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Protecting Patients with Chronic Pain-Ensuring Health and Safety in Opioid Prescribing and Deprescribing PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Protecting Patients with Chronic Pain: Ensuring Health & Safety in Opioid Prescribing and Deprescribing" by Beth Darnall, PhD.

Tags : Chronic Pain, Opioid Prescribing, Opioid Deprescribing

Published on : Mar 14, 2023 | Views : 710 | Downloads : 0

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Beth Darnall, PhD Director, Stanford Pain Relief Innovations Lab Associate Professor Stanford University School of Medicine Anesthesiology, Perioperative and Pain Medicine Psychiatry and Behavioral Sciences (by courtesy) Wu Tsai Neurosciences Institute (affiliated faculty) @BethDarnall Protecting Patients with Chronic Pain: Ensuring Health & Safety in Opioid Prescribing and Deprescribing
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Contracts and Grants NIH / NIDA Brief digital treatment for chronic pain PCORI Patient-Centered Opioid and Pain Reduction NIH / NCCIH Behavioral Treatment for Chronic Pain Chief Science Advisor: AppliedVR Board of Directors American Academy of Pain Medicine Institute for Brain Potential Scientific Member CDC Opioid Workgroup (2020-2021) NIH Interagency Pain Research Coordinating Committee (IPRCC) Disclosures
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2011 IOM Report: Relieving Pain in America 100 million adults $635 billion annually Erodes quality of life, confers suffering
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Long‐Term Use of Daily Prescription Opioids Mojtabai R. Pharmacoepidemiol Drug Saf. 2018;27:526-534. 3.4 % of US adults 11 million individuals
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Patients taking long-term prescription opioids require careful considerations Reducing opioid doses creates new risks Right methodology can be applied to minimize iatrogenic risks from de-prescribing Apply patient-centered principles Credit: Celia Krampien
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Nov 2018 Dec 2018 April 2019 April 2019 April 2019 HP3 Letter Kertesz, Satel, et al. 300+ signatories 3 former U.S. Drug Czars AMA signs support Human Rights Watch Declares the issue a “human rights violation” Laura Mills FDA Clarifies labeling and cautions against abrupt discontinuation CDC Dowell et al. Clarification of opioid prescribing guidelines publish in NEJM. Growing Outcry Against Iatrogenic Opioid Reduction Risks and Harms International Stakeholder Letter publishes Darnall BD, Juurlink D, Kerns R, et al. Reuters Wire service >20 news outlets worldwide
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What we are getting wrong Lack of patient-centered pain care Systems that do not collect patient reported data One-size-fits-all approaches Lack of flexible policies that support clinicians and patients Lack of meaningful access to comprehensive pain care Failure to implement tapers properly and maintain flexibility based on patient response to taper
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Tapering the wrong way Withdrawal Symptoms Discomfort Distress Failed tapers False belief that outpatient tapering is impossible Remaining on high doses Overdose Suicidal ideation Suicide Aggressive Taper Forced Taper
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Treat the person, not the pill
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Opioid Cessation vs. Opioid Reduction VS.
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We Optimized Patient Choice and Control in Their Taper Participation was VOLUNTARY Patients could control the pace of their taper Patients could pause their taper Patients were free to drop out of the study at any time The taper was NOT to a pre-defined opioid dose unless patient chose it Patients partnered with their doctor to achieve their lowest comfortable dose over 4 months The taper was NOT unidirectional
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Study Variables Demographics (Gender, Age) Pain Treatment History (Pain Dx, Duration of Opioid Use) Opioid Dose (MEDD) Average Pain Intensity (0-10) Pain Catastrophizing Scale PROMIS Measures Marijuana use (Y/N) 16 Weeks
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Sample Characteristics (N=51) 55% female 52 years of age (range = 25 – 72) 6 years on opioids (range = 1 – 38) Moderate pain intensity Marijuana: 37% (18) Opioid MEDD = 288 (60, 1005) Darnall BD, Ziadni MS, Mackey IG, Kao MC, Flood P (FEB 2018; JAMA Int Med)
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Kruskal-Wallis rank sum test
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Ziadni MS, Chen A, Krishnamurthy P, Flood P, Stieg RL, Darnall BD. Patient-Centered Prescription Opioid Tapering in Community Outpatients with Chronic Pain: 2- to 3-year follow-up in a subset of patients. PAIN Reports®: September/October 2020 - Volume 5 - Issue 5 - p e851
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15-Mar-23 October 2019
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Darnall BD (PI) Comparative Effectiveness of Pain Cognitive Behavioral Therapy and Chronic Pain Self-Management Within the Context of Voluntary Opioid Reduction Funded by the Patient-Centered Outcomes Research Institute® https://empower.stanford.edu/
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Pragmatic We are directly influencing clinical care
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Surveyed 250 patients taking opioids on preferences: Patients wanted the choice to taper or not (voluntary) More willing to be randomized to behavioral treatment or not Patients chose co-primary outcomes: Pain & Opioid Dose at 1 year
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Darnall BD et al. Pain Med. 2019 (study protocol paper) *You DS et al. Brief Screening Tool for Opioid Use Disorder: EMPOWER Study Consensus Protocol. Front. Med. 2021 Comparative Effectiveness of Pain Cognitive Behavioral Therapy and Chronic Pain Self-Management Within the Context of Voluntary Opioid Reduction Patients partner with their doctor to achieve their lowest comfortable dose over 12 mos We exclude for moderate OUD*
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1365 patients taking long-term opioids for chronic pain Stanford Pain Management Center (CA) Stanford Primary Care (CA) Kaiser Permanente (Oakland, CA) Intermountain Health (Utah) Veterans Affairs (Phoenix, AZ) MedNOW Clinics (Denver, CO) Lehigh Valley Health Care (Allentown, PA)
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We must create a caring and safe system that makes patients want to join and remain in EMPOWER
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Assessments & Monitoring Baseline, 6- and 12-month: comprehensive battery Psychosocial factors (PROMIS) Opioids Substance use Degree of choice Readiness to taper Taper beliefs Satisfaction with clinician relationship **Comments** WEEKLY surveys for withdrawal symptoms, mood, comments MONTHLY surveys for mood, suicidality, opioid dose, satisfaction, comments
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Close Monitoring of Patient Response to Opioid Reduction WEEKLY surveys for withdrawal symptoms, mood, comments MONTHLY surveys for mood, suicidality, opioid dose, satisfaction, comments Alerts are sent to prescribers in real time Patients receive tailored messages We track patients over 12 months
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In 2019 HHS called for patient centered voluntary tapering practices as a priority HHS also called for patient support during tapering Multiple groups have called for close and extended patient monitoring (home-based e-reports) to assure patient safety We offer MN all of our established systems at no cost: EMPOWER study methods Patient e-reporting system Single-session, 2-hour, online pain management skills class to support those who wish to reduce prescription opioids.
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Opioid tapering is NOT right for all patients
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Colleagues and Collaborators Sean Mackey, MD, PhD Partha Krishnamurthy, PhD Jesmin Ram, BS Lanja Sinjary, BS Regina Visca, MA Ming-Chih Kao, PhD, MD Ian Mackey, BA Ming-Chih Kao, PhD, MD Rob Louis, MD Kate Lorig, PhD Wendy Schadle Anu Roy, MA Lu Tian, PhD Joel Porter, MD Penney Cowan Garrick Olsen, PhD Laura Garcia, PhD Ashley Gomez Sara Davin, PsyD Maisa Ziadni, PhD Pamela Flood, MD Heather King, PhD Sophia You, PhD Corinne Jung, PhD Kristen Slater, PsyD Todd Maddox, PhD Josh Sackman, MBA Brandon Birckhead, MD
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