Narrator - Dr. Abel  00:00
Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions.

Narrator - ?  00:11
This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy.

Narrator - Dr. Abel  00:17
This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider.

Narrator - ?  00:27
And now on to the show.

Dr. Sean Kane  00:31
Welcome to HelixTalk. Episode 61 I'm your host, Dr. Kane.

Speaker 1  00:34
I'm Dr. Schuman, and I'm Dr. Patel, and so today, I know we're going to shift gears and talk about an issue that I'm really noticing a trend toward hitting the forefront lately, something I've been really passionate about, and that's going to be chronic pain management, or, in this case, correcting the course — careful opioid prescribing.

Dr. Sean Kane  00:51
This really deals with the idea that over the past decades, we've had had an issue in the US about opioid prescribing and patients becoming addicted to prescription medications and non patients abusing those prescription medications. Hence why, you know, hydrocodone–acetaminophen combination products have now made it to the CII DEA schedule, where they used to be CIII, things like that. Yeah.

Speaker 2  01:14
And then I think we knew about the issues, maybe like in a pocket-by-pocket basis. But then CDC took the lead and said, we're going to take a bird's-eye view and look at this sort of epidemic that is going on right now, and we're going to spend a lot of time talking about some of the recommendations that came through the CDC in 2014, right?

Speaker 1  01:33
So a brief background is that this is something, this idea about chronic pain is what the main piece of it is, and that's something that, based upon data, we found that anywhere between 11% of individuals in the US have daily pain, and then, based upon another set of standards, 15% of US adults have a definition of chronic pain. And it's something where a lot of primary care providers, if you survey them, and I don't talk to our own primary care providers, don't always feel that they have necessarily the training as far as either to manage patients who have addiction or dependence, as well as their long term treatment of pain and how to have that discussion. So the CDC put out an initial set of guidelines in 2014 and then put out a new review. In 2016 they put it up online for public comments. They got 4,300 comments, which obviously shows this is a hot topic, and in March of 2016 they published the updated guidelines, and now we're a little over a year out, sitting down and reading through: what are they saying and what's the impact moving forward?

Dr. Sean Kane  02:32
You know? And this is clearly a complex topic. Anything that has 4,300 comments on it, clearly you could spend hours talking about, but what we've decided to do for this HelixTalk episode is to really focus on those 12 recommendations from the most recent update and give the audience an idea of what the CDC is saying about the problem and how opioids should be prescribed, right?

Speaker 1  02:53
So I think to lead off the first one of these is the recommendation that non pharmacologic and non opioid therapy really is the preferred method for treating chronic pain. Opioids are to be considered and as an option, really a case by case basis, and never on their own. This is something you really need to look at the risk versus benefit, and should combine them with non opioid regimens,

Speaker 2  03:15
yeah, and I think this is a big thing, because this is how you can maybe taper off some of the patients on opioid use, and, you know, lessen the the risk of abuse potential that way. But the problem with using non pharmacologic or non opioid regimens is that these studies were ranging anywhere from two weeks to six months, and we don't know if the data is sufficient enough to evaluate the safety of these agents or the non pharmacologic treatment venues, right?

Speaker 1  03:46
And so based upon those two-week to six-month studies, the CDC and a number of other organizations have said that nonpharmacologic and nonopioid therapies are both effective and do work. My initial concern, like Dr. Patel's, was whether we were trading one unknown for another, And they're quite adamant that, yes, correct. But what we have enough evidence of the harms of the opioids of this part, that while we don't have data that says a year later, Gabapentin is going to have any robust benefit, what we do know is Gabapentin does not appear to have some of that same risk of use potential. So because of that, they're willing to say, then we know enough to say that our current practice does need to change, of

Dr. Sean Kane  04:29
course for background, some of the non pharmacologic interventions that are recommended include cognitive behavioral therapy. This is modifying your situation, your behaviors that might be making your pain worse, like anxiety, addressing anxiety sometimes, you know, a mental health provider has to get involved in that relaxation exercise, especially for kind of lower extremity pain, low back pain, fibromyalgia, and then even a multimodal treatment approach. So combining the psychologic and the physical approaches together in a non pharmacologic way. Right?

Speaker 2  05:00
Yeah, in my clinic setting too. You know there are, there have been times where patients are sent to me for opioid tapering, and I tell physicians that I'm not the best person to help this patient, but I do know some of the other modalities, and one mentioned here is exercise. And I think the importance of working with the interprofessional colleagues of ours, such as PT and OT, is invaluable. I've seen some patients of mine who have diabetes, they're in pain, they're not able to exercise, but then PT has actually been able to lessen their osteoarthritic type of knee pain, and they're able to walk a little bit more. So little thing, like just a referral to PT and OT can also help out.

Dr. Sean Kane  05:39
And of course, some patients will pursue pharmacologic interventions — combination products with acetaminophen are fairly common with opioids, but they can also take acetaminophen on their own as well. This is first-line therapy in many guidelines for low back pain and for osteoarthritis, mostly because of its favorable side-effect profile versus NSAIDs. Of course, if the patient has alcohol use disorder or cirrhosis, you might want to reduce their dose. And then NSAIDs are another first line, and effective for arthritis, low back pain as well. But of course, we're worried about an increased risk of cardiovascular events, and especially GI bleeding. And you know, bleeding events as well. Yeah, the

Speaker 2  06:17
multifactorial approach to pain is also important. One of the drug you already mentioned, Dr. Shuman, was Gabapentin. Shuman, was gabapentin, but to kind of consider that neuropathic component of the treatment, we can use agents such as gabapentin, pregabalin, or some of the tricyclic antidepressants such as amitriptyline or nortriptyline.

Speaker 1  06:36
Yeah, and it's especially for those types of neuropathic pain — fibromyalgia and diabetic peripheral neuropathy; pregabalin and duloxetine actually have FDA approvals, and then you go on further — not used as much, but carbamazepine was listed in the guidelines as something specifically for trigeminal neuralgia and then tricyclic antidepressants based upon their use. No one's gone out and gotten an FDA approval, but there's plenty of data to support their effectiveness for a whole host of neuropathic types of pain.

Dr. Sean Kane  07:03
As we consider more and more aggressive therapies, we're also thinking about direct injections of glucocorticoids into a joint, for example, treating other disease states that are involved, so treating a patient's rheumatoid arthritis, for example, or their diabetes, and then really at that point, that's where the CDC guidelines say, once you've failed some of these non opioid therapies, at that point, consider opioids.

Speaker 2  07:24
The second recommendation from CDC in the evaluation or management of pain is that before starting a medication, or let's just say, starting an opioid for chronic pain, there needs to be a real conversation occurring between the provider and and the patient in in setting up the goal. You know, what are the treatment goals for your pain? Is that to completely eliminate the pain, or is that to lower the pain enough that patient is able to carry out day to day function, right?

Speaker 1  07:54
I think this is a shift from, say, when, even when I was in pharmacy school, the idea that pain is the fifth vital sign, and therefore somebody is in pain, and that's a problem we need to be addressing with aggressive therapy. And so we're kind of moving away from that, and realistically looking at the ideas that we will take care of some of your pain, but you're going to have exacerbations in pain. We're not, you know, it's not going to be everything as a flat line. There's certain days better or worse than others, and there is going to be that in everyday life, but we can at least take it to a level where your quality of life hasn't been impaired.

Dr. Sean Kane  08:22
And you know, if you think about it really, this is probably a conversation that should happen with almost any drug therapy that we initiate for a patient, especially symptomatic management type drug therapies. And I think that having the patient involved in that decision making process, having some kind of evaluation at the beginning and then on therapy is really important. I think that really for any direct therapy, that makes sense too. Yeah.

Speaker 2  08:43
And, I mean, if you understand, if we talk about the simple pathophysiology of pain, we all know that everybody's pain perception and tolerance and their seminar to put up with the pain they have is different. So a medication that may be able to ease out pain, maybe 50% might not be enough for somebody, and so we need to intensify the therapy. And so that's why shared decision making, I think you were referring to, Dr. Kane, is very important, especially with the opioid prescribing Sure.

Speaker 1  09:11
And again, Dr. tell back to what you said about, you know, the different thresholds for me. And one of the things that the studies have shown is, for example, individuals with stress, anxiety, depression, have a poor pain tolerance or a higher perceived pain, and that goes back to previously in Recommendation one about the involvement of psychiatry and psychology, because a lot of times by addressing those concerns, you can address the pain. And as we'll see a little bit later, on the flip side of it too is as you pull back some pain management medications, and you sometimes will see that there was a depression or an anxiety that was underlying there that was kind of covered up by just throwing down lots of pain medication, and that you may as it comes up, address that too.

Dr. Sean Kane  09:50
The third recommendation is pretty obvious, discuss the risk and benefits, and this is important, again, for any medication we think about. Hopefully this conversation happens, but it's. Really important with the opioids. So it's something as simple as talking about sedation, respiratory depression, withdrawal, effects of being accustomed to the opioid and then removing that opioid. So things as simple as bowel regimens, hydration, avoiding alcohol, and also just how you store it, how you make sure that it's safe in the home, how you dispose of it, if you are done with that medication?

Speaker 2  10:22
Yeah, I think when there is a prescribing of opioid substances occurring, lot of parties are responsible, not only for prescribing it responsibly, utilizing it responsibly on the patient side, but then safeguarding it right by just signing a prescription. You think that you've treated the patient, you've addressed their complaints, but understand that this is then going to the pharmacy, then going to the patient's hand, and if the patient doesn't safeguard it, it's going to out in the community where the abuse detrimental process and outcomes could be greater than what we think is. We're just focused on the patient, and so safeguarding discussion needs to occur.

Speaker 1  11:03
And examples, there is a number of communities here in around where we're at, North Chicago, all of Lake County is a number of these disposal boxes that are and so for those readers, all across the country or the world, there is a number of facilities that are able to take back some of these medications, no questions asked, to be able to then get either they destroy them or put them or guard them in an area where they're less likely to be abused. So seek out that aid within your community or with your

Speaker 2  11:27
health department. The fourth recommendation CDC put out was to try and use the immediate release formulations before going to the ER formulation. I know we're considering a treatment for the chronic pain, that's what we're focusing on right now. But even with that, they're recommending that we use the IR formulation and set up the ER formulation.

Speaker 1  11:48
So again, there's, there's not a huge number of sites, but there was one fair quality say that they did say again, that the ER is more more dangerous than the immediate release forms of it, and not just immediate‑release formulations, but in general those with a longer half‑life — for example, methadone (which doesn't come as an extended‑release formulation) — has a relatively high number of overdoses disproportionate to its frequency of use. You know, it's not the most frequently used, but has a higher amount of overdoses that will be expected based upon how often it's used. And then you throw that on board with some of its cardiovascular considerations and even the way to convert it to and from morphine, for example, there's a lot of us a wonky kinetics about that medication. So doesn't mean you can't use it, but that that one generally does not become your first

Speaker 2  12:32
go to, yeah, and I'm glad you you mentioned that conversion talk. Even though CDC doesn't specifically talk about it, it's important to understand that proper conversion occurred, otherwise, the overdosing or under dosing is very

Speaker 1  12:44
likely, right? So a good rule of thumb is that being on the immediate release form of the medication at least a week before you go to the extended release formulation. And if you're going from an immediate release form of, say, morphine, and it's switching to extended release of, say, hydrocodone, you probably want to decrease the dose rather than just go with straight conversion, because there may be incomplete cross tolerance where the person's body, you know again, isn't necessarily ready for that. Their receptors aren't quite ready for that new drug with a little bit more potency.

Dr. Sean Kane  13:11
And kind of going along the lines of er versus IR, we should never be using our extended release formulations as needed medications. And if you think about it, if you can have a patient use less opioid per day by taking it as needed, that makes a lot of sense. So that there's another kind of feather in the hat of the immediate release formulation that that's the one used for PRN. And if you can get away with PRN versus scheduled dosing, that makes sense.

Speaker 2  13:33
Yeah. I think that goes back to, you know, those students who are out there listening to it too, is patient education on the product that contains opioid, or opioid like products, is that sometimes the prescribers will write direction on a scheduled basis, but it's okay to tell the patient that you know this is just to take your pain away. So if you don't have pain, you don't have to take the medication. It's as simple of recommendation to make.

Speaker 1  13:57
So the fifth recommendation is to use the lowest effective dose and be cautious when titrating upward. The CDC identifies thresholds expressed as morphine milligram equivalents (MME) per day — a common breakpoint is 50 MME/day. If you're on more than 50 MME/day, you need to be careful about further titration because of risks like respiratory depression and sedation.

Speaker 2  14:38
Yeah. And I think I can speak from experience. In Wisconsin, their new PDMP system flags physicians on certain morphine equivalency per day usage on the patient side, and so those will be your telltale sign. Hey, hey, I think patient, patient is using more opioids than they they should. They also flag that. On concomitant opioid and benzodiazepine use, because, as we know, the respiratory depression side effect is aggravated by the concomitant use of these two medications.

Speaker 1  15:08
Yep, Dr. Patel, there's a whole coming up a little bit later. There's a whole guidance step there, specifically for benzodiazepines. They're a big piece of this. I guess I'm excited and jumping ahead, yeah, but that's a huge one so, but it's with just the opioids on their own. The next breakpoint, they said some facilities will choose 50 as their cut point. Some will say 100 some will say 150 but try to really avoid going above 90. And then, if you are again, carefully justify if needed, not just to yourself, but to the patient, and be very clear about what the goal is again. And if you don't meet that goal, talk about bringing it down so and they said these were, quote, empathetically discuss the risk and the benefits. We are not villainizing our patients or making it that they're the bad guy or a girl because they're on these high doses. But they talk about a real talk about the risk versus benefit, and then slowly work together to get it to one of those safer doses.

Dr. Sean Kane  15:58
Again, kind of segue into using immediate release using PRN, using lower doses. The sixth recommendation is to limit long term use, minimize the duration of use, so only give the quantity that the patient will need for what you would perceive as a short term severe pain problem. So in the recommendations, they say somewhere between three and seven days is probably a pretty reasonable initial duration, as opposed to giving a patient a month worth of their Norco when they have a fracture or something like that. You know, many patients will still have pain after that, but it doesn't necessarily mean that they have to continue on the opioid. We just talked about a lot of other alternative therapies, and anything above about three months is really kind of the threshold for acute versus chronic pain. So if they're having pain for more than three months, we kind of classify that as chronic pain. We really start thinking about some of these other options as well. Yeah.

Speaker 2  16:48
And then, even with all these parameter placed, one more guidance, CDC put out, is to go ahead and monitor the usage of opioids, right? Whether it be monitoring the efficacy is the pain better? Has it helped the patient, and also monitoring for the safety of the use of opioids or the patient experiencing any side effect or not? So they're recommending that usually, three to seven days is the timeframe to kind of watch out for. That's the timeframe individuals are at highest risk of overdose. But then again, if patient is stable, every three month evaluation on the regimen, provided it's important to occur.

Speaker 1  17:24
And what they also occur, though, is that continuing therapy beyond three months does increase the risk of opioid use disorder. And so the idea that is, if we can avoid that again, at that three month cut off, then to do so that we, you know again, can use them for chronic pain, technically, but you are adding that risk of potential. Again, either physical physical dependence, psychological dependence, or addiction down the road. So again, Dr. Kane, as you said, we're really looking at those non pharmacologic and non opioid regimens. And again, if at that point we start seeing real problems, taper down to a lower dose — for example, below 50 MME/day — or taper to discontinuation.

Dr. Sean Kane  18:00
And the DEA has already made some steps to somewhat enforce this — by making Norco (hydrocodone–acetaminophen) a CII, so you can't get an automatic refill and typically only get a one‑month supply; in a way that forces the prescriber to be deliberate about additional prescribing. And that's one of the reasons that, I'm sure that they made that step, yeah.

Speaker 1  18:23
And I think what it should do, though, is create a dialog, rather than the idea that, I think sometimes the provider says, I'm not going to give it to you, so tell my nurse I'm not going to give it to you. But versus, I think, sitting down and having that discussion, or saying, you know, the idea, oh shoot, I'm just gonna give it to you one more time, and the next one, it's one more time, but really sitting on having a good discussion about, here's the concerns. Let's come up with a plan. And these are tough conversations we've had. Them from a pharmacy perspective, with patient, it is. It's a really tough one to have, but again, doing it and some of the patient, I didn't, I didn't realize there were those concerns, you know, if I had known that, again, that would have made me change my perspective.

Speaker 2  18:56
Yeah, and I like the fact you mentioned. Sometimes it's saying no, bluntly, but then sometimes it's extending the prescription. I've noticed the extension also happens on the phone, or it happens because nurse told the doctor, and doctor said, Fine, give them another 30 days and they can come pick up the script at the clinic itself. So that's a no, no. I think the guidance over here is to for you to see, or for the providers to see the patient, talk about the pain, evaluate the pain, and then prescribe as needed. No.

Dr. Sean Kane  19:24
The eighth recommendation is really focusing on evaluating for risk factors, for bad things to happen because of the opioid therapy, such as over sedation, respiratory depression, things like that.

Speaker 2  19:35
So one of the examples I jumped ahead to was the benzodiazepine use concomitantly with the opioid use, and that's limited as a PV use, along with the greater than 50 or morphine mill equivalent dose per day.

Speaker 1  19:51
And again, I try to talk to patients that the idea here is that your brain, like a car, has sensors that should go off saying, “Hey — your oxygen levels are too low, your carbon dioxide is too high, we need to breathe more to increase ventilation.” Opioids and benzodiazepines blunt that response. So what you end up with is you end up with slowly increasing the carbon dioxide and again, and then you you may pass away, or the very least, you know, end up with, you know, unarousable and needing to have a reversal.

Dr. Sean Kane  20:19
So, you know, some of the patient populations that we're particularly concerned about are those with obstructive sleep apnea, and we really should avoid opioids in patients who have moderate or severe OSA, because they're at very high risk for respiratory depression, especially

Speaker 2  20:35
when they're sleeping. Yep. And then if we go back to the pharmacology, pharmacokinetic and dynamic of the opioids used in patient with active liver disease or renal disease, should also be cautious because of the drug accumulation or metabolite accumulation,

Speaker 1  20:52
and then the elderly, defined here as those above 65 again, drug accumulation. But think about the other things we're looking at is cognitive impairment. We're looking at falls, risks, constipation, all these very real bad outcomes in the elderly that can be very serious. And again, how many of these are causing we're treating this using getting this med for that pain, but then we cause you to fall break a hip. And again, now we're back in the vicious cycle of treating your pain with more

Dr. Sean Kane  21:16
opioids and switching gears a little bit. Pregnant women is another higher risk group, not so much because of respiratory depression and things like that, but just because of the risk of neonatal withdrawal, where the fetus is used to having a certain amount of opioid and when the baby is born, the baby may actually go through opioid withdrawal because they were, you know, tolerant to it during the pregnancy.

Speaker 1  21:36
And then another thing that is again going back theme so far has been those individuals with psychiatric disorders, alcohol use disorder, substance use disorders, their anxiety, depression, can impact pain management, and then managing those symptoms can also help pain management. The big thing, though, is through a provider that says, Well, I'm not, you know, I don't, I don't treat those disease states. Well, the one thing you can do is there are a number of self‑rating questionnaires that can be used, like the PHQ‑9 for depression or the GAD‑7 for anxiety — brief tools that can be done in a few minutes. And you can screen there and then, using that tool, you may not need to treat them yourself, but you can then refer them to a mental‑health provider to help with

Speaker 2  22:14
that man, yeah. And then identification of highest patient is also very important, because the management for those patients will be different than for people who are getting an opioid for a one‑time procedure, and we want to make sure we're providing proper care and directing them to substance‑use or mental‑health services as needed. And another step in identifying this high risk individual is not to just label them that you're high risk, but then provide them with the proper rescue therapy as well. As we know, naloxone is the agent used to rescue those patients. So things that we can look at in identifying this high risk patient would be, do they have history of overdose? Do they have history of substance abuse disorder? Are they using benzodiazepine and other opioid therapy together? Are they restarting their opioids after a long period of time? So a good example would be maybe they were in the hospital being clean, you know, they were in the substance abuse program and not using it, but they're back to using it again, or if they were in the prison, they were not getting the opioids. So those were the patients who would be back to the opioid, naive kind of a state. So restarting them at a higher dose can lead to overdose issues. And those who are using higher morphine milligram equivalent (MME) dosing per day will be at higher risk. And so prescribing, talking to them, talking to the individuals that are around them about the Naloxone rescue

Dr. Sean Kane  23:45
therapy would be important. So then the ninth recommendation is that prescribers should review the prescription drug monitoring program or PDMP, and look at that data for polypharmacy and other medications that that particular prescriber doesn't know about that other prescribers are giving the patient, because obviously that could increase the risk of harm if you're giving the patient an ER opioid, and another prescriber is giving another opioid, and another prescriber is giving benzos, and no one knows about any of the other medications, that can be a really big deal. So they recommend doing this at the onset of prescribing the opioid, and then periodically, every month or every year based on discretion of the provider, the risk of abuse, diversion, things like that.

Speaker 2  24:25
And tell you what, just in April, April 1, there is a new initiative in Wisconsin where anyone who's prescribing opioid product has to go into patient's PDMP chart, review the chart, and then and only they can go ahead and issue a prescription, and pharmacy then goes ahead and compiles the dispensing data and reports back to PDMP, and that's how the providers are monitored, whether they check the patient's PDMP or not. And I

Speaker 1  24:51
think an important thing there is to be clear to the patient again, it was not the idea that, “Oh shoot — if I can just bust you at two pharmacies, boom, no more opioids.” But the point is this: if you are getting medications from multiple providers, I don't know what you're being prescribed, so I might prescribe more or less. But if I know you're getting two sources, then it's a real danger. And give that as the case, and not the idea, again, that I'm just looking for a reason to drop you off of my panel. So the 10th recommendation is perform a urine drug screen before starting opioids. So again, right off the bat, and then at the very least annually thereafter, and they can use them. The main thing, though, with your introductory is to is to know about what you can and can't get from that. So again, we can check whether or not somebody is taking that opioid medication. But what we can't do is we cannot assess for synthetic opioids unless you request that test specifically. A number of times, provider says to me. Well, you know, I did the Basic panel, it came back negative. Are they, you know, they're not taking it, okay? What are they supposed to be on? Well, they're supposed to be on oxycodone, okay. Well, what you did was the standard five‑panel, which only detects natural opiates such as morphine and codeine. You'd need follow‑up testing (GC/MS or mass spectrometry) to detect semisynthetic opioids like oxycodone. So again, be very careful, because there's a lot of power that you have in terms of what you can do with that information. The other thing with that is encouraging open dialog with the patient too, that if you know, if you do have the results, saying to them, you know, should I be expecting anything different on these results? Give them a chance to come clean, discuss the results. And again, if you if they can't explain it or they're lying out, do your confirmation testing. And then from there, you know, don't dismiss patients from the clinic is the big thing. But you can, you can say, Look, I can't safely give you opioids. I'm willing to work with you and manage your pain, but I cannot safely give you opioids. So again, it comes to how you process it, because if you just kick them out of your clinic, say, I don't want to see you again. They're going to find it somewhere else, or they're going to treat their pain somewhere else. So if you can still ally with them, but in a safer way, I think maybe again, you may be able to save their life there. And of

Dr. Sean Kane  26:51
course, if the patient has a problem, you know you're at that point, you have all the information. You're in a good position to recommend something like a substance abuse treatment program, as opposed to, as you said, kicking them out and starting from ground zero with a new provider that doesn't know any of their history, doesn't know that they need help. That's probably not the best approach.

Speaker 2  27:10
Yeah, and I think there is that little bit of a stigma and conversation that comes to the table, not only with the patient, but also with the providers that you know don't stigmatize the patient, they obviously are there to get some help.

Speaker 1  27:22
So, Dr. Patel, I know you were passionate before about talking about combo of opioids and benzos. So if we do say, all right, somebody's on the benzo as well, and we want to get rid of it, what do we need to do with the benzodiazepines? Do we just stop it cold?

Speaker 2  27:34
No, well, first of all, we need to assess what they're using the benzodiazepines for, right? We know probable users are maybe curbing the anxiety. Sometimes they're used as muscle relaxant, so they might be using that as another avenue for pain management. So let's figure out, first of all, where is this coming from, and if it's really for anxiety, can we switch them to some of some of the other options, such as SSRIs or SNRIs, or have them see a specialist or counselor to do some of the cognitive behavior therapy as well. So that's one justification. And if you're giving them opioids and they're using benzodiazepines for more of a muscle relaxant use, maybe we can use another muscle relaxant that is not interacting with opioids as significantly, or maybe explain that, hey, we're giving you something stronger than what benzodiazepine is doing. So maybe duplication is not necessary. So to answer your question, assessing why they're using is important. But then if you want to de escalate the therapy, let's not stop it completely cold turkey, maybe gradual taper. We can consider about 25% benzodiazepine dose reduction over one to two weeks.

Speaker 1  28:39
Yep, and I believe, some other facilities, or some other guidelines, we'll talk about even going further the patient's been on a longer period of time. Can you can extend it out a few months, but yeah, doing a gradual taper, certainly versus you've had a few times where they try cold turkey, and again, you've not only is it bad outcome for the patient, but you've probably lost them as far as that therapeutic alliance.

Dr. Sean Kane  28:57
So then the 12th recommendation really gets at what we've touched on a couple times already, and that's if you identify an opioid use disorder, you should offer or arrange for treatment of that opioid use disorder, not kick the patient out, not just refuse to give them anything. And that treatment could be something like behavioral therapy. Could be medication assisted treatment, medications like naltrexone, which is a full antagonist of opioids, buprenorphine, which is a partial agonist sometimes combined with Naloxone, which is a full antagonist that has no oral bioavailability, but if the patient chooses to try to inject the medication, now they have a full antagonist and they don't get any opioid effect at all. Then of course, methadone is another option that's just a very long acting full agonist that is commonly used for this indication.

Speaker 2  29:42
Those are good options you mentioned as far as the medication assisted treatment goes. But the really good outcome is actually when you combine that behavioral therapy along with the medication assisted treatment, so a conversation plus the medication together can help patient better. All right. So we talked about a lot of different points, and kind of summarize the 12 different items that CDC 2016 recommendation has highlighted. And I pick my favorite to summarize — that's to avoid concomitant use of opioids and benzodiazepines whenever possible.

Speaker 1  30:17
And then something to also be aware of is collaboration. Is that this is, you know, to support primary care in helping to manage very complex patients working with mental health to again, to identify better methods of treating any anxiety or depression that may be exacerbating some of the pain, as well as any kind of depression anxiety to come about as you bring off some of these opioids, as well as between primary care and identifying pain specialists, whether it's interventional techniques like steroid injections, whether it's acupuncture or other types of treatment options. Again, that that kind of alliance there to find other providers that can assess, assist, and then lastly, really, between the patient and primary care. About some of that, that good dialog to say, you know, we are doing this because we want to help treat your pain, but in the safest imaginable way. And then lastly, with pharmacies, with pharmacies that are dispensing that their job is not simply just to bust you, but that they too are part of it. And as if you see a patient that you believe is maybe using, misusing or diverting that again, having that good discussion about the providers know again, so you as well can help them to better manage their pain, as well as any underlying psychiatric illnesses.

Dr. Sean Kane  31:25
And of course, one strategy here is to use either no opioid by using non opioid alternatives, using non pharmacologic therapy, or if you are choosing an opioid use the lowest effective dose for the shortest possible duration, emphasizing immediate‑release products rather than extended‑release products whenever possible.

Speaker 2  31:42
Whenever possible. And we mentioned one recommendation was to do a drug screen (UDS), but we have to make sure the conversation between provider and patient is open and nonjudgmental — we don't just wash our hands and say goodbye, we provide proper avenues for further care.

Dr. Sean Kane  32:03
And of course, if we identify a patient that has many of these risk factors, evaluation of something like a Naloxone kit, so that, at a minimum, that we have this rescue therapy for the patient if they do get into trouble that presumably a family member or friend would be able to administer to them, especially if they have many of these risk factors that we worry about, like multiple agents that cause respiratory depression, higher doses, hepatic or renal impairment, older age, the whole the whole list is really important to evaluate with each and every patient. So with that, that kind of wraps up the recommendations from the CDC regarding Opioid Prescribing use, and again, it was last updated in 2016 hopefully some of these interventions will start having an impact on the epidemic of opioid abuse and misuse in the US. If you'd like to take a better look at the CDC document, it's available at our website, at HelixTalk.com Again, this is episode 61 we love the five star reviews in iTunes. With that, I'm Dr. Kane, I'm

Speaker 2  32:58
Dr. Schuman, and I'm Dr. Patel, and as always, study hard.

Narrator - Dr. Abel  33:03
If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there to

Narrator - ?  33:14
suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.