprenophine for pain : Induction, stabilization, maintenance. 7a. Or offer a 12ucg/mo taper to 50ucg/hr. 8. Explain that our clinic policy is either THC or opioids but not both and let her choose.
Addiction Services In Oregon By County
Drug & Alcohol Services by County: http://www.oregon.gov/oha/amh/publications/provider-directory.pdf
Nasal Naloxone
1. SB 384 legalized for lay administration in 2013.
2. Stock in your pharmacies. 3. Some patients must pay out of
pocket ($25.00.) 4. http://www.prescribetoprevent.org/
wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf
Buprenorphine
1. Schedule III opioid. 2. Morphine Equivalence 30:1. 3. FDA approved for pain - Butrans & addiction - Suboxone. 4. Ceiling effect for respiratory
suppression. 5. Follow the QTc. 6. Contra-indications: coprescribing
benzo’s, sedatives, or alcohol use.
Pain or Fear of Withdrawal?
It’s Easier Not to Start Opioids, Than to Stop Em.
It’s Easier Not to Start Opioids, Than to Stop.
More than ½ of patients receiving opioids for 90d
remain on opioids for years.
1/3rd Of Patients Treated in Addiction Clinics Come
From Pain Clinics
Oregon Ranks #1 in the Nation in Prescription
Opioid Abuse
Prescription Opioid Deaths
Addiction Tx By Age
Age of Opioid ODD
Prescription Opioid Deaths & Addiction Treatment
Parallel Opioid Prescribing
Top Oregon Counties for Opioid Prescriptions
0.0000
52.5000
105.0000
157.5000
210.0000
Josep
hine
Dougla
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Sher
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Linco
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Clatso
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Tillamoo
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Marion Po
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County
Special Thanks To:
• Andrew Kolodny, MD, Chief Medical Officer Phoenix House
• Jim Shames, MD, Medical Director Jackson County, OR Health & Human Services
• Andrew Mendenhall, MD, Medical Director Hazelden, Beaverton, OR
