Risk Mitigation Strategies to Reduce Opioid Overdoses

NOTE: This transcript has not been reviewed by the presenters and is made available solely for your convenience. A final version of the transcript will be posted as soon as the presenter's review is complete. If you have any questions concerning this transcript, please send an email to coca@cdc.gov.

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Moderator: Dr. Loretta Jackson-Brown

Presenters: Deborah Dowell, MD, PhD; Joseph O Merrill, MD, MPH; Jane Ballantyne, MD, FRCA

Date/Time: December 6, 2016, 2:00 - 3:00 pm ET

Coordinator: Good afternoon and thank you for standing by. And welcome to today’s conference call. Your lines have been placed on a listen-only mode until the question and answer segment of today’s conference. At that time, you may press star followed by the number 1 to ask a question. Today’s conference is being recorded. If you have any objections to please disconnect at this time. I would now like to turn the call over to Dr. Loretta Jackson-Brown. Thank you may begin.

Dr. Loretta Jackson-Brown: Thank you, (Michelle). Good afternoon. I’m Dr. Loretta Jackson-Brown and I’m representing the Clinical Outreach and Communication Activity (COCA) with the Emergency Risk Communication Branch at the Centers for Disease Control and Prevention. I’m delighted to welcome you to today’s COCA call, Risk Mitigation Strategies to Reduce Opioid Overdoses.

You may participate in today’s presentation by audio only, via webinar, or you may download the slides if you are unable to access the webinar. The PowerPoint slide set and the webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. Free continuing education is offered for this COCA Call. Instructions on how to earn continued education will be provided at the end of the call.

CDC, our planners, presenters, and their spouses, partners wish to disclose they have no financial interests or other relationships with the manufacture of commercial products, part of commercial services or commercial supports with the exception of Dr. Jane Ballantyne and Dr. Joseph Merrill. They would like to disclose that their employer, the University of Washington received a contract payment from the Centers for Disease Control and Prevention. Planners have reviewed content to ensure there is no bias. This presentation will include discussion of the unlabeled use of a product or products under investigation of use.

At the end of the presentation, you will have the opportunity to ask the presenters questions on the phone. Dial star 1 will put you in the queue for questions. You may submit questions through the webinar system at any time during the presentation by selecting the Q&A tab at the top of the webinar screen and typing in your question. Questions are limited to clinicians who would like information on prescribing opioids. Those with media questions, please contact CDC media relations at 404-639-3286 or send an email to media@cdc.gov. If you are a patient, please refer your questions to your healthcare provider.

At the conclusion of this session, the participant will be able to describe evidence for opioid prescribing risk mitigation strategies, review different opioid prescribing risk mitigation strategies, summarize steps that clinicians can take when concerning information is discovered through prescription drug monitoring program check and urine drug testing, and evaluate factors that increase risk for opioid overdose and determine when co-prescribing naloxone can be beneficial.

COCA is excited to partner with CDC’s National Center for Injury Prevention and Control to offer this call series. On CDC guideline for Prescribing Opioids for Chronic Pain. Save the date for the next scheduled call for December 13 and plan to join the discussion starting at 2:00 pm Eastern Time.

Today’s first presenter is Dr. Deborah Dowell. Dr. Dowell is senior medical advisor for the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention. She previously led CDC’s prescription drug overdose team and served as advisor to New York City’s health commissioner. Dr. Dowell is lead author for the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

Our second presenter, Dr. Jane Ballantyne received her medical degree from the Royal Free Hospital School of Medicine in London, England. She trained in anesthesiology at the Dodd Radcliffe Hospital, Oxford, England before moving the Massachusetts General Hospital Harvard University. Dr. Ballantyne joined the University of Washington in 2011 as a medicine professor of education and research and serves as the Director of the Pain Fellowship. Dr. Ballantyne has editorial roles in several leading journals and textbook and is a widely-published author.

Our third presenter is Dr. Joseph Merrill. Dr. Merrill is an associate professor in the department of medicine at the University of Washington. He has extensive clinical teachings in research experience and in addiction medicine in opioid prescribing for chronic non-cancer pain. Board certified in addiction medicine by the American Board of Addiction Medicine, Dr. Merrill developed both methadone maintenance and buprenorphine programs in primary care settings. He is a telemedicine panel expert in chronic pain, hepatitis C, and opioid addiction programs.

As a reminder, the PowerPoint slide set and the webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. At this time, please welcome Dr. Dowell.

Dr. Deborah Dowell: Thank you Dr. Jackson-Brown. Today’s webinar content on risk mitigation strategies prescription drug monitoring programs, urine drug testing and naloxone is based on the CDC Guideline for Prescribing Opioids for Chronic Pain, released in March, in the Morbidity and Mortality Weekly Report, and in JAMA.

Here are key relevant findings from the evidence reviews for the guideline. One study found most fatal overdoses were associated with patients receiving opioids from multiple sources and/or with high total daily opioid dosages. The clinical evidence did not find studies evaluating the effectiveness of urine drug screening for risk mitigation during opioid prescribing for pain. However, concurrent use of opioids with other drugs such as benzodiazepines or heroin increase overdose risk and urine drug tests can provide information about drug use that is not reported by the patient.

Potential harms of risk stratification include underestimation of risks of opioid therapy when screening tools are not adequately sensitive as well as potential overestimation of risk which could lead to an inappropriate clinical decision. This graph shows how most patients prescribed opioids, 94% in the column on the left do not receive opioids from multiple sources or receive cumulative dosages of 100 morphine milligram equivalence or more. However, a majority of patients, 55% in the column on the right who are prescribed opioids and experience fatal opioid-related overdose had one or both of these risk factors.

Most of these risk factors can be identified through review of the patient’s data in the state prescription drug monitoring program or PDMP. PDMPs are databases that collect information on controlled prescription drugs dispensed by pharmacies in most states. The guideline recommends that clinicians review state PDMP data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain ranging from every prescription to every three months.

Take action to improve patient safety. If your patient is receiving high opioid dosages or dangerous combinations or prescriptions from multiple sources, Discuss safety concerns with your patient and with other prescribers they may have including their increased risk for overdose. For patients receiving high total opioid dosages consider tapering to a safer dosage and consider offering naloxone.

For more information on tapering, you can view and listen to the archive webinar on dosing and titration of opioids webinar 4 in this COCA series on the CDC Guideline for Prescribing Opioids for Chronic Pain. You can also refer to CDC’s pocket guide on tapering opioids available at www.cdc.gov/drugoverdose .

Consider opioids use disorder and discuss concerns with your patient if you find concerning information in the PDMP. If patients are taking dangerous combinations such as benzodiazepines with opioids, communicate with others managing your patient to discuss your patient’s needs, prioritize patient goals, weigh risks of concurrent benzodiazepine and opioids exposure and coordinate care. Importantly, do not dismiss patients from care. Use the opportunity to provide potentially lifesaving information and interventions. You can find additional resources including a fact sheet with information on how to use PDMP data on CDCs website at www.cdc.gov/drugoverdose .

The guideline also recommends testing urine for prescribed opioids and other drugs before starting opioids therapy and considering urine drug testing at least annually. In most situations, initial urine drug testing can be performed with the relative inexpensive immunoassay panel for commonly prescribed opioids and other controlled substances including illicit drugs that increase risk for overdose.

Confirmatory testing adds substantial cost and should be based on the need to detect specific opioids that cannot be identified on standard immunoassay or on the presence of unexpected urine drug test results. You should be familiar with the drugs included in urine drug testing panels used in your practice and understand how to interpret results for these drugs.

For example, a positive opioids immunoassay detects morphine which might reflect patient use of morphine, codeine or heroin. But this immunoassay does not detect synthetic opioids for example fentanyl or methadone and might not detect semi synthetic opioids such as oxycodone. However, may laboratories use an oxycodone immunoassay that detects oxycodone and oxymorphone.

In some cases, positive results for specific opioids might reflect metabolites from opioids the patient is taking and might not mean the patient is taking the specific opioids for which the test was positive. For example, hydromorphone is a metabolite of hydrocodone and oxymorphone is a metabolite of oxycodone. These examples highlight the complexities involved in interpreting the results of urine drug tests and highlight how it’s helpful to know what the testing panels used in your practice test for. How to interpret the results and have a low threshold for talking to the local lab or toxicologist to understand unexpected results.

When discussing urine drug testing with patients, explain that drug testing is used to improve safety. Explain expected results, the presence of a prescribed medication and absence of unreported drugs including illicit drugs. Ask about use of prescribed and other drugs and if there might be unexpected results and provide an opportunity for patients to disclose changes in their use of prescribed opioids or other drugs. If unexpected results are not explained, confirm them with a test selective enough to differentiate specific opioids and metabolites. For example, gas or liquid chromatography mass spectrometry.

Use unexpected results to improve patient safety. Do not dismiss patients from care based on a urine drug test result. Consider as appropriate changing the pain management strategy, tapering and discontinuing opioids, more frequent re-evaluation, offering naloxone, and treatment for substance use disorder. Naloxone is an opioids antagonist that can reverse severe respiratory depression. Its administration by lay persons such as friends and family of persons who experience opioids overdose can save lives.

The guideline recommends clinicians consider offering naloxone when patients have a history of overdose, have a history of substance use disorder, are taking central nervous system depressants with opioids, are on higher dosages of opioids such as 50 or more morphine milligram equivalence per day, or are at high risk for returning to a high dose to which they’re no longer tolerant. For example, patients recently released from prison.

Practices should provide education on overdose prevention and naloxone use to patients receiving naloxone prescriptions and to members of their household. Experts noted that naloxone co-prescribing can be facilitated by clinics or practices with resources to provide naloxone training and by collaborative practice models with pharmacists. Resources for prescribing naloxone in primary care settings can be found through Prescribe to Prevent at prescribetoprevent.org.

I’ll now turn the floor over to Dr. Joseph Merrill) and Jane Ballantyne who will discuss how to apply these principles with examples you might see in practice.

Dr. Joseph Merrill: This is Joe Merrill. Thanks for the opportunity to be here. We’re going to talk about a couple of cases today. In terms of risk mitigation strategies, the first case is Beth, a 65-year-old woman with rheumatoid arthritis and mild joint deformity with transferring her care due to insurance changes. She’s been adherent to her disease modifying rheumatoid arthritis treatment and it’s been partially effective.

She’s also been prescribed 60 oxycodone with acetaminophens each month for about 10 years and she denies any adverse effects or symptoms of opioids use disorder. So, she’s on a relatively low dose total opioids dose of 15 milligrams of morphine daily. She hasn’t had any of the risk mitigation strategies implemented in her care; no urine testing, no prescription drug monitoring program checks and no controlled substances agreement.

So, today I’m just going to outline some risk mitigation strategies and how they might apply to this case; the prescription drug monitoring program, urine testing and controlled substances agreement. Jane will go on and talk about a higher risk case after that.

So, the first strategy is prescription drug monitoring program. And these can identify patients with high risk prescribing, those patients who seek out prescription opioids or other controlled substances from multiple prescribers, pick them up in multiple pharmacies and from the perspective of a state which has implemented this program, it can really be useful to identify very high risk patients who may require specific kinds of intervention whether that’s addiction treatment or restriction to a specific pharmacy or practitioner.

And there is some good evidence that states that require prescription drug monitoring checks prior to prescribing, and that’s happened in a number of states, that that’s helpful in terms of reducing the number of patients who do have multiple prescribers, multiple pharmacies. So, that’s one situation where the prescription drug monitoring program has been effective, but it really applies to a small number of patients.

For most patients aren’t going to have such clear evidence of misuse of opioids. There is some evidence that physicians how have access to prescription drug monitoring program data may prescribe more opioids. So, there’s a randomized trial of emergency department physicians looking at giving them the information or not giving them the information. And it turned out that physicians who got access to the information and it didn’t show any problem seem to prescribe more opioids. So, we don’t know overall how these programs are going to work in terms of reducing or increasing prescribing of opioids.

Secondly, results can be difficult to interpret in clinical care. So, in this case and this is our 65-year-old woman with- who’s relatively low risk. She did have prescription drug monitoring program results showing two prescriptions in the past year. Both of them were from a dentist for hydrocodone/acetaminophen just 10 tablets for each of the prescriptions and then there was also an emergency department visit after an ankle sprain where she got oxycodone, 12 of them.

So, in this case it may not be that, even though the patient appears to have now three different prescribers, these are very small numbers and in a low risk patient may not be concerned so much about misuse of the medication, but it is an opportunity for you to discuss some important safety information with the patient. So, the risk of co-prescribing of opioids in terms of overdose, the potential toxicity actually of the acetaminophen and that’s being prescribed in her chronic pain medication and then also, acetaminophen that may be prescribed in other opioids prescriptions.

And then, just reaffirming the importance of the patient reporting this outside prescribing to you as the primary prescriber so that you can assess the safety of it. And they need one to document the discussion as well as the PDMP results so if this does turn into a pattern and there is- they’re multiple other prescriptions that aren’t reported and that might be risky that you have that information in the medical record.

The second strategy I’m going to discuss is urine toxicology testing. Again, this can assist in safety monitoring. It can also be helpful in diagnosing substance use disorders. These tests can be complex to interpret. There are a lot of different kinds of test that vary in sensitivity and specificity. There’s false positive results, false negative results that are pretty common.

So, really the recommendation is to not make clinical decisions on the basis of a single test. Really looking for patterns in testing and using the testing as potentially a trigger for closer follow up of patients. Maybe more intensive monitoring, repeated testing, to see if an abnormal result is actually part of a pattern that could be used to diagnose a substance use disorder or a safety concern. Or maybe it’s just a mistake in the test.

So, applying this- oh, so there are some pitfalls. Deborah mentioned some of them. Opioids can have false positive results with poppy seeds although actually it’s not really a false positive because poppy seeds actually do contain morphine and can trigger a positive test on the opioids screen. There are also false negatives with oxycodone on some of the screens because oxycodone does not necessarily cross-react very well especially at low doses with the opioids tests. So, you may need a specific test.

That’s pretty common nowadays to have an oxycodone test that’s included in these screens, but not all panels of these tests have that. Amphetamine, methamphetamine the main risk is false positives and I’ve listed a few of the many prescription drugs that can cause false positives. So, a lot of strategies in clinical testing is to use a positive screening test to then reflex to a confirmatory test to see if amphetamine or methamphetamine is actually present.

Benzodiazepines that test can also have problems. It can be falsely positive with citrulline. Can be falsely negative with especially clonazepam and lorazepam. These are benzodiazepines that appear only in very small quantities in the urine so the tests are not always sensitive enough to pick up even a patient who is taking those medications as prescribed if the dose is fairly low. So, you wouldn’t want to assume that that a negative test means the patient is not taking the medication.

So, going back to our case, in this case, the urine toxicology was actually negative for oxycodone. The specific test that was done was also negative. So, you take that information back to the patient and the patient reports taking the medication really primarily before activity and not even every day. So, you look back and this makes sense. She hasn’t necessarily picked up her prescription on time every month. Sometimes it’s been after a month. She’s using low doses. She’s having intermittent use and this is a set up to make the testing falsely negative or it’s not falsely negative, but the way the patient’s taking the medication actually did discover that she’s not taking it consistently.

So, urine toxicology testing really can be helpful for safety. And figuring out if patients are taking medications that can raise the risk of overdose. And it’s particularly useful in addiction assessment, but there many pitfalls to it and really discussing these results with the patient and with the lab can really help you understand and interpret the tests more effectively.

So, the last piece I’m going to talk about is controlled substances agreement. And this is a common approach for informing patients about opioids risks, informing patients about clinic polices related to prescribing opioids and even anticipating potential problems. When you’re presenting this, this isn’t common when you’re prescribing a medication, but really you can present the rationale as providing more effective informed consent for patients who are getting a potentially risky treatment.

So, if patients are getting surgery we go through a more formal informed consent process because of the risks that exist in surgery and we do the same thing with opioids prescribing because of the risks of opioids prescribing in the long run.

So, one of the key features of these agreements and the one that I emphasize most in the patients when I’m going over these is to have the patient understand that they really shouldn’t- they should not escalate their dose of opioids without talking to me first. So, I use the phrase let me be the doctor. Help them understand that I don’t want them to be the doctor in terms of the dose of their opioids.

And I find this is a very helpful one because both it points out to the patient the importance of keeping their dose within the limits that we talk about. And also, if I then later find that the patient did escalate their dose without talking to me, that really increase as my concern that there may be control problems with the medication and a substance use disorder may be actually present. So…

Dr. Loretta Jackson-Brown: Dr. Merrill can I cut in for a moment? This is Dr. Loretta Jackson-Brown. I just want to inform folks we are aware that some folks had difficulty accessing the webinars. The updated webinar link is on the COCA webpage. So, please go to the COCA page at emergency.cdc.gov/coca and you can click on that link and you can join the webinar if you’re only listening to audio and you would like to use the webinar. So again, emergency.cdc.gov/coca and click on today’s COCA call. Thank you. Continue Dr. Merrill.

Dr. Joseph Merrill: So, with the controlled substances agreement there can be another part of the conversation which is really assessing the patient side effects related to opioids and I don’t mean that just side effects like constipation, although that can be an important one for patients. But there’s a range of possible problems that patients identify related to opioids.

People can feel sedated. They can be constipated. And then then there are symptoms of depression really, not having much energy, or actually having depressed mood-related to their opioids. And really trying to assess whether the patient seems to feel that their depression symptoms might be related to opioids is an important conversation to have.

The other part is symptoms related to addiction, although some patients don’t have full-fledged addiction, but do feel like they’ve lost control over the medication at times. Maybe their pain gets a little bit out of hand and they increase the dose. Then run out and have some withdrawal problems. So, these can be addiction-like symptoms that could lead you to wanting to diagnose a substance use disorder. And use the controlled substances agreement conversation as a way of assessing that can open up the possibility of seeing other problems with opioids that the patient’s currently having.

So, in this case the patient over the last couple of years actually has noted that her energy level and she has a little bit of difficulty concentrating, if she’s had a day where she takes the opioids. And there was a time when she almost fell after taking a couple of tablets when she was having a particularly active day. So, she has identified some issues that might be concerning to her and she does express interest as a result of this conversation in additional non-medication approaches. So, using controlled substance agreement to open the conversation can also lead to enhancement in the care overall.

So, just to summarize these risk mitigation strategies are an important component for monitoring safety of long-term opioids prescribing. The PDMP and the urine toxicology tests can be useful, especially when patients have addiction issues. But their limitations really need to be understood in order to not misinterpret the tests. And patient education about the risk of prescribing and clinic policies can provide an opportunity to avoid problems with prescribing and to reconsider opioids prescribing. So, that’s my talk and I’ll turn it over to Dr. Ballantyne who will talk about a higher risk case.

Dr. Jane Ballantyne: Thank you, Joe and Deborah and Loretta. This is- I’m going to present the second case in this webinar. And this patient is a patient who is at very high risk because he’s taking high doses of opioids. This is Mr. Thomas. He’s a 46-year-old man who has low back pain but persisted for eight years. The back pain began when he was injured at work.

He’s actually pretty healthy apart from his back pain. He has no other health issues and takes no medications other than opioids. He actually hasn’t worked since the injury, so the injury was disabling. He has some residual low back pain and some left leg pain. And he has evidence on his MRI of slight encroachment of L4 nerve root due to some foraminal stenosis.

He is not considered a suitable candidate for surgery. He has had epidural steroid injections and they’ve been helpful providing him with some pain relief in the past. But having had several injections, he’s no longer interested in receiving injections because he feels that the effect doesn’t last long enough to be worth it. He’s tried physical therapy but feels that it’s not helped and he’s not willing to try more physical therapy.

The opioids he takes is 30 milligrams of methadone which he takes three times daily plus oxycodone immediate relief 10 milligrams which he takes up to six times daily. So, when calculated his total opioids dose is 1,170 milligrams of morphine equivalent daily dose. As you’re probably remember the CDC guideline is now recommending a range between 50 and 90 milligrams morphine equivalent daily dose. So, this is a very high dose that he’s taking.

He’s actually always been a compliant patient. He’s never had urine tox screening since early in the course of treatment. So, he had an initial urine tox screen, but since then has not had any. And largely because he has been a compliant patient. And the PDMP, the prescription monitoring has never been checked. There’s also no opioids agreement on file since he started his treatment a long time ago at the time when there was less concern about opioids usage and particularly less concerned about high dose opioids usage.

The provider recently learned that CDC guideline for prescribing opioids for chronic pain and when he looked at the recommendation, he’s realized for the first time that his patient was on a dose that was no longer considered safe. So, for the past two decades or so, teaching has been that there is no specific ceiling dose for opioids, but because of the data that’s been coming in showing that many of the adverse outcomes of opioids therapy directly correlated with dose. So, high doses now understood to be much less safe than lower doses. There’s now more effort to control those and in particular to teach the patient about the safety of the high doses and initiative initiatives to control the dose.

So, the question is now what must the provider do to improve the safety of the current regime? The first thing that really needs to be done is to speak to the patient and his family about this new information that’s emerged about serious safety considerations related to high dose opioids. The patient and the family need to understand that new measures will be taken in order to comply with today’s standard of care. And it’s necessary to explain but one measure will be to gradually taper the opioids to a safer dose or to discontinuation.

Patients who have been on opioids for a long time can be quite frightened of the idea of tapering their opioids. So, it’s very important to spend time on this conversation. You can explain that the taper can be done slowly so that there’s no unpleasant withdrawal and that most people feel better on the lower dose. Also, that pain relief usually is not compromised. In fact, many people report that their pain actually improves when their either on the lower dose of opioids or when they’re off opioids all together. And that’s because when opioids are used long term, tolerance develops to the extent that the opioids are no longer as effective as it was at the lower doses.

The other initial thing that can be done to improve safety for this patient who is already on very high doses of opiates is to prescribe naloxone and to explain to the patient and his family why this has become necessary and how and when to use it. Naloxone is an effective antidote to opioids. So, if the patient does get into trouble in terms of being over sedated or having a lower respiratory rate or even apnea, naloxone will effectively reverse it.

And this needs to be explained to the patient and the family. Obviously, it’s usually the family member that needs to administer the naloxone. The patient is not able to do that to themselves. So, it’s very important to have a family member not only understand the safety issues, but understand how to use the naloxone.

Patients who are told that their dose of opiates that they’re taking is now considered unsafe often are very upset and often because they’re frightened of needing to reduce the dose. They feel dependent on it. They feel that their pain is going to get markedly worse if they are forced to reduce the dose, but also because it may be completely new information to them that the dose is unsafe.

And they feel sometimes that they were prescribed the dose believing it was safe and trusting their doctor to give them safe medication and now they’re being told that it’s no longer safe. So, sometimes it takes a lot of time and effort to explain why the doctors have changed their mind. What the new information is. And how it is possible to keep them safe and to keep them with excellent pain relief even after a dose reduction.

The second thing to do is to evaluate for comorbidity including increased risk and there are many of them. Patients who have psychiatric comorbidity such as depression or anxiety are much more likely to get into trouble with control issues or taking the medication and this can be treated either with medication, counseling or both.

Patients with a history of stress or abuse or trauma or patients who have post-traumatic stress disorder can be treated and that can be really helpful in terms of helping them manage pain and their opioids usage. Patients with poor sleep and sleep apnea should be treated because in both cases the risk of dying of overdose during the night is increased or dying of respiratory depression and apnea is increased. Obesity, again, increases the risk of dying during sleep.

Constipation can be treated with diet. The risk of misuse or abuse should be determined especially in a patient like this who’s on a very high dose and may not have had any evaluation of risk prior to the recognition that the dose really needs to be addressed. Screen for reaction times and discuss driving risks in terms of the cognitive impairment may arise because the high dose opioids use and protect against falls.

Many of these patients on high dose are also at increased risk of falling --particularly elderly people. This patient is not elderly, but anybody on high dose of opiates is at risk of falling. And discuss any additional medication issues.

The third thing to do is to get the baseline UDT. This was done at the beginning of his treatment, but hasn’t been done in the eight years since the medication was started. So, just for a baseline in terms of following this patient now that the treatment is going to be to try and gradually reduce the dose is useful and also a decision will need to be made about how often to repeat that UDT. Also, check for prescription monitoring as (Joe) has described much more fully than I have time to here. It’s very useful and this patient has not had his prescription monitoring data check for eight years.

And even though he’s been on opioids for a long time he’s never had an opioids agreement. And again, Joe has explained many of the reasons for the value of an opioids agreement. And one thing I’d like to mention that I think is very helpful with these agreements is that the agreement is self- directed. That is it’s an opportunity for the patient and his physician together to decide what the goal of the treatment is. And to use that as a basis for measuring whether the treatment is successful.

The next thing to do once those baseline things have been achieved is to explain to the patient and to the family the tapering options. The most common way to taper is to taper slowly starting with either the long-acting or the short-acting for a patient who’s on both. And this patient is actually on both. Methadone a long-acting opioid and oxycodone immediate release a short-acting opioid.

We find that it’s easier to select one or the other with a view to which one. If the patient is going to remain on opioids or you envisage the patient’s going to remain on opioids which one will be the one that is remaining? So, start by tapering the other one. Usually the goal would be to get them on either no opioids at all or just occasional short-acting opioids in which case taper the long-acting first.

The taper can be very simple. Something like 10% per month or 10% reduction per prescription. Also, always be prepared to stop the taper if it’s difficult and have a pause so that things can settle down rather than increase the dose again. As long as our trajectory is downward then the tapering is successful.

It’s also possible to do a rapid tapering using suboxone. So, suboxone so-called induction that is allowing a patient to go into withdrawal and treating the withdrawal with suboxone allows you to reduce an opioids dose much more rapidly than just doing a slow taper.

Often during a taper, patients do experience either depression, anxiety or both and it may be helpful to actually treat new onset of depression or anxiety. We find a small dose of a tricyclic is helpful for treating the depression or anxiety during the taper. If the patient’s also on a benzodiazepine, it may be necessary to choose between the opioids and the benzodiazepine to taper because it would be very difficult to taper both the opioids and the benzodiazepine at the same time. We often give the patient the choice. Ask them which they would rather taper first and explain to them that it’s not safe for them to remain on both medications.

The first thing that we would recommend is that depending on the results of the urine tox screen and the PDMP data and the medical evaluation, make a decision as to how the tapering will progress. That is how rapidly it is necessary to taper. Usually 10% is sufficient, but occasionally it may be advisable to do it a bit slower especially for someone who’s been on for a very long time.

This patient had only been on for eight years. So, 10% would be reasonable. Sometimes it’s necessary to do immediate discontinuation, but that would be very rare. Usually it’s not a good idea to cut people off opioids especially if they’ve been on opioids for a while because then they will have such bad cravings that they may need to get illicit medication and they were maybe driven to try and get illicit medication or to borrow medication from other people or to use their own supplies which again is not really very safe.

So, generally we don’t recommend immediate discontinuation, but one of the exceptions would be if you know the patient is taking heroin. You also want to discuss the future frequency of provision of prescriptions. If there’s very high risk identified, it may be helpful to provide prescriptions more often, for example weekly instead of monthly or monthly instead of two monthly. Also, well determine the urine tox screen schedule.

The frequency of looking at the prescription monitoring data. And also, the need for referral to additional providers -- particularly psychology, psychiatry, or in order to optimize in-treatment possibly to physical therapy, behavioral therapy, group therapy. Other providers can be very helpful in helping to manage the pain and, if necessary, managing substance use disorder.

Finally, if addiction is diagnosed and the patient needs to be referred for addiction treatment, once that treatment has begun with an addiction provider, then it’s usually recommended not to prescribe opioids for pain. And let the opioids prescribing be done by the addiction specialist. But to continue treating the pain using non-opioids modalities.

I think that is my last slide. Thank you for your attention.

Dr. Loretta Jackson-Brown: Thank you, presenters, for providing our COCA audience with such great information. We will now open up the lines for the question and answer session. Questions are limited to clinicians who would like information on prescribing opioids. For those who have media questions, please contact CDC media relations at 404-639-3286 or send an email to media@cdc.gov. If you are a patient, please refer your questions to your healthcare provider. When asking a question, please state or your organization and also remember you can submit questions through the webinar system. Coordinator?

Coordinator: Thank you, at this time if you do have any questions or comments, you may press star followed by the number1. Please unmute your phones and state your first and last name when prompted. Again that is Star 1 to ask a question and Star 2 to withdraw your question. One moment please. (Ashley Ghaffarzadeh), you may ask your question.

Ashley Ghaffarzadeh: Hi, good afternoon. I’m sorry I was contacting the operator just to notify there was issues with the webinar, but no specific questions for the presenters.

Coordinator: And we do have another question. Would you like to go ahead and take that?

Dr. Loretta Jackson-Brown: Please do, and thank you, (Ashley).

Coordinator: Thank you, (Jerry Haldrick) you may go ahead.

Jerry Haldrick: Can you hear me?

Dr. Joseph Merrill: Yes.

Jerry Haldrick: We have a methadone clinic here called Medmark and we actually have the director, (David Saball) and he is extremely instrumental in eradicating the overuse of prescription opioids and we’re very interested in having training brought here to El Paso, Texas. I am an instructor at Vantage College. I’m also a certified instructor for community health workers for the State of Texas. How may we bring or create a training to alleviate to control to educate and create awareness here in the El Paso, Texas region? We would like very much to collaborate with your department in doing that.

Dr. Deborah Dowell: So, this is Debbi Dowell from CDC, I’ll start. When resource is available, this COCA webinar series will be archived and available on the CDC website. In addition, the University of Washington has ongoing case presentations. So, I’ll let one of the University of Washington faculty talk about whether there might be opportunities to connect with that. And other federal agencies including NIH in addition to CDC are developing additional training as the CDC. If you can get in touch with us after the webinar, my email is GDO7@cdc.gov. We can follow up.

Jerry Haldrick: And would you be kind enough to repeat that email address?

Dr. Deborah Dowell: G as in Gary, D as in David, O as in Oliver 7 @ cdc.gov.

Jerry Haldrick: Okay, got it. Then we’ll go ahead and take care of that and we do appreciate your time and your courtesy and the content of this seminar.

Dr. Deborah Dowell: Thank you.

Jerry Haldrick: My pleasure.

Coordinator: Thank you. Once again, if you do have any questions or comments, please press Star 1. (Reynold Bergman) you may go ahead.

Reynold Bergman: Yes, do you hear me okay?

Dr. Jane Ballantyne: Yes.

Reynold Berman: Okay, question, thanks Jane and Joe for a really nice presentation. I’m getting a lot of patients who are coming from other providers on high doses and I need to start a tapering program and I do that. However, I do find that offering alternatives such as complementary alternative medicine and as Jane mentioned also, PT, exercise programs. Anyway, I just want to focus on the possibility of at least making the tapering process change a little bit more palatable for patients by offering alternatives. Thanks.

Dr. Jane Ballantyne: I will comment on that. Thank you for your interest. I agree that it’s very important to offer alternatives to opiates. It’s very difficult for patients to first of all to taper. It’s tough. It’s sometimes actually painful to taper. You can avoid a lot of that by doing the taper slowly or by using suboxone. But nevertheless it is tough and it’s psychologically difficult.

And it’s very helpful if the patients understand that there are alternatives. And it’s very helpful if they understand that actually when the dose has been successfully tapered, they probably won’t make as much difference to their pain experience as the introduction of alternative treatments. And you use the word complementary. I presume you mean complementary medical approaches and I think they’re very helpful as well. So, I agree with you that it’s important part of this is to offer alternatives.

Reynold Bergman: Thanks Jane. I have another comment if allowed one more comment. Can I do that please?

Dr. Loretta Jackson-Brown: Yes, go ahead.

Reynold Bergman: Okay and while seeing pain patients, I do also mix them with- I also do the medication treatment with suboxone and I find it very helpful if you’re having a patient that you suspect there’s a substance use disorder, I switch them over to suboxone and what the advantage is they have the same provider. So, I don’t need to send them anyplace else. They have, kind of, developed a personal relationship with me and therefore, I just switch them over to suboxone and continue on. And that seems to work really well. I just want to pass that along. Thanks.

Dr. Jane Ballantyne: Thanks Ro). This is Joe Merrill. I would definitely encourage providers who are dealing with patients, especially higher dose patients, to get the training that they need in order to prescribe suboxone for substance use disorder. The training is fairly brief. It’s an eight-hour training, but it really provides an opportunity to treat patients as (Ron) said and keep them in your practice and treat the problem that is keeping them from being able to function well. And patients who are switched to suboxone from higher doses of opioids for pain, often do a lot better and a lot of the non-opioids medications, the non-medication treatment for chronic pain are much more effective in that context.

The only other thing I wanted to comment on is that there are a lot of complementary and alternative medication or treatments that, some are medications and some are not, can be helpful for individual patients. I always try and emphasize some of the more active approaches to treatment. In other words, not necessarily the things that are done passively to patients whether that’s massage or acupuncture. But more the active strategies including getting more active in terms of exercise and behavioral changes that can be helpful with lifestyle changes that can really help people feel a lot better. And that’s a kind of a different conversation, but a very productive one.

Dr. Jane Ballantyne: I’d also like to add in terms of the use of suboxone or buprenorphine. That the patient doesn’t necessarily have to have a substance use disorder diagnosis for it to be useful, particularly patients who’ve been on opioids for the treatment of pain for a long time. The will be dependent on the opioids and will have difficulty tapering from a high dose without such aids or it may be a very prolonged process that can be speeded up by using suboxone. So, its not- it shouldn’t be considered just restricted to the use of substance use disorder as a formal diagnosis.

Dr. Joseph Merrill: I agree with that Jane. The only issue for some patients is that most insurance companies won’t pay for suboxone for the treatment of pain. And will require an addiction kind of diagnosis. That’s not universal, but and I think it’s a bad policy. I think it should be changed so that patients can benefit from this much safer medication.

Dr. Jane Ballantyne: And I think it’s state dependent as well. You know, not all- I know Washington State, the state we’re in, it’s very difficult to get insurance to pay for it, but other states it’s not so difficult.

Reynold Bergman: Jane I have one other comment if you don’t mind real quick.

Dr. Jane Ballantyne: Yes.

Reynold Bergman: I find that when I’m going into an exam room with a patient I’m going to have to take some action. It is really nice to pull out of your back pocket. Say I am following the CDC guideline and I attend their regular conferences and it gives you, as a provider, additional credibility in terms of moving forward. And patients really don’t fight that when you bring like- I attend the University of Washing pain management seminars and just to have that resource in your back pocket is really helpful. Thanks.

Dr. Jane Ballantyne: Thanks. Also to answer the previous question about what is available, we do have telemedicine and sessions that anybody can sign onto. They’re completely free of charge the University of Washington telemedicine and there’s also Joe can probably tell you about similar sessions for the treatment of dependence and addiction.

Dr. Loretta Jackson-Brown: Thank you. Coordinator, do we have another question from the phone?

Coordinator: At this time I am showing no further questions.

Dr. Loretta Jackson-Brown: Okay, thank you. Presenters do you have any additional comments?

Dr. Deborah Dowell: No further comments.

Dr. Loretta Jackson-Brown: So, on behalf of COCA, I would like to thank everyone for joining us today with a special thank you to our presenters, Doctors Dowell, Merrill and Ballantyne. The recording of this call and the transcript will be posted to the COCA webpage at emergency.cdc.gov/coca within the next few days. Free continuing education is available for this call. All continuing education for COCA Calls are issued online through CCE online. The CDC training and continuing education online system at www.cdc.gov/tceonline. Those who participated in today’s COCA call and would like to receive continuing education, should complete the online evaluation by January 8, 2017 and use course code WC2286 If you will review the call on demand and would like to receive continuing education, complete the online evaluation between January 9, 2017 and January 10, 2019 and use course code WD2286.

Miss the previous opioid call? No worries. View call recording and earn free continuing education for the June 22, July 27, August 3, August 17 and November 29 all by visiting the COCA webpage. This Thursday, December 8 at 2:00 Eastern Time, join COCA for a call entitled Gearing up for the Travel Season, How Clinicians can Ensure their Patients are Packed with Knowledge on Zika Prevention. During this COCA Call, clinicians will learn about current CDC’s travel recommendations, help determine which patients should receive Zika testing after traveling to an area with Zika and the recommendations for patients before and after travel to help and protect themselves and others from Zika. Get detailed information about this call by visiting COCA webpage at emergency.cdc.gov/coca

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Thank you again for being a part of today’s COCA call. Have a wonderful day.

Coordinator: Thank you. This concludes today’s conference. You may go ahead and disconnect at this time.

END