Adolescent Depression and Suicide - Download as PowerPoint by shimeiyan

VIEWS: 27 PAGES: 69

									Evaluation and Treatment of
Opioid Depencence in IHS


              2009 IHS Behavioral
                Health Summit
              Connie Hunt, PhD
              Chief BH, PIMC
              Anthony Dekker, DO
              Phoenix Area Office
The Problem of Pain
     Costs US economy estimated
      $100 billion/year
           Healthcare
           Welfare & disability payments
           Lost tax revenue
           Lost productivity (work
            absence)

     40 million physician visits
      annually
         Most common reason for
          medical appointments

     Push toward opioid
      maintenance therapy in non
      malignant pain

National Institutes of Health. New Directions in Pain Research. Sept
1998. PA-98-102.
        Pain Treatment
 in Patients with an Addiction
These patients suffer thrice:
  1. from the painful disease
  2. from the addiction, which makes pain
     management difficult
  3. from the health care provider’s ignorance
               Pain Treatment
        in Patients with an Addiction

Must consider:
1. High tolerance to medications
2. Low pain threshold
3. High risk for relapse
  1. Pain treatment
  2. Inadequate pain treatment
  3. Psychological status
                 Pain Treatment
          in Patients with an Addiction

1. Use adjunctive modalities and
   medications
2. Avoid the patient’s drug of choice
3. Consider “safer” longer acting opioids
4. Use medication with lower street value
 Avoid self administration, if possible
 Case management
                Pain Treatment
         in Patients with an Addiction

1.   Explain potential for relapse
2.   Explain the rationale for the medication
3.   Educate the patient and the support system
4.   Encourage family/support system involvement
5.   Frequent follow-ups
6.   Consultations and multidisciplinary approach
                  Pain Treatment
           in Patients with an Addiction

1.   Address addiction
2.   Use non-medication approaches, if effective
3.   Use non-opioid analgesics, if effective
    Provide effective opioid doses, if needed
    Treat associated symptoms, if indicated
    Address addiction
      Non Pharmacologic
        Interventions
1. Behavioral Interventions-ie guided imagery,
   Progressive Muscle Relaxation therapies
2. Traditional Indian Medicine & Meditation
3. Osteopathic Manipulation, Chiropractic, Body work,
   Massage, etc
4. Acupuncture with or without stimulation
5. Physical Therapy and Yoga modalities
6. Regional anesthetic blocks- epidural injections
7. Tran-cutaneous Nerve Stimulation
8. Hypnosis
Non-opioid medications for CNMP

   Non-steroidal anti-inflammatory drugs (NSAIDS)
   Tricyclics
   Anti-depressants/anxiolytics
   Anti-convulsants
   Muscle relaxants
   Topical preparations–e.g. anesthetics, aromatics
   Others (e.g., tramadol)
         July 6, 2009

 FDA released concerns over
  acetaminophen causing 52,000 cases of
  liver toxicity
 NSAIDs have been related to 16,500
  deaths secondary to GI bleeding (15th
  leading cause of death in the US
 2007 the CDC announced that opioid
  overdoses are the second leading cause
  of accidental death in the US
      Deaths per 100,000 related to
      unintentional overdose and annual sales
      of
      prescription opioids by year, 1990 - 2006
      Source: Paulozzi, CDC, Congressional testimony, 2007
                         8                 600
                         7
                                           500
Crude rate per 100,000




                         6




                                                 Sales in mg/person
                                           400
                         5                                            Deaths per 100,000
                         4                 300
                                                                      Opioid sales (mg per
                         3                                            person)
                                           200
                         2
                                           100
                         1
                         0                 0
                             '90
                             '91
                             '92
                             '93
                             '94
                             '95
                             '96
                             '97
                             '98
                             '99
                             '00
                             '01
                             '02
                             '03
                             '04
                             '05
                             '06
            Addiction
        Abuse/Dependence



     Prescription Drug Misuse


Aberrant Medication Use Behaviors:
  A spectrum of patient behaviors
      that may reflect misuse



   Total Chronic Pain Population



                Adapted from Passik. APS Resident Course, 2007
    Treatment of Chronic Pain
   in Patients with an Addiction

1. Search for physical causes
2. Identify and address possible non-pain
   sustaining factors
3. Address and improve functional status
4. Treat associated symptoms, if
   indicated
5. Case management
Pain Control for Opioid Maintained Patients

  1. Must satisfy baseline opioid requirements
     before treating pain
  2. The usual maintenance dose (e.g., methadone)
     will not control the new pain
  3. The usual methadone dose needs to be
     supplemented with appropriate medication(s)
     for pain control
  4. May need slightly higher amounts for slightly
     longer periods of time
Buprenorphine maintained patients

 1. If non-opioids are ineffective, may need to
    increase the BUP or stop buprenorphine and
    add a pure Mu agonist for pain (OR-
    fentanyl)
 2. May need to switch to pure Mu agonist for
    maintenance (baseline requirements)
 3. Care needed if/when buprenorphine is
    restarted for maintenance
           Chronic Pain Patients

Goals of treatment
  1.   Pain reduction
  2.   Functional improvement
  3.   Safe and Tolerable side effects
  4.   Prevention of addiction or relapse
            Chronic Pain Patients

Treatment
  1. Case series studies suggest that opioids are safe
     and effective for most patients
  2. Long-term randomized controlled trials have
     not been performed
  3. Trials of opioid treatment are indicated for
     patients who have moderate to severe pain,
     significant functional interference, and poor
     response to other treatments
FDA Methadone Warning
 FDA ALERT [11/2006]: Death, Narcotic
   Overdose, and Serious Cardiac
   Arrhythmias
 FDA has reviewed reports of death and life-
    threatening side effects such as slowed or
    stopped breathing, and dangerous changes in
    heart beat in patients receiving methadone.
    These serious side effects may occur because
    methadone may build up in the body to a toxic
    level if it is taken too often, if the amount taken
    is too high, or if it is taken with certain other
    medicines or supplements. Methadone has
    specific toxic effects on the heart (QT
    prolongation and Torsades de Pointes).
    Physicians prescribing methadone should be
    familiar with methadone’s toxicities and unique
    pharmacologic properties. Methadone’s
     elimination half-life (8-59 hours) is longer
     than its duration of analgesic action (4-8
     hours). Methadone doses for pain should be
     carefully selected and slowly titrated to
     analgesic effect even in patients who are opioid-
     tolerant. Physicians should closely monitor
     patients when converting them from other
     opioids and changing the methadone dose, and
     thoroughly instruct patients how to take
     methadone. Healthcare professionals should tell
     patients to take no more methadone than has
     been prescribed without first talking to their
     physician.
NASPER
National All Schedules Prescription Electronic
Reporting Act

 Signed into law by President Sale of Opioids 1997-2002
  Bush August 2005
                                                  450%

 Point of care reference to all                                                   402.9%      410.8%
                                                  400%


  controlled substances                           350%

                                                  300%
  prescribed to a given patient                   250%


 Each state will implement                       200%

                                                  150%
  it’s own program                                100%    73.3%
                                                                      117.1%




 Treatment tool vs. Law                           50%

                                                    0%

  enforcement tool?                                      Morphine   Hydrocodone   Oxycodone   Methadone




   Source: 2002 National Survey on Drug Use and Health (NSDUH).
   Results from the 2002 National Survey on Drug Use and Health: National
   Findings. Department of Health and Human Services
“Doctors are easy to find and
they don’t carry guns” Medical
Economics
  “To stop Rx diversion,
   the agency (DEA) has
   hired hundreds of
   new investigators and
   expanded it’s local
   and state task forces”
  “Quantity alone…may
   indicated diversion
   and trigger an
   investigation”
Harrison Narcotic Act
1914
               Made it illegal to treat
                addiction with
                opiates
               >25,000 Physicians
                indicted between
                1914-1938
               3000 Physicians
                actually went to jail
               20,000 Paid
                substantial fine
Narcotic Addict Treatment Act
of 1974- Schedule II substances

Who can Rx
 Methadone?
 ADDICTION:
   Must be federally
    approved methadone
    treatment facility.
   Once daily dosing
 PAIN:
   Any provider with a
    schedule II DEA can
    prescribe.
   Divided dosing.
Drug Abuse Treatment Act
(DATA) 2000 Schedule III
substances
 ADDICTION:
   Obtain DEA waiver; MD/DO
   30 patients only for addiction
      2007: 30/100 pt limit
   Once daily dosing


 PAIN:
   Any provider with a schedule
    III DEA can prescribe.
   Divided dosing.
Pain Definitions
  Tolerance
     Decreased effect over time
  Physical Dependence
     Withdrawal symptoms upon discontinuation
  Addiction
     Impaired control, compulsive use, continued use in spite of
      negative consequences
  Pseudo Addiction
     Behavior surrounding obtaining adequate pain meds
  Pseudo Tolerance
     Worsening of underlying condition
  Universal Precautions: In
  Pain
  Medicine
  Gourlay, Heit, Pain Medicine Vol 6, No 2, 2005

1. Make a Diagnosis with Appropriate
   Differential
     Cause of pain identified
         Documented workup…somewhere
     Therapy directed toward pain generator
         Nosioreceptive Pain
         Neuropathic Pain
         Inflammatory Pain
  Universal Precautions: In
  Pain
  Medicine
  Gourlay, Heit, Pain Medicine Vol 6, No 2, 2005

2. Psychological Assessment Including Risk of
      Addictive Disorder
       Personal and two generation CD history
          30-40% risk CD with 1st degree relative
          Generation Skip
       Urine Drug Testing (UDT)
          EKG Analogy
       Questionnaires;
          Depression, Mood, Sleep
          SOAAP
   Universal Precautions: In
   Pain
   Medicine
   Gourlay, Heit, Pain Medicine Vol 6, No 2, 2005

3. Informed Consent
    Risks versus benefits of opioids
    Alternate treatments
    Opioids result in:
         Tolerance
         Physical dependence
         Withdrawal symptoms
         Risk of addiction
Universal Precautions: In
Pain Medicine
Gourlay et al, Pain Medicine Vol 6, No 2, 2005

 4. Treatment Agreement
     Written or Verbal
           Slack is gained and lost
           Go with the first story
       One provider prescribing
       One pharmacy filling
       Pill Counts for early refills
           It’s easy to bring in an empty bottle!
32% Misuse their meds or
violate guidelines for treatment
Ives et al BMC Health Services Research, April 4 2006, 6,
46

 169 pts on opioids in            62 Pts “misused”
  an academic medical                  40% UDS + coc/amph
  center                               24% UDS – for Rx
 Opioid Misuse                        9% + non Rx meds
     Neg UDS for opioids              3% diverted/forged
     Positive UDS for illicits   “Failure to guard
     Multiple prescribers          against diversion and
     Diversion                     drug misuse
     Forgery                       represents a public
                                    health threat” DEA
Universal Precautions: In
Pain Medicine
Gourlay et al, Pain Medicine Vol 6, No 2, 2005

 5. Pre- and Post- Intervention
     Assessment of Pain Level and
     Function
     Pain Questionnaire
           Numerical scales, Visual analog
           Medication effects, Side effects
       Roland Disability Scale
       Mood Survey
       Beck Depression Index, etc
Universal Precautions: In
Pain Medicine
Gourlay et al, Pain Medicine Vol 6, No 2, 2005



 6. Appropriate Trial of Opioid Therapy
     With or without adjunctive medication
     Emphasis on trial
Universal Precautions: In
Pain Medicine
Gourlay, Heit, Pain Medicine Vol 6, No 2, 2005



7. Reassessment of Pain Score and
   Level of Function
      Response to therapy should show
       improvement in pain and function and mood
Universal Precautions: In
Pain Medicine
Gourlay, Heit, Pain Medicine Vol 6, No 2, 2005



8. Regularly Assess the 4 “A’s” of
       Pain Medicine
       Analgesia
           Ideally <5 on a 1-10 scale
       Activity
       Adverse Effects
       Aberrant Behavior
           Don’t ignore it!
Universal Precautions: In
Pain Medicine
Gourlay, Heit, Pain Medicine Vol 6, No 2, 2005



9. Periodically Review Pain Diagnosis
       and Co-morbid Conditions,
       Including Addictive Disorders

       Pseudotolerance, Urine drug screens,
        Attitude toward Recovery
Universal Precautions: In
Pain Medicine
Gourlay, Heit, Pain Medicine Vol 6, No 2, 2005



10. Documentation
      Legible
        Aberrant Drug Related Behaviors -
         Less Predictive of an Addiction

1. Aggressively complaining of the need for more drug
2. Drug hoarding during periods of reduced pain
3. Requesting specific drugs
4. Openly acquiring similar drugs from other medical
   sources if primary provider is absent or under-treated
5. Unsanctioned dose escalation or other non-
   compliance on one or two occasions
     Aberrant Drug Related Behaviors -
        Predictive of an Addiction
1. Selling prescription drugs
2. Prescription forgery
3. Stealing or “borrowing” drugs
4. Obtaining prescription drugs form non-medical
   sources
5. Concurrent abuse of alcohol or illicit drugs
6. Multiple dose escalations or other non-
   compliance with therapy
  Aberrant Drug Related Behaviors -
     Predictive of an Addiction
1. Multiple episodes of prescription “loss”
2. Prescriptions from other clinicians/EDs
   without seeking primary prescriber
3. Deterioration in function that appears to be
   related to drug use
4. Resistance to change in therapy despite
   significant side effects from the drug
        Differential Diagnoses of
     Aberrant Drug Related Behaviors
1.   Addiction
2.   Pseudo-addiction
3.   Other psychiatric disorder
4.   Encephalopathy
5.   Family disturbance
6.   Criminal intent
7.   Exacerbation of pain syndrome
8.   Side effect (s) of opioid
Differential Diagnosis of Functional Downturn

    Syndrome of opioid abuse/dependence
    Other substance use disorder
    Other psychiatric disorder
    Exacerbation of pain syndrome
    Other medical problem
    Side effect of opioid
Buprenorphine: Dosage Forms
    Buprenex: Buprenorphine IM formulation *

    Suboxone 8/2 mg, 2/0.5mg **
       Buprenorphine/Naloxone sublingual tablet


    Subutex 2mg, 8mg**
       Buprenorphine sublingual tablet


    Transdermal Buprenorphine Not FDA approved in the
     US


    Implant    Investigational


 *Intramuscular form FDA approved for pain
 **Sublingual form FDA approved for addiction
Buprenorphine Maintenance/Withdrawal:
Retention


                                  20
    Remaining in treatment (nr)




                                  15


                                  10


                                  5                                Control
                                                                   Buprenorphine

                                  0
                                       0   50   100   150   200   250       300   350
                                                Treatment duration (days)     (Kakko et al., 2003)
Buprenorphine: Considerations
for Pain Management
Rolley E Johnson et al. Journal of Pain and Symptom Management, Vol
29, No 3, March 2005, pp297-326
Buprenorphine 2001-7

    4.1 million prescriptions
    585,000 patients treated
    30% Detox
    70% Maintenance
    16,232 Physicians trained
    13,318 Waivered

                 J Renner Boston U Bup Summit
                             2-08
Emerging Issues
  ED visits 2003 (1) vs 2007 (Q1-3) 368
  Compared to methadone (6000) and
   oxycodone (9000)
  Toxic exposures higher in children BUP 2% vs
   methadone, oxycodone or heroin 0.5%
  27% of all reported toxic exposures to BUP
   were under the age of 6 vs methadone 7% and
   oxycodone 8%
  Six deaths in 2006-7 all with EtOH or sed
   hypnotics

                  E McKanz Katz UCSF Bup
                       Summit 2-08
Baltimore Sun Articles

  1-17-08 …October, its consultants found
   that half the doctors they surveyed were
   aware of an illegal trade in
   Buprenorphine and their numbers have
   been climbing”
  1-25-08 “..addicts using the drug on the
   street mostly say they do so to avoid
   withdrawal, not to get high.”
RADARS

 Governmental non-profit operation
 Rocky Mountain Poison and Drug Center
 Reckitt Benckiser did support the
  Pediatric data analysis in an educational
  grant
 11 of 60 US Centers (18%) 2003 Q1
 43 of 60 US Centers (72%) 2007 Q2
              Dasgupta RADARS BUP Summit
                          2-08
RADARS BUP ABUSE

 125 cases were reviewed for abuse per
  methodology
 Mean age 27
 Male 65%
 7% chronic buprenorphine abuse
 34% ingestion, 28% parenteral, 18%
  inhalation
             Dasgupta RADARS BUP Summit
                         2-08
RADARS Mortality Data

  “associated medical outcome”
  2003 to 2007Q3 data set
  Not causally linked to death
  5 deaths related to BUP with intentional
   use/abuse No PEDS Deaths
  Methadone has 126 deaths in the same
   time frame
  3/5, 60% were intentional self harm
2009

  Over one million patients treated
  October 2009 exclusivity expires and
   generic brands will appear
  Some concerns about mono formulation
  No deaths solely from buprenorphine
   overdose
  Leading causes of death MVA, homicide
   and suicide if mono exposure
RADARS Peds Data 2003-6
                      Hydrocodone
            BUP                   Fentanyl Oxycodone
            N=176     N=6003 N=123         N=2036
 Age        2.1 (0.9) 2.3 (1.2) 2.0 (1.2) 2.1 (1.1)
 (SD)
 Male       99       3232       64         1081
 (%)        (56.3)   (53.9)     (52.5)     (53.5)
 Site       169 (96) 5581       111        1821
 Home %              (93)       (90.2)     (89.4)
 Ingest %   174      5993       77         2020
            (99.4)   (99.8)     (62.6)     (99.1)
Parental Morphine
Equivalency

    Morphine        10mg
    Buprenorphine   0.3mg
    Methadone       10mg
    Oxycodone       10-15mg
    Pentazocine     30mg
    Codiene         120mg
 Open label study 95 consecutive patients on long term
  opioid therapy (LTOA) failing treatment based on:
    Increased pain
    Decreased Functional Capacity
    Emergence of opioid addiction (8%)
 Induced on buprenorphine 4-16mg (8mg mean dose)
 86% Experienced moderate to substantial pain relief
    Mood and function improved
 8% Discontinued due to side effects or increased pain
Buprenorphine: Pain Dosage
OFF LABEL
  Opioid Naïve
    1-2 mg BID- QID (3-6mg/day)
  Opioid Tolerant
    4mg TID-QID (12-16mg/day)
    24mg/day upper limits
    32mg/day maximum dose
  Cost
    Suboxone 8mg      $5.97 Costco $3.15
     FSS
    Suboxone 2 mg
Ceiling effect on
respiratory depression
                 17

                 16
                                          Human respiratory rate
                 15
Breaths/Minute




                 14

                 13

                 12

                 11

                 10
                      0    1    2          4            8    16        32
                      PL       Buprenorphine (mg, sl)

                                                    Adapted from Walsh et al., 1994
Buprenorphine-
Benzodiazepine Relative
Contraindication
 CNS depressants and sedatives (eg,
  benzodiazepines):
   All opioids have additive sedative effects when
    used in combination with other sedatives
      Increased potential for respiratory depression,
        heavy sedation, coma, and death (France, IV
        aprazolam and buprenorphine)

 Despite favorable safety, use caution with
  concomitant psychotropics (eg,
  benzodiazepines)
   Plateau effect on respiratory depression lost
    with pre-administered benzodiazepine
   Also looked at methadone which potentates
    respiratory depression
   Buprenorphine not worse than methadone

Drug and Alcohol Dependence 79 (2005) 95-101
Disadvantages:
Buprenorphine for Pain
 Disadvantages of
 buprenorphine over pure mu
 agonists:
      Binds so well to mu
       receptor that other opioids
       have little effect
      No prn sort acting opioids
       for breakthrough pain
      Ceiling on effectiveness
          24 mg “yellow light
          32mg “red light
             Ed Johnson Phd, Personal
                         Communication

      Surgery, Trauma?
       FENTANYL?
Buprenorphine- The DEA
    7/8/2005
  Both DEA number and unique identification
   number on ADDICTION Rx
  Records of Rx written for maintenance or
   detoxification
    Inventory, receipt, loss, theft, destruction,
     dispensing of controlled substances for 2 years
    Separate record of buprenorphine addiction
     treatment patients
  Securely locked, substantially constructed
   cabinet
  Refills are legal
     Number of Waivered Physicians
     Estimated Number Prescribing
                                                                                                  67% Prescribing*
           Number of Physicians who Have
            Received Waivers (in Thousands)


                                              5.0
                                                                                                  (Waivered Physician Survey)
                                              4.5
                                              4.0
                                              3.5
                                                                     52% Prescribing
                                              3.0                  (Addiction Physician Survey)
                                              2.5
                                              2.0   BUP Approved
                                                      Oct. 2002
                                              1.5
                                              1.0
                                              0.5
                                              0.0
                                                    Q3     Q4   Q1     Q2       Q3      Q4          Q1      Q2      Q3      Q4    Q1
                                                    2002             2003                                  2004                  2005
* An estimated 2,353 physicians were providing treatment under the Waiver Program in early 2005

SAMHSA/CSAT Evaluation of the Waiver Program, CPDD June 05
     Practice Setting of
     Waivered Physicians
                             1800                                                       Not Prescribing
      Number of Physicians




                             1600
                             1400                                                       Prescribing
                             1200
                             1000
                              800
                              600
                              400
                              200
                                0
                                     2003

                                            2005



                                                     2003

                                                            2005



                                                                     2003

                                                                            2005



                                                                                         2003

                                                                                                2005



                                                                                                          2003

                                                                                                                 2005
                                                   Individual       Specialty             OTP
                                    Hospital                                                             Medical
                                                    Practice       SA Tx Clinic                          Group
40% and 43% of the sample work
in more than one practice setting                           Practice Setting
in 2003 and 2005 respectively
                                                                                   2003 data are from the Addiction Physician
                                                                                    Survey, 2005 data are from the Waivered
SAMHSA/CSAT Evaluation of the Waiver Program, CPDD June 05                                     Physician Survey
     Cumulative Estimate of Number
     of Patients Inducted
                                  120,000
                                            Treatment Provided by Physicians        104,640
                                            Providing Detox No Maintenance
                                  100,000
             Number of Patients




                                   80,000                                               32%
                                                   63,204
                                   60,000                                               34%
                                                      38%
                                   40,000

                                   20,000

                                       0
                                                Sept - Dec 2003                Jan - March 2005
      Mean # of Patients/Physician   57                                                     46
      SD                              6                                                     147
      Range                        1-800                                                    1-1011
                                                                          2003 data are from the Addiction Physician
                                                                          Survey, 2005 data are from the Waivered
SAMHSA/CSAT Evaluation of the Waiver Program, CPDD June 05                Physician Survey
     Patients Inducted by Setting
     & Treatment Offered
                                       40,000

                                                                               3,791                                        Detox Only
                                       35,000
                                                                                                                            Other
          Number of Patients Treated




                                       30,000

                                       25,000
                                                                      4,485
                                       20,000                                                       10,862
                                                         13,542
                                                 8,896                        34,078
                                       15,000

                                       10,000                        19,322
                                                                                                    14,651      5,243
                                                12,360 12,209                                                           3,462         2,867
                                        5,000                                                                                                 2,114
                                                                                            5,538
                                                                                                               5,097 3,640           3,847 3,940
                                           0                                               1,509

                                                2003     2005        2003     2005         2003     2005        2003    2005          2003    2005

                                           Hospital               Individual            Substance                                    Other
                                                                                                              OTP
                                                                   Practice            Abuse Clinic                                 Setting
                                                                                 Setting              2003 data are from the Addiction Physician
                                                                                                      Survey, 2005 data are from the Waivered
SAMHSA/CSAT Evaluation of the Waiver Program, CPDD June 05                                            Physician Survey
2004 DAWN REPORT

 2004 the Drug Abuse Warning Network data
  estimated
  495,732 emergency department visits for
  nonmedical use of prescription medications, of
  which 236 (0.05%) were reports of nonmedical
  use of buprenorphine and or the
  buprenorphine/naloxone combination.
 During this same time, there were no reports of
  buprenorphine associated with suicide
  attempts.
DIVERSION ISSUES OF
BUPRENORPHINE
  T Cicero, JAMA, 2006, provided information
   demonstrating low levels of buprenorphine diversion.
  Finland report of the street value of
   buprenorphine/naloxone, compared to buprenorphine
   mono in Finland, once buprenorphine/naloxone was
   introduced due to buprenorphine mono formulation
   abuse.
  80% of Finnish IV users said that the IV
   buprenorphine/naloxone experience was "bad". The
   street value of buprenorphine/naloxone was less than
   50% of buprenorphine mono formulation.
DEA Response Aug 2 2009

  All DEA waivered OBOT physicians will
   be visited at least once every five years
  DEA is considering requiring 3 hours of
   training per 3 year cycle for DEA renewal
  NASPER program will go live for all 50
   states in 2010
  Sub lingual buprenorphine for pain may
   require the waiver from the DEA
Some Resources
 www.painedu.com
   PainEdu Manual
   Opioid Risk Management Supplement
 www.pain.com
   Links to many pain sites
 www.legalsideofpain.com
   Current status of laws regarding opioid Rx
 www.partnersagainstpain
   Purdue site with access to patient
    management forms

								
To top