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4 Managing Chronic Pain in Patients with Opioid Use Disorders RPH Videoconference Series June 25, 2014 Christina M. Delos Reyes, MD Medical Consultant Center for Evidence-Based Practices at Case 4

5 Learning Objectives: At the conclusion of this presentation, the learner will be better able to: Review key concepts in the assessment, diagnosis and treatment of co-morbid chronic pain in patients with opioid use disorders List strategies for collaboration with other disciplines who are involved in the care of patients with co-morbid chronic pain and opioid use disorders 5

6 DEFINITIONS

7 Pain An unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain, 1986) Pain is subjective and may not always be corroborated by objective data

8 Non-verbal pain indicators NOTE: these may be diminished in chronic pain! Facial wrinkling, blinking eyes, grimacing Guarding an area of the body Crying, moaning Decrease in social interaction Change in routines Aggression Increase in body movements (squirming) Irritability, increased confusion 8

9 Acute vs. Chronic Pain Acute pain: lasting 30 days Subacute pain: lasting 30 days but 6 months Chronic pain: lasting 6 months Some define chronic pain, not in terms of time, but rather pain that extends beyond the expected period of healing 9

10 Hyperalgesia and OIH Hyperalgesia: An abnormally intense response to a normally noxious stimulus Opioid-induced hyperalgesia: Hyperalgesia that results from the effects of opioids on the central nervous system (CNS)

11 Tolerance TOLERANCE is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time. Tolerance to the desired effects of drugs and physical dependence are normal and predictable responses that often occur with long-term use of certain medications Tolerance is either: needing more of the drug to get the same effect OR having a diminished effect when using the same amount of the drug

12 Physical Dependence and Withdrawal PHYSICAL DEPENDENCE is a state of adaptation that is manifested by a drug-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist Drugs are taken in order to relieve or avoid withdrawal symptoms

13 Substance Use Disorder (SUD) (Substance-Related and Addictive Disorders) As of May 2013, consolidate substance abuse with substance dependence into a single disorder called substance use disorder Rationale: Dependence is a misunderstood term that has negative connotations when in fact it refers to normal patterns of withdrawal that can occur from the proper use of medications. Copyright American Psychiatric Association.

14 DSM-5 Substance Use Disorder: 11 Criteria Taking the substance in larger amounts or for longer than intended Persistent desire or unsuccessful efforts to cut down or control use Great deal of time spent getting, using, or recovering from use Craving, or a strong desire or urge to use Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home Continued use despite persistent social/interpersonal problems caused/exacerbated by use Giving up important social, occupational or recreational activities because of substance use Recurrent use in situations in which it is physically hazardous Use despite knowledge of physical or psychological problem caused or exacerbated by use **Tolerance **Withdrawal *This criterion is not considered to be met for those taking stimulant, opiate, or sedativehypnotic medication solely under appropriate medical supervision. 14

15 Substance Use Disorder (cont d) Rationale continued: Further, studies from clinical and general populations indicate DSM-IV substance abuse and dependence criteria represent a singular phenomenon but encompassing different levels of severity. Mild SUD (2-3/11 criteria) will be coded with the DSM-IV substance abuse code to reflect the intent but not reality of considering substance abuse less severe than substance dependence. Moderate (4-5/11 criteria) and severe (6+/11 criteria) SUD will be coded with DSM-IV substance dependence codes. Copyright American Psychiatric Association.

16 Pain related to addiction Patients with addiction tend to be more sensitive to pain in general, and to the pain of withdrawal Post-acute withdrawal may last for weeks/months after patient stops using Psychoeducation, self-help groups, anticraving meds may help patients handle cravings 16

17 Pseudoaddiction A controversial term coined to describe aberrant drug-related behaviors (e.g., clock watching, drug seeking), that resemble those of patients with addiction but that actually result from inadequate treatment of pain (Weissman & Haddox, 1989). It may be extremely difficult to distinguish pseudoaddiction from true addiction 17

18 ASSESSMENT

19 Substance Use & Chronic Pain Adapted from TIP 54, SAMHSA, 2011 Category People > 20 who report pain > 3 months Statistic 56% (National Center for Health Statistics, 2006) People > 65 who report pain > 12 months 57% (National Center for Health Statistics, 2006) People experiencing disabling pain, in past year 36% (Portenoy, Ugarte, Fuller, & Haas, 2004)

20 Substance Use & Chronic Pain Adapted from TIP 54, SAMHSA, 2011 Category People > 12 who report initiating illegal drug use with pain relievers Statistic 19% (SAMHSA, 2008) People with opioid addiction who report chronic pain 29 60% (Peles, Schreiber, Gordon, & Adelson, 2005; Potter, Shiffman, & Weiss, 2008; Rosenblum et al., 2003; Sheu et al., 2008) Chronic pain patients who may have addictive disorders 32% (Chelminski et al., 2005)

21 BOTH Pain and Addiction: Are neurobiological conditions with evidence of disordered CNS function Are mediated by genetics and environment May have significant behavioral components May have serious harmful consequences if untreated Often require multifaceted treatment Have similar physical, social, emotional, and economic effects on health and well-being Effective chronic pain management in patients with or in recovery from SUDs must address both conditions simultaneously

22 Elements of a Comprehensive Assessment Pain and coping Collateral information Function Contingencies Substance Use and Risk for Addiction Co-occurring Mental/Other Disorders Physical Exam Mental Status Exam

23 DIAGNOSIS & TREATMENT

24 Acute vs. Chronic Pain Acute pain arises suddenly in response to a specific injury and is short-lived It is very rare to cause a new addiction to opiates by treating acute pain on an inpatient unit In a patient with addiction or dual disorders, treat acute physical pain in the same way as you would treat it in any other patient 24

25 Intervention Strategies Clarify patient vs. staff goals Empathy Psychoeducation Communication and feedback Menu of choices 25

26 Patient vs. staff goals Patient goals may include: Relief of physical pain Wanting emotional support Staff goals may include: Not wanting to cause addiction Not wanting to give in to drugseeking behavior 26

27 Empathy A little goes a long way Lack of empathy may actually escalate drug seeking behaviors Empathic approach may decrease the need for extra medications 27

28 Acknowledge Emotional Pain Encourage patient to describe feelings Give verbal and non-verbal support Acknowledge that physical symptoms may be a part of emotional pain What has helped in the past? What can staff do now/today to help? 28

29 Psychoeducation Recovery involves making positive decisions in addressing all 5 areas Interrelationship of the PMESS spheres Physical Mental Emotional Social Spiritual 29

30 Communication and Feedback Make sure the patient knows that her concerns are taken seriously Clarify the degree and location of the patient s pain, using one of the singleitem assessment tools Follow-up and follow through with planned interventions 30

31 Menu of Choices Types of interventions Non-medication approaches Non-addictive medications Potentially addictive medications 31

32 Non-medication Approaches Distraction Meditation Deep breathing, Relaxation Rest, elevation Heat, cold Physical therapy and massage Exercise 32

33 Non-opioid Analgesics: Non-addictive Tylenol Non-Steroidal Anti-Inflammatory Drugs NSAIDs (ibuprofen, naproxen, etc.) SNRIs (venlafaxine, duloxetine) TCAs at low doses Anticonvulsants (i.e. gabapentin) 33

34 Non-opioid Analgesics: Addictive Muscle relaxants Carisoprodol is addictive, others have significant abuse potential Benzodiazepines consensus panel concludes they have no role in the treatment of CNCP in patients with comorbid SUD, beyond very shortterm, closely supervised treatment of acute anxiety states 34

35 Non-opioid Analgesics: Addictive Consensus panel does not recommend smoked marijuana for treating CNCP as inhaled smoke is an unacceptable delivery mode for medication Cannabinoids as medications Dronabinol or Marinol (THC) US: chemotherapy-induced nausea and AIDS-induced anorexia Nabilone or Cesamet (synthetic THC) US: chemotherapy-induced nausea and AIDS-induced anorexia weaker than codeine in a controlled study of neuropathic pain (Frank, Serpell, Hughes, Matthews, & Kapur, 2008) Sativex (THC and cannabidiol mix) Canada: pain of multiple sclerosis 35

36 Algorithm for Managing Chronic Pain in Patients with Substance Use Disorders (TIP 54)

37 BEFORE Starting Opioids

38 10 Universal Precautions 1. Make a diagnosis with appropriate differential 2. Perform a psychological assessment, including risk of addictive disorders 3. Obtain informed consent 4. Use a treatment agreement 5. Conduct assessments of pain level and function before and after the intervention

39 10 Universal Precautions 6. Begin an appropriate trial of opioid therapy with or without adjunctive medications and therapies 7. Reassess pain score and level of function 8. Regularly assess the 4As of pain medication 9. Periodically review pain diagnosis and cooccurring conditions, including addictive disorders 10. Document initial evaluation and followup visits (Adapted from Gourlay et al., 2005)

40 Before Starting Opioids:

41 Evaluate Risk of Developing Problematic Opioid Use (TIP 54) Low Risk No hx of substance use disorder Minimal risk factors Medium Risk Hx of non-opioid substance use disorder Fam Hx of addiction Personal Hx or Fam Hx of mental illness Nonadherence to scheduled medication Poorly characterized pain Hx of injection-related diseases Multiple unexplained medical events (trauma, burns, etc0 High Risk Active substance use disorder Hx of prescription opioid abuse A medium risk patient exhibiting aberrant behaviors

42 Evaluating Risk: Tools SOAPP-R Screener and Opioid Assessment for Patients with Pain-Revised Score of 18 or higher suggests high risk ORT Opioid Risk Tool Score of 8 or higher suggests high risk

43 AFTER Starting Opioids

44 Opioid Response: 4 A s Monitor and document opioid response using the 4As (Passik et al, 2004): Analgesia Activities of daily living (ADLs) Adverse events ADRBs

45 Aberrant Drug-Related Behaviors (ADRBs) Failure to adhere to treatment agreement Behaviors that suggest substance misuse, abuse, or addiction Tools ABC: Addiction Behaviors Checklist 3+ yes responses should trigger more careful monitoring or intervention COMM: Current Opioid Misuse Measure Authors recommend a conservative cutoff score of 9, which yields some false-positive results, but misses fewer patients who may be misusing medications

46 Landing the Plane

47 Why Discontinue Opioids? Pain has resolved Opioids are no longer effective. Opioids no longer stabilize the patient or improve function The patient loses control over the medication The patient is diverting the medication The patient is using alcohol, benzodiazepines, or illicit drugs Adverse effects are unmanageable

48 Discontinuing Opioids Stopping opioids does not mean stopping treatment! When harms outweigh the benefits, D/C opioid therapy Offer to provide non-opioid therapies & treatment When discharging a patient from a practice Inform the patient in writing Avoid abandonment charges: give contact info for other clinicians, a written tapering schedule and Rx for the medications that require a taper If clinician patient relationship is hostile or dangerous, a letter alone can suffice

49 CASE DISCUSSION

50 Resources SAMHSA. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, PCSS-O Providers' Clinical Support System for Opioid Therapies PCSS-MAT Providers Clinical Support System for Medication Assisted Treatment NIDAMED website

51 51 Christina M. Delos Reyes, MD Medical Consultant Center for Evidence-Based Practices Case Western Reserve University Euclid Avenue Cleveland, Ohio