Opioid detoxification slow. Charles Brooker Pain Medicine, Royal North Shore Hospital Sydney

Transcription

1 Opioid detoxification slow Charles Brooker Pain Medicine, Royal North Shore Hospital Sydney

2 Summary I will ask several questions : Do we agree opioid reduction is a good thing? Are pain management programs are a good thing? Do you need opioid reduction in your pain management program? Do you need a pain program to achieve opioid reduction? What is the retention/abstinence rate? Can we predict which patients will not benefit from this approach? I will also discuss Techniques used during reduction More long term results from our pain management program Advantages / disadvantages of this approach Conclusions

3 Opioid reduction - a good thing? Several publications have noted the reduction in pain associated with cessation of opioids in various different situations. Townsend CO, Kerkvliet JL, Bruce BK, Rome JD, Hooten MW,Luedtke CA,Hodgson JE A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission Pain 140 (2008) Baron, MJ. McDonald, PW.Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. Journal of Opioid Management. 2(5):277-82, 2006 Sep-Oct. Lee Beeston Long-Term Follow-Up Of Patients Treated In A Cognitive Behavioural Pain Management Program,Adapt - MScMed Thesis University of Sydney Miller NS. Swiney T. Barkin RL.Effects of opioid prescription medication dependence and detoxification on pain perceptions and self-reports. American Journal of Therapeutics. 13(5):436-44, 2006 Sep-Oct. Williams, A C, Richardson, P H Nicholas, M K Pither, C E et al. Inpatient vs outpatient management : results of a randomised controlled trial. Pain. 66 : 13-22, 1996.

4 ADAPT programme Opioid use? Pre program Post program Yes (>6x in month) 67% 7% None 31% 91%

5 ADAPT programme - Pain Severity (0-6) (median, 25-75th percentile) Pre Post 4.3 ( ) 4.0 ( )

6 Adapt medication use (By number of classes) PRE POST 0 13% 82% 1 23% 9% 2 27% 4% 3 22% 4% 4 12% 0%

7 Adapt programme - Disability (R&M: 0-24; median, th percentile) Pre Post 15 (11-18) 8 (4-11) Note: Change of 3 or more = clinically significant

8 Adapt programme - Depression severity (BDI, 0-63: median, 25-75th percentile) Pre Post 21 (15-27) 10 (5-17) Note: In chronic pain population : <13 = Not depressed > 21= Clinically depressed

9 Do you need opioid reduction to achieve improvements in pain program?

10 if you are still taking opioids at the end of the programme you will be caned or hung Hmm Stimulation or traction sounds good to me The ADAPT program (Singapore version)

11 Do you need opioid reduction to achieve improvements in pain program? MacLaren JE, Gross RT, Sperry JA, Boggess JT. Impact of opioid use on outcomes of functional restoration. Clin J Pain 2006;22: No requirement to reduce opioids 48% were on opioids mean morphine equivalent 29mg (SD +/-28mg) 8% ceased anyway during program Pain decreased to similar degree in opioid / non opioid group Other functional outcomes were the same

12 Why do we reduce opioids then? Still a belief that it s a good thing to do No clear increase in pain when patients come off opioids Avoid side effects / diversion Anaesthetic experience strongly suggests acute pain episodes would become easier to treat ( bearing in mind incidence of surgery / acute degenerative episodes and flare ups in these patients) Opportunity to challenge cognitions about needing drugs for pain

13 Do you need a pain management program to achieve opioid reduction? Probably. (what do I do about the pain doctor?) Most patients that we see need multiple medications, passive treaments and maladaptive beliefs and behaviors sorting out anyway at some stage. Practical to co-ordinate the approaches

14 Other questions What dose can we reduce from? Who will do well? What is the long term abstinence rate?

15 St Thomas s study Admission dose mean 36 mg Discharge dose mean 17 mg 100% on opioids at beginning 33% on opioids at discharge 36% on opioids 1 month later 45% on opioids at 6 months ( mean dose 19mg) Ralphs JA. Williams AC. Richardson PH. Pither CE. Nicholas MK. Opiate reduction in chronic pain patients: a comparison of patient-controlled reduction and staff controlled cocktail methods.pain. 56(3):279-88, 1994 Mar.

16 Mayo clinic study 373 patients of whom. 218 taking opioids morphine equivalent mean -99mg/day (SD 142 Range1-1013mg) 195 of these opioid taking patients completed - mean dose 87 mg 14 patients still taking opioids at end of 3 weeks 132 were analysed at 6 months 30 of these were on opioids at 6 months mean dose - 67mg (137 SD) Townsend CO, Kerkvliet JL, Bruce BK, Rome JD, Hooten MW,Luedtke CA,Hodgson JE A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission Pain 140 (2008)

17 Adapt programme - opioids Pre program Post program F/U -3 years On opioids (>6x in month) 67% 7% 39% No opioids 31% 91% 58%

18 Can we predict which patients will not benefit from this approach? 24 year old lady Pars defect at L5 post MVA with back pain] On short acting morphine 400 mg per day (MS contin doesn t work) Has just been taken off morphine in hospital with valium and clonidine (IE through most severe withdrawals but only just) First week of comprehensive multidisciplinary pain management program Video of standard walk

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20 Mayo clinic study -Townsend et al 33 patients out of total 373 didn t complete the program 218 patients were on opioids 23 of 33 non completers were on opioids and 8 were 2 standard deviations above the mean for the whole group IE around 400 mg or more per day Morphine dose of this group was a mean of 197mg (SD176) Proportion of non completers statistically the same in non opioid group ( IE other issues were also important)

21 Mayo clinic study -Townsend et al Dose of opioids did not predict improvement of pain or function provided program completed But High dose opioids were associated with program non completion in opioid taking group??? High opioid use a marker of distress /unrealistic expectations rather than a problem in itself

22 How? Fordyce in Seattle Famous case report - 6 weeks reduction Cocktail St Thomas 4 week program Cocktail method for heavier users/more drugs Simple reduction for others Both methods work

23 Adapt program medication reduction ASSESSMENT Rationalise, reduce and trial medications Treating doctor involved Follow up appointment PMRC Contact with co-ordinators prior to ADAPT

24 Adapt medication reduction Achieve maximum limits before entering the programme Morphine oral equivalent 60mg /day Time contingent v prn Maintain current doses while settling in to programme Gradual reduction over first 2 weeks Reduce strongest to weakest if > 1 analgesic Patient s usual time schedule Complete reduction on different days Outline withdrawal effects Reduce, cease reliance on medications, aids, herbals, caffeine nicotine, alcohol, recreational drugs

25 What were the long term results of ADAPT program apart from the opioids?

26 Adapt programme - pain severity (0-6) (median, 25-75th percentile) Pre Post Fu at 3-5 years 4.3 ( ) 4.0 ( ) 3.7 ( )

27 MEDICATION USE (By number of classes) PRE POST F/U 0 13% 82% 35% 1 23% 9% 25% 2 27% 4% 19% 3 22% 4% 14% 4 12% 0% 5%

28 Adapt programme - disability (R&M: 0-24; median, th percentile) Pre Post FU at 3-5 yrs 15 (11-18) 8 (4-11) 7.5 (2-14) Note: Change of 3 or more = clinically significant

29 Adapt programme - depression (BDI, 0-63: median, 25-75th percentile) Pre Post Fu at 3-5 yrs 21 (15-27) 10 (5-17) 12 (6-19) Note: In chronic pain population : <13 = Not depressed > 21= Clinically depressed

30 WORK STATUS PRE F/U F/T 6.5% 20.3% P/T 13.8% 17.1% Vol. 0.8% 4.9% Training 5.7% 8.9% Home/retired 7.0% 15.1% Unemployed 61.8% 29.3% (due to pain) Note: total work 33 (28.9%) 63 (55.2%)

31 What are the advantages of a slow reduction of opioids? Cheap (on its own) Less severe withdrawal effects gaining of confidence in own ability / self efficacy from not needing another drug / inpatient help etc Allows increasing function at the same time as reduction during a program Observing time course of pain - Allows flair ups to come and go despite stable dosing

32 Disadvantages? Withdrawal may interfere with program, may increase chance of failing program with opportunity costs, loss of face in group etc,? Successful compared with intensive methods Not good for high doses/ out of control patients

33 Conclusions Opioid reduction/cessation is usually part of a comprehensive pain management approach and can be done slowly as an outpatient. It is unclear whether reduction can be achieved outside a program with the same success rate Patients on higher doses are more likely to fail the program approach and the solution for this maybe to wean pre program or go for more intensive approach in combination or accept they going to stay on opioids for now and engage in more longer term plan

34 How did our morphine free patient turn out?

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36 10 years later? Post program video shows huge change physically Stayed off opioids Husbandoplasty 2 Kids FTW for centrelink After 7 years MVA with neck injury and WC claim Still works full time, uses strategies from program but..makes do with 20 mg diazepam at night!