Pain Management in Patients with Opioid Use Disorders

Transcription

1 4:30 p.m. - 5:15 p.m. Pain Management in Patients with Opioid Use Disorders Aleksandra Zgierska, MD, PhD Assistant Professor, University of Wisconsin-Madison Department of Family Medicine and Community Health Center for Addictive Disorders

2 Pain Management in Patients with Opioid Use Disorders Aleksandra Zgierska, MD PhD UW-Madison School of Medicine & Public Health Department of Family Medicine, Center for Addictive Disorders, Program for Pain and Opioid Education, Therapy and Studies ICOO 2015 Jun 8, 2015, Boston, MA Disclosure: I have no conflict of interest Objectives Opioid use disorders (OUDs) Medication-assisted treatments (MATs) for opioid addiction Treating pain in patients with OUDs Legal aspects of addiction-related care Discussion Papaver somniferum Wikimedia Creative Commons 1

3 Opioid addiction & pain: main points Opioid addiction is a chronic disease that overlaps with pain conditions MATs: effective public health strategy for reducing harms of opioid addiction Pain should be treated in opioid-addicted patients; if long-term opioids are needed, the treatment and monitoring plan should be appropriately adjusted What is Opioid Addiction? Addiction: most severe disorder Addiction Abuse A Public Health Approach to Drug Control in Canada Health Officers Council of British Columbia, October

4 What is Addiction? Am Society Addiction Medicine 2011 Addiction = opioid dependence primary chronic brain disease affecting multiple brain circuits adverse effects on mental and physical health interactions with pain-related circuitry hallmark symptom: loss of control over drug use in spite of harm addicere [in Latin]: to give over, dedicate or surrender What is Addiction? Am Society Addiction Medicine 2011 unless treated, addiction is progressive, can lead to disability and premature death. Question 1 J.S. is a 45 yo man with CLBP, on OxyContin 40 mg BID. He lost tablets when travelling and is calling for an early refill. He reports sweats, diarrhea, anxiety. His record / history: negative for addictive behaviors. Based on this information, J.S. meets criteria for: A. Opioid addiction B. Physical dependence C. Pseudo-addiction D. Neither 3

5 Medication Assisted Treatments (MATs) for Opioid Addiction Wiki Commons, Papaver somniferum Addiction is treatable.if the patient receives treatment chronic disease model long-term (often lifetime) treatment more treatment = better outcomes multidisciplinary approach address comorbidities pain, mental health, sleep problems Saitz R et al. J Addict Med 2008; 2:55 65 Addiction is treatable: treatment outcomes at 6-12 months Opioid Addiction Alcoholism 50-80% abstinent 50-70% abstinent Diabetes Type % good control < 50 % are compliant with medications Hypertension, asthma 20-50% good control < 30 % are compliant with medications O Brien CP & McLellan AT, Lancet

6 MAT for Opioid Dependence Methadone (only licensed programs) full agonist of µ receptors 1-2 x/day PO; half-life: (mean 22) hours Buprenorphine (any certified physician) partial agonist of µ, antagonist of κ receptors 1 x/day SL; half-life: (mean 37) hours Naltrexone (any clinician) Antagonist of µ receptors 1 x/day PO; monthly IM MAT for Opioid Addiction improves individual and societal outcomes enables patients to re-integrate into the society and live productive normal lives Mattick RP, Cochrane 2009; Soyka M, World J Biol Psych 2011; Connock M, Health Technol Assess 2007; Syed YY, CNS Drugs 2013; Krupitsky E, Addiction 2013; Hartung DM, J Subst Abuse Treat 2014 MAT treates Opioid Addiction drug use deaths criminal activity risk / spread of HIV cost retention-in-treatment engagement in work / social roles pregnancy / child outcomes Mattick RP, Cochrane 2009; Soyka M, World J Biol Psych 2011; Connock M, Health Technol Assess 2007; Syed YY, CNS Drugs 2013; Krupitsky E, Addiction 2013; Hartung DM, J Subst Abuse Treat

7 Methadone maintenance Wiki Commons, SubDural12: Methadone spacefill Methadone maintenance licensed programs only Methadone compared to other opioids: long-acting fat-soluble variable metabolism rates ( fast metabolizers ) risk of respiratory depression risk when used with EtOH or benzodiazepines QTc prolongation concerns Buprenorphine maintenance Wiki Commons, Jynto: Buprenorphine molecule 6

8 Buprenorphine maintenance any certified physician Buprenorphine compared to other opioids: similar withdrawal agonist analgesic effects may have efficacy for neuropathic pain, constipation, hyperalgesia, hormonal problems less respiratory depression (ceiling effect) risk when used with EtOH or benzodiazepines Buprenorphine for pain can be prescribed by ANY provider as Butrans patches Wiki Commons, 9ballguy, Butrans10mcg Buprenorphine for addiction can be prescribed by certified physicians only (special X DEA is required) certification: 8-hr online course (CME credit) buprenorphine.samhsa. gov/training_main.html Wiki Commons, Jr de Barbosa, Suboxone SL Tabs 7

9 Buprenorphine for addiction usually once/day dosing can be flexible if the patient takes it at home primarily prescribed as a combo of buprenorphine and naloxone deterrent against IV abuse Suboxone = buprenorphine + naloxone Subutex = buprenorphine Buprenorphine for addiction Induction at the clinic: patient in moderate withdrawal high-affinity for μ receptor: precipitates withdrawal if other opioids are still on board supervised initiation, incremental dosing Avoid (when possible) temporary switching of bupe to a different opioid the patient will need to be re-induced again when re-starting bupe Naltrexone maintenance Wiki Commons, Benjahbmm27, Naltrexone 3D balls 8

10 Naltrexone Maintenance Blocks opioid receptors can t get high removes pleasure of using drugs No diversion, non-addictive no withdrawal FDA-approved for both opioid and alcohol addiction Naltrexone maintenance Difficult to initiate in out-patient settings requires several days off opioids discomfort of acute withdrawal relapse Patient concerns: Does it work? What if I need pain medications..? Question 2 B.C. is a 72 yo woman with chronic neck pain and a remote h/o opioid addiction, now in recovery. Existing treatments were not effective, and you ve decided to start a trial of long-term opioid therapy. What is the best opioid choice for her? A. Fentanyl B. Buprenorphine C. Methadone D. Either B or C 9

11 Treating Pain in Patients with Opioid Use Disorders Papaver somniferum Wikimedia Creative Commons Addiction Pain Interactions Treatment of pain is the basic human right including among those with opioid addiction Wiki Commons, Vincent van Gogh, Sorrowing Old Man Addiction Pain Interactions uncontrolled pain: worse outcomes in addiction risk factor for continued use and relapse clinical challenge: distinguishing addiction from undertreated pain Wiki Commons, Vincent van Gogh, Sorrowing Old Man 10

12 Opioids for acute pain evidence-based for severe acute pain not controversial unless the patient has a history of or a current addiction especially to opioids on the maintenance treatment acute severe pain should be treated regardless of addiction Opioids for acute pain in opioid addiction Expect needing higher opioid doses (due to tolerance) in those with active opioid addiction opioid maintenance therapy opioid-treated chronic pain Opioids for acute pain in opioid addiction Methadone maintenance patients: add additional opioids Naltrexone maintenance patients: non-opioid analgesics; tramadol can override the blockade using higherdoses of opioids monitored settings monitor vitals, especially respiratory status 11

13 Opioids for acute pain in opioid addiction Buprenorphine maintenance patients non-opioid analgesics; tramadol increase bupe dose continue bupe, add regular opioids higher doses of opioids are expected no need to stop bupe for small surgeries if stopped, it is hard to re-start it Opioid therapy for chronic pain Controversial for non-cancer pain lack of evidence on long-term efficacy dose-dependent adverse effects Chou R, AHRQ review of evidence, 2014 epidemic of prescription opioid abuse Opioid therapy for chronic pain in opioid addiction Initiate long-term opioids ONLY if the potential benefit outweighs the risk 12

14 Opioid therapy for chronic pain in opioid addiction Methadone maintenance patients once/day dosing (twice/day doses for fast metabolizers ) not adequate for pain control only methadone clinics can prescribe methadone for addiction Other opioids or extra methadone can be added to methadone prescribed for addiction Opioid therapy for chronic pain in opioid addiction Opioid-treated chronic pain patients with an active opioid addiction limited data suggest that rotating other opioids to methadone is superior to opioid discontinuation 1990 Kennedy JA, Crowley TJ, J Subst Abuse Treat, Tennant FS, Rawson RA, Arch Intern Med, 1982 Opioid therapy for chronic pain In opioid addiction Naltrexone maintenance patients stop naltrexone. IM naltrexone works for 1 month 13

15 Opioid therapy for chronic pain In opioid addiction Buprenorphine maintenance patients SL preparations are approved for addiction only can address pain with TID-QID dosing Malinoff HL, Am J Ther, 2005 patches are approved for pain only can address opioid addiction Opioid therapy for chronic pain in opioid addiction Opioid-treated chronic pain patients with an active opioid addiction limited data suggest that rotating other opioids to buprenorphine is superior to opioid discontinuation Blondell RD, J Addict Med, 2010 Chronic pain and addiction: special populations Pregnancy: avoid opioid withdrawal, as fetal abstinence syndrome can be fatal avoid partial agonists and antagonists bupe vs methadone: both can be used bupe may cause less neonatal withdrawal Minozzi S, Cochrane Database Sys Rev, 2013 Elderly: buprenorphine is the preferred opioid Consensus statement: Pergolozzi J, Pain Pract,

16 Opioid therapy for chronic pain in opioid addiction: practical considerations If long-term opioid therapy is needed: assess the risk (it s high!) and comorbidities to map out a comprehensive treatment plan strive to use one type of a long-acting opioid consider abuse-deterrent ones close monitoring detailed treatment agreement: discuss it up front frequent (random) urine drug testing, pill counts adherence to recommended other treatments Opioid therapy for chronic pain in opioid addiction: practical considerations Mental health / sleep co-morbidities limit # of sedating medications avoid benzos and z-drugs maximize SSRIs, pain modulating meds gabapentin often helpful monitor as it has some addictive potential fatigue, ADHD avoid stimulants consider atomoxetine Question 3 M.H. is a 36 yo woman with chronic pain, treated with Kadian 40 mg/day + morphine IR 15-30mg q4 hrs PRN. You discover she is actively abusing opioids, and recommend addiction treatment. She declines, noshows at the clinic, and gets Rx for opioids and benzos from the ED. Which approach would you choose? A. Switch to buprenorphine therapy B. Switch to methadone therapy C. Initiate slow opioid taper D. Discontinue opioids 15

17 Opioid discontinuation Primum non nocere if addiction, serious adverse effects, or diversion are suspected or documented, opioids may need to be discontinued Opioid discontinuation TAPER, if the patient contracts for safety develop a treatment plan taper ~25% a daily dose every 1-2 weeks close monitoring (short supply) STOP prescribing (abrupt cut-off) if it is not safe to gradually taper opioid withdrawal is unpleasant, but not fatal* * except in-utero, when it can be fatal Opioid withdrawal: treatment Clonidine (if BP / Pulse are OK) do not prescribe to unknown patients 0.1mg PO q 4-6 hours; tab, close F/U; if longer duration: consider taper Symptomatic care for anxiety, insomnia, aches, nausea, diarrhea, cramping, dehydration ibuprofen, tylenol, dicyclomine, loperamide, anti-emetics, heating pad gabapentin, trazodone, etc, but avoid benzos 16

18 Legal Aspects Relevant to the Treatment of Opioid Addiction Wiki Commons, Papaver somniferum Legal Aspects of Addiction Care It is illegal to treat opioid addiction or withdrawal with an opioid unless it s methadone in a licensed program or buprenorphine prescribed by a certified physician Legal Aspects of Addiction Care Patient can be discharged from practice - 30 day notice letter (need to provide care for 30 days) - have clear guidelines - have good documentation Engage Patient Resources opioid therapy termination discharge from practice 17

19 Conclusions Opioid addiction is a chronic disease that overlaps with pain conditions MATs: effective public health strategy for reducing harms of opioid addiction Pain should be treated in opioid-addicted patients; if long-term opioids are needed, the treatment and monitoring plan should be appropriately adjusted Additional resources screening tools exist to assess the risk of opioid therapy comprehensive resource: OpioidRisk site Additional resources Pain and addiction (ASAM) The Medication Guide for a Safe Recovery by PH Earley NIDA Fact Sheets on substance abuse, current concepts & emerging trends search for a desired topic 18

20 Thank you! 19