4/10/2014 Poorly Controlled Pain and Prescription Drug Abuse Mary Lynn McPherson, Pharm.D., BCPS, CPE Nina Cimino, Pharm.D. University of Maryland School of Pharmacy mmcphers@rx.umaryand.edu Objectives • Describe the public health challenges related to the abuse and diversion of controlled prescription drugs. • Design tactics on how pharmacy practice settings can identify controlled prescription drug abuse and diversion. • Explain how pharmacists and pharmacy technicians can effectively work towards reducing the abuse and diversion of controlled prescription drugs. What is pain? • “It is so much more than just pain intensity. Over time, many [patients] find the effects of living with chronic pain impact their ability to work, engage in recreational and social activities, and for some, [perform] the most basic everyday activities that people just take for granted. Not surprisingly, pain begins to chip away at their mood, often leaving them angry, frustrated, anxious, and/or depressed. Our families suffer along with us, and many relationships are forever altered.” …An advocate for people with chronic pain www.iom.edu; Relieving Pain in American 1 4/10/2014 IASP Definition of Pain • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage…Pain is always subjective…It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience.” www.iom.edu; Relieving Pain in American Why Focus on Chronic Pain Issues? Disease Number of Sufferers Diabetes 25.8 million people Coronary Heart Disease and Stroke 23.3 million people Cancer 11.9 million people TOTAL 61 million people Disease Number of Sufferers Chronic Pain 100 million people Institute of Medicine Report. 2011; http://www.painmed.org/patient/facts.html#incidence. The Prevalence of Pain is Staggering Age Adjusted Rates of U.S. Adults Reporting Pain in the Last 3 Months 30% 25% 20% 15% 10% 5% 0% Low Back Neck Knee Headache Shoulder Finger Hip CDC and NCHS. Health. 2011. 2 4/10/2014 Extent of Pain-related Disability Among Adults with Pain in the Last 3 Months, 2009 The Disability of Pain is Crippling 45% 40% 35% Basic Actions 30% Complex Activities 25% 20% 15% 10% 5% 0% Low Back Knee Headache Neck Shoulder Finger Hip CDC and NCHS. Health. 2011. The Prevalence of Pain is Increasing Trends in Pain Prevalence, 1999-2004 40% 35% 30% 25% 99-00 20% 01-02 15% 03-04 10% 5% 0% All > 20 yrs 20-44 yrs 45-64 yrs > 65 yrs Men Women Institute of Medicine Report. 2011. Pain is a Chronic Problem Trends in Pain Prevalence, 1999-2004 70% 60% 20 20years yearsand andover over 50% 20-44 20-44years years 40% 45-64 45-64years years 30% 65 65years yearsand andover over 20% 10% 0% 3 months to less than 1 year 1 year or more Institute of Medicine Report. 2011. 3 4/10/2014 Just the Facts – on Pain • > 50% hospitalized patients have pain in their last days; 50-75% patients die in moderate to severe pain • ~ 20% of American adults report pain or physical discomfort that disrupts their sleep a few nights a week or more • Chronic pain patients receiving opioids: – > 50% state little or no control over pain – 6/10 experience breakthrough pain • Impact on quality of life – Almost 2/3 report an impact on overall enjoyment of life – Over 70% report depression, trouble concentrating, reduce energy – 86% report an inability to sleep well American Academy of Pain Medicine - http://www.painmed.org/patient/facts.html Just the Facts – on Pain • Chronic pain sufferers make major adjustments – 20% take disability from work – 17% change jobs altogether – 13% need help with ADLs – 13% move to a home easier to manage – 63% have seen their physician about their pain; 40% have seen a specialist – Almost 40% have seen more than one doctor about pain American Academy of Pain Medicine - http://www.painmed.org/patient/facts.html Barriers to Improved Pain Care • System-level barriers – Failure to routinely implement strategies to address the biological-cognitive-emotional aspects of pain through a comprehensive and interdisciplinary approach to pain management • Institutional, educational, organizational, reimbursement-related – Clinical services and research endeavors are performed in silo, disease-specific fashion www.iom.edu; Relieving Pain in American 4 4/10/2014 Barriers to Improved Pain Care • Clinician-level barriers – Some pain conditions have no treatment guidelines – HCP are not well educated in best practices in pain management – Difficult for PCPs to identify/engage other clinicians – Lack of understanding of importance of pain management – Regulatory/law enforcement policies constrain the appropriate use of opioids – Insurance coverage restrictions – Additional basic and clinical research is needed www.iom.edu; Relieving Pain in American Barriers to Improved Pain Care • Patient-level barriers – Pain patients are closely scrutinized; questions and reservations may cloud the perceptions of clinicians, family, employers and others – Some patients will try to scam the system <<<<< legitimate pain patients – Cultural beliefs (pain = weakness, “suck it up”) – Doctor shopping (“didn’t take me seriously,” “didn’t listen,” “still had too much pain”) – Disproportionately undertreated pain in children, older adults, women, rural residents, lower education/income, certain racial and ethnic groups www.iom.edu; Relieving Pain in American Steps in Care • Self-management – Possibly in consultation with family/friends • Primary care – Rx drugs, exercise, PT, weight loss • Specialist care – Specialist in underlying disease, pain specialist • Pain center – Interdisciplinary approach may be offered www.iom.edu; Relieving Pain in American 5 4/10/2014 Evaluating a Complaint of Pain • • • • • • • • P – precipitating P – palliating P – previous treatment or therapy Q – quality R – region and radiation S – severity T – temporal U – you – how does the pain affect you Management of Pain • Non-pharmacologic – – – – – PT, OT Acupuncture Exercise, stretching Energy therapy Cognitive behavior therapy • Pharmacologic – Non-opioids – Opioids – Adjuvant analgesics Acetaminophen • Acetaminophen – also known as: – Paracetamol – APAP (N-acetyl-para-aminophenol) – Brand names (Tylenol) • Indication • Mild to moderate non-inflammatory nociceptive pain • Role in therapy • Self-limiting painful conditions such as tension headache, mild to moderate musculoskeletal pain, dental pain • Low back pain • Osteoarthritis 6 4/10/2014 Acetaminophen • Mechanism of action – acts centrally – Analgesic and anti-pyretic – Lacks anti-inflammatory activity (probably) • Analgesic effects are in the central nervous system – Inhibits COX enzymes in the CNS – Interactions with nitric oxide containing pathways – Block substance P action • Adverse effects – Very well tolerated – Hepatotoxicity seen with acute and chronic use • Alcoholism, supratherapeutic dosing Smith HS. Pain Physician 2009;12:269-280. NSAIDs Nonsteroidal Anti-inflammatory Drugs • • • • • • • • • • Aspirin Salsalate (Disalcid) Diflunisal (Dolobid) Choline magnesium trisalicylate (Trilisate) Ibuprofen (Motrin, Advil) Naproxen (Naprosyn, Aleve) Fenoprofen (Nalfon) Ketoprofen (Orudis) Flurbiprofen (Ansaid) Oxaprozin (Daypro) • • • • • • • • • • • Indomethacin (Indocin) Tolmetin (Tolectin) Sulindac (Clinoril) Diclofenac (Voltaren) Etodolac (Lodine) Meclofenamate (Meclomen) Mefenamic acid (Ponstel) Piroxicam (Feldene) Nabumetone (Relafen) Ketorolac (Toradol) Celecoxib (Celebrex) NSAIDs • Indication: – To lower a fever – Treatment of mild to moderate pain that may be inflammatory in nature • Role in therapy: – Acute and chronic pain – Especially helpful in certain types of somatic pain such as muscle and joint pain, bone/dental pain, inflammatory pain, post-operative pain – Opioid-sparing effect 7 4/10/2014 Selected NSAID Indications • • • • • • • • Headache Toothache Sinus pain Muscular pains Bursitis Tendonitis Backache Primary dysmenorrhea • Pain due to fever, cold, flu • Rheumatoid arthritis • Osteoarthritis • Ankylosing spondylitis • Gout • Acute painful shoulder • Sprains Oral, rectal, parenteral, topical NSAID Mechanism of Action • Primary mechanism is to inhibit the enzyme cyclooxygenase (COX), resulting in blockage of prostaglandin synthesis. There are two COX isoforms. • COX-1 – Constitutively expressed in most normal tissues – Plays a particularly important role in GI tract, kidneys and platelets – COX1 produces PG with beneficial effects such as regulation of blood flow to gastric mucosa and kidneys – COX-1 causes platelet aggregation via the thromboxane A2 (TXA2) pathway NSAID Mechanism of Action • COX-2 – Not usually present, but can be induced in response to inflammatory stimuli – Expressed constitutively in renal vasculature – COX-2 produces prostaglandins that activate and sensitize nociceptors – Minimal antiplatelet effects because COX-2 selective NSAIDs do not affect the TXA2 pathway – The goal with COX-2 inhibitor therapy is preserving prostaglandin-mediated gastroprotection (which occurs through the COX-1 enzyme) 8 4/10/2014 NSAID Adverse Effects • • • • • • • • Dyspepsia, abdominal pain GI discomfort, GI bleeding Clotting problems, bleeding Cardiovascular complications Hepatic complications Impaired renal function Prolonged pregnancy/labor Aspirin-exacerbated respiratory disease Opioids Phenanthrenes • Codeine • Morphine • Hydromorphone • Levorphanol • Hydrocodone • Oxycodone • Oxymorphone • Buprenorphine • Nalbuphine • Butorphanol Benzomorphans • Pentazocine Phenylpiperidines • Fentanyl • Alfentanil • Sufenanil • Meperidine Diphenylheptanes • Methadone • (Propoxyphene) Atypical Opioids • Tapentadol, Tramadol Opioids • Indications: – Treatment of moderate to severe pain that does not respond to non-opioids alone – Cough, diarrhea, dyspnea, opioid dependence • Role in therapy: Acute (trauma, postoperative pain) Breakthrough pain Cancer pain Chronic noncancer pain Effective in visceral and somatic pain; and (to a lesser extent) neuropathic pain – Frequently given with non-opioid therapy (opioid-sparing) – Management of opioid addiction – – – – – 9 4/10/2014 Opioid Adverse Effects • Nausea and vomiting • Constipation • CNS adverse effects – Sedation – Decreased cognition/delirium • • • • Respiratory depression Pruritus Pupillary constriction Long-term effects Opioids and Patient-Related Variables • Age • Opioid tolerant/naïve – History of responsiveness, adverse effects • • • • • • • Renal impairment, hepatic impairment Ethnicity Body habitus Ability to manipulate/use dosage formulation History of substance abuse Health beliefs Fever, pregnancy, breast-feeding P’col Management Neuropathic Pain • First line recommendations – Tricyclic antidepressants – Dual reuptake inhibitors of serotonin and norepinephrine – Calcium channel α2-δ ligands – Topical lidocaine • Second line recommendations – Opioid analgesics – Tramadol Dworkin RH et al. Mayo Clin Proc March 2010;85 (3) (suppl):S3-S14 10 4/10/2014 P’col Management Neuropathic Pain • Third line recommendations – Other antidepressants and anticonvulsants – Topical low-concentration capsaicin – Dextromethorphan, memantine, mexiletine • Directions for the future – Cannabinoids – Botulinum toxin – High-concentration capsaicin patch – Lacosamide – Selective serotonin reuptake inhibitors – Combination therapies Dworkin RH et al. Mayo Clin Proc March 2010;85 (3) (suppl):S3-S14 Who’s Still With Me? • Which of the following is an adverse effect associated with NSAID therapy? – A. Increased cardiovascular events/death – B. Gastrointestinal upset and bleeding – C. Respiratory depression – D. A and B are correct – E. A, B and C are correct So we’ve got the tools…. What’s the dealio? http://www.cdc.gov/HomeandRecreationalSafety/pdf/PolicyImpact-PrescriptionPainkillerOD.pdf 11 4/10/2014 Poorly controlled pain Drug abuse and diversion http://www.cdc.gov/homeandrecreationalsafety/rxbrief/ Where are the prescription painkillers coming from? Got drug from dealer or stranger Took from friend or relative without asking Bought from friend or relative Prescribed by one doctor Obtained free from friend or relative Other source http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#2.16 12 4/10/2014 Manchikanti et al. 2012 Scope of the Problem • In 1997 opioid sales in the US were equivalent to 96mg morphine equivalents/person; 710mg/person in 2010 • This equates to hydrocodone 5mg Q6H x 45 days for every adult in the US • Hydrocodone/acetaminophen was the most prescribed drug from 2006-2011 • The US has 4.6% of the world’s population but consumes 83% and 99% of the world supply of oxycodone and hydrocodone, respectively Manchikanti et al. 2012 Growth of Opioid Sales Opioid Growth in Sales 1997-2007 Hydrocodone 280% Oxycodone 866% Methadone 1,293% Manchikanti et al. 2012 13 4/10/2014 Global Use of Hydrocodone • Britain + France + Germany + Italy – 3.237 grams • United Stated – 27,400,000 grams Manchikanti et al. 2012 Extent of Misuse • 20% of Americans use opioids for non-medical purposes – Non-medical costs $500 billion every year • 7 million Americans over age 12 report using prescription psychotherapeutic drugs for nonmedical purposes in the past month – 5.1 million report using pain relievers nonmedically Manchikanti et al. 2012 Opioids in Chronic Pain Patients • 5-41% of patients receiving opioids for chronic non-cancer pain abuse them • Among patients with chronic pain who are treated with opioids – 3.3% develop addiction – 11.5% show aberrant drug-related behavior or use of illicit drugs – 20.4% divert opioids Manchikanti et al. 2012 14 4/10/2014 • We must provide adequate analgesics to those in pain • This must be balanced against growing concerns about harm due to analgesics – Abuse and addiction – Serious injury and death – Due to both prescription and nonprescription medications NEJM 2009;361:2105-2108 Voluntary Strategies to  Opioid Abuse • Assessment (history, physical exam) includes psychosocial factors, family history, risk of abuse • Monitor aberrant behavior that may indicate abuse • Random urine drug screening, pill counts, agreements • State prescription drug monitoring programs • New abuse-deterrent opioid formulations • Remove unused drugs through a “drug take-back” event • Required strategies - REMS www.iom.edu; Relieving Pain in American REMS Components • Medication Guide or PPI • Communication Plan – Communication plan to healthcare providers to support implementation of this REMS • Elements to Assure Safe Use – Training of prescribers, certification of dispensers – Patients in registry, monitoring parameters • Implementation System – To monitor and evaluate implementation of above http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM188155.pdf 15 4/10/2014 Pharmacists and REMS • Providing Medication Guide and reviewing with patient/caregiver • Informing prescribers of which opioids have a REMS in place and what the requirement elements are – Elements to assure safe use – Implementation system Poll Question • Which of the following statements is CORRECT regarding REMS? – A. Every opioid on the market has a mandatory REMS strategy – B. REMS strategies may include a medication guide, elements to assure safe use, implementation system and communication plan – C. Patients must take a knowledge test before receiving a prescribed opioid – D. Answers A, B and C are correct Education Challenges • Improving care for people with acute or chronic pain requires broad improvements in education regarding: – The multiple causes and effects of pain – The range of treatments available to help people obtain relief, and – The need to consider chronic pain as a biopsychosocial disorder • Educational efforts should be directed to: – People with pain – General public – Health professionals www.iom.edu; Relieving Pain in American 16 4/10/2014 Patient Education • • • • • • • • • • • • Steps people can take on their to prevent or obtain relief Differences between pain that is protective and not protective Reasons why the need for pain relief is important When and how emergency or urgent care should be sought Treatment-related pains, major categories of pain therapies, and advantages and disadvantages of each Different types of HCP who may be able to help and how Treatments health insurers may or may not reimburse Ways in which others can help prevent pain from progressing How pain is measured including different assessment scales Pain is a complex mind-body interaction The right to pain care, including access to medications Self-management techniques www.iom.edu; Relieving Pain in American Educating Patients • • • • American Chronic Pain Association American Pain Foundation American Pain Society PainKnowledge.org • American Society of Pain Educators • Become a Certified Pain Educator (CPE)! – www.paineducators.org 8 Prescribing Guidelines • Assess patients at risk of abuse before opioid therapy and manage accordingly. – Opioid Risk Tool (ORT) – Dr. Lynn Webster • • • • • Family history of substance abuse Personal history of substance abuse Age History of preadolescent sexual abuse Psychological disease – Screener and Opioid Assessment for Patients with Pain (SOAPP) http://www.zerodeaths.org/ 17 4/10/2014 Patterns Suggestive of Habituation • Adverse consequences/harm due to use – Intoxicated/somnolent/sedated; declining activity – Irritable/anxious/labile mood – Increasing sleep disturbance, pain complaints, relationship dysfunction • Impaired control over use / compulsive use – – – – Reports lost or stolen prescriptions or medications Frequent early renewal requests; urgent calls or unscheduled visits Abusing other drugs or alcohol; cannot produce medications on request Withdrawal noted at clinic visits; observers report over- or sporadic use • Preoccupation with use due to craving – Frequently misses appointment unless opioid renewal expected – Does not try nonopioid treatments; cannot tolerate most medications – Requests medications with high reward; only opioids relieve pain Clin J Pain 2002;18:S28-S38 8 Prescribing Guidelines • Watch for and treat co-morbid mental disease when it occurs • Use conventional conversion tables cautiously when rotating (switching) from one opioid to another • Avoid combining benzodiazepines with opioids, especially during sleep hours http://www.zerodeaths.org/ 8 Prescribing Guidelines • Methadone should be started at a very low dose and titrated slowly regardless of whether the patient is opioid tolerant or not • Assess for sleep apnea in patients on high daily doses of methadone or other opioids and in patients with a predisposition http://www.zerodeaths.org/ 18 4/10/2014 8 Prescribing Guidelines • Tell patients on long-term opioid therapy to reduce opioid dose during upper respiratory infections or asthmatic episodes • Avoid using long-acting opioid formulations for acute post-operative or trauma-related pain http://www.zerodeaths.org/ http://www.azcjc.gov/ACJC.Web/Rx/AZ%20Dispensing%20Guidelines%20(Printable).pdf Arizona Guidelines 1. Use prescription drug monitoring program before dispensing 2. Use clinical judgment regarding contacting prescriber 3. Use clinical judgment regarding contacting other pharmacies 4. Require government-issued ID for all new or unknown patients 5. Do not fill suspect prescriptions 6. Educate patients about proper storage and disposal of controlled substances http://www.azcjc.gov/ACJC.Web/Rx/AZ%20Dispensing%20Guidelines%20(Printable).pdf 19 4/10/2014 Symptom Analysis • • • • • • • • Precipitating Palliating Previous treatment Quality Region/radiation Severity Temporal Associated Symptoms Is an opioid even REALLY the right analgesic for this pain? • Probably – Chronic somatic or neuropathic pain • Musculoskeletal pain • Peripheral neuropathy • Postherpetic neuralgia • Probably not – Chronic visceral or central pain syndromes • Abdominal or pelvic pain • Fibromyalgia • Headache Pharmacist – Last Line of Defense • Monitor prescriptions for falsification or alteration – Legitimate prescription pads could be stolen from physician’s office and Rx’s written for fictitious patients – Patient may alter physician’s prescription – Patient may “call in” their own prescription – Watch “doctor-shoppers” 20 4/10/2014 Pharmacist – Last Line of Defense • Monitor prescriptions for falsification or alteration (be suspicious of…) – More prescriptions or larger quantities than normal – Patient returns to pharmacy too frequently – Prescriptions for antagonistic drugs (depressants and stimulants) – New customers show up with series of prescriptions from same physician Monitoring Patient Response – 4A’s • Analgesic – What was your pain level on average during the past week? – What was your pain level at its worst during the past week? – What percentage of your pain has been relieved during the past week? – Is the amount of pain relief you are now obtaining from your current pain reliever(s) enough to make a real difference in your life? • Query to clinician: is the patient’s pain relief clinically significant? Pain Assessment and Documentation Tool (PADT), as described in: Chou R, et al. Opioid Treatment Guidelines: Clinical guidelines for the Use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130 Monitoring Patient Response – 4A’s • Activities of Daily Living (better, same, worse) – Physical functioning – Family relationships – Social relationships – Mood – Sleep patterns – Overall functioning Pain Assessment and Documentation Tool (PADT), as described in: Chou R, et al. Opioid Treatment Guidelines: Clinical guidelines for the Use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130 21 4/10/2014 Monitoring Patient Response – 4A’s • Adverse Effects (none, mild, moderate, severe) – Nausea, vomiting, constipation – Itching, mental cloudiness, sweating – Fatigue, drowsiness, other • Patient’s overall severity of side effects (none, mild, moderate, severe)? Pain Assessment and Documentation Tool (PADT), as described in: Chou R, et al. Opioid Treatment Guidelines: Clinical guidelines for the Use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130 Monitoring Patient Response – 4A’s • (Potential) Aberrant Drug-Related Behavior – Purposeful oversedation – Negative mood changes – Appears intoxicated – Increasingly unkempt or impaired – Involvement in car or other accident – Requests frequent early renewals – Increased dose without authorization – Reports lost or stolen prescriptions Pain Assessment and Documentation Tool (PADT), as described in: Chou R, et al. Opioid Treatment Guidelines: Clinical guidelines for the Use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130 Monitoring Patient Response – 4A’s • (Potential) Aberrant Drug-Related Behavior – Attempts to get prescriptions from other doctors – Changes route of administration – Uses pain medication in response to situational stressor – Insists on certain medications by name – Contact with street drug culture – Abusing alcohol or illicit drugs – Hoard (i.e., stockpiling) of medications – Arrested by police – Victim of abuse, other Pain Assessment and Documentation Tool (PADT), as described in: Chou R, et al. Opioid Treatment Guidelines: Clinical guidelines for the Use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130 22 4/10/2014 Other Strategies Urine Drug Testing and Opioid Agreements • Analysis of a urine specimen to detect the presence of, or absence of a drug and/or the metabolites of a drug • Consider metabolic pathway – Oxycodone → oxymorphone – Codeine and heroin → morphine – Hydrocodone → dihydrocodeine • Opioid Treatment Agreements Magnani B, Kwong T. Clin Lab Med 32(2012):379-390. Reality Check!  • Which of the following statements is CORRECT regarding opioid prescribing guidelines? – A. There are validated instruments available to screen patients for potential abuse – B. Most prescription analgesics used in an unintended fashion were obtained freely from a friend or relative – C. Benzodiazepines plus opioid therapy increases the risk of adverse events – D. A and B are correct – E. A, B and C are correct Six Steps to Zero – Patient Counseling • Never take a prescription painkiller unless it is prescribed to you • Do not take pain medicine with alcohol • Do not take more doses then prescribed • Use of other sedatives or anti-anxiety medications can be dangerous • Avoid using prescription painkillers to facilitate sleep • Lock up prescription painkillers http://www.zerodeaths.org/ 23 4/10/2014 Public Education – Why? • Educated people can take steps to avoid pain • Educated people can give appropriate advice and assistance to friends, family, colleagues • Advocate for and accept appropriate treatment of acute and chronic pain personally or for family or friends • An educated public can act at the community level to minimize hazards that contribute to pain-producing injuries among students and in the general community • Educated citizens can advocate for improved pain prevention and control policy measures www.iom.edu; Relieving Pain in American Pharmacist Pain Educators • Public education is a normal public health activity • “Inform, educate and empower people about public health issues” is one of the Ten Essential Public Health Services that every public health agency is expected to provide • Public education enhances the effects of all major influences on disease control: – Policy, community-wide environmental control measures, community awareness support and action, work and school support, clinical expertise, family involvement and patient self-management www.iom.edu; Relieving Pain in American Health Care Provider Education • • • • • • • • Physicians Nurses Psychology Pharmacy Dentistry Physical Therapy Occupational Therapy Others www.iom.edu; Relieving Pain in American http://extracredit1020.wordpress.com/authors/rezwana-2/becoming-a-pharmacist/ 24 4/10/2014 Pharmacists • Assessment of pain complaint • Over-the counter analgesic selection and counseling • REMS and other abuse reduction strategies • Educating – Patients – The public – Healthcare providers • CERTIFIED PAIN EDUCATOR! www.iom.edu; Relieving Pain in American Maryland Board of Pharmacy Annual Continuing Education Breakfast “Prescription Drug Monitoring In Maryland” The Role of Opioid therapy in the Management of Chronic Non-Cancer Pain Mary Lynn McPherson, Pharm.D., BCPS, CPE Nina Cimino, Pharm.D. University of Maryland School of Pharmacy mmcphers@rx.umaryand.edu 25