How to Successfully Complete a Narcotic Tapering with Functional Restoration

How to Successfully Complete a Narcotic Tapering with Functional Restoration Fernando Branco M.D. F.A.A.P.M.R. Medical Director Rosomoff Comprehensive Rehabilitation Center and Brucker Biofeedback Center Miami Jewish Health Systems Disclaimer: I have no financial relationship in regard to the content of this presentation

Disclaimer I am the Medical Director of the Rosomoff Comprehensive Rehabilitation Center at MJHS This Presentations does not contain off-label and/or investigational use of drugs or products

Conundrums of Chronic Pain Care: Avoid Overuse of Narcotics Functional Restoration Return to Work Treat Psychological and Physical Problems Avoid Overuse of Interventional Treatments More Deaths from prescription drugs than illicit drugs, Fort Lauderdale had more Pain Clinics than McDonald s

P A I N Can t see it Can t measure it Can t diagnose it on x-ray or MRI 75% of general population will have abnormal MRIs bulging or herniated discs or narrowing..and NO PAIN.

Pain Cycles

Drug Addict? Drug Abuse? Excessive use of a drug for purposes for which it is not medically intended.

The Risk of Addiction Published rates of abuse and/or addiction in chronic pain populations are 3-19% Known risk factors for addiction to any substance are good predictors for opioid abuse 1. Past cocaine use, h/o of alcohol or cannabis use 2. Lifetime history of substance use disorder 3. Family history of substance abuse, history of legal problems and drug and alcohol abuse 4. Tobacco dependence 5. History of severe depression and anxiety Ives et al 2006 Reid et al 2002 Michna et al 2004 Akbik et al 2006

Addiction is A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations A clinical syndrome: Loss of control Compulsive use Continued use despite harm Craving Savage SR et al JPain Symptom Manage 2003

Pseudoaddiction Opiophobia Overestimate potency and duration of action Fear of being scammed Fear of addiction potential Morgan J 1985 Smith 1989

Yellow Flags Complaints of more medications needed Drug hoarding Requesting specific pain medications Openly acquiring similar medications from other providers Occasional unsanctioned dose escalation Nonadherence to other recommendations for pain therapy Passik SD Mayo Clinic Proc 2009

Red Flags Deterioration in functioning at work and socially Illegal activities selling, forging, buying from nonmedical sources Injecting and snorting medication Multiple episodes of lost or stolen scripts Resistance to change therapy despite adverse effects Refusal to comply with random drug screens Concurrent abuse of alcohol or illicit drugs Use of multiple physicians and pharmacies Passik SD Mayo Clinic Proc 2009

Narcotic Cycle Patients need higher doses to achieve results = TOLERANCE Eventually lack of pain relief may lead to steady increases in amount and types of pain medication Long term use of narcotics leads to OPIOD INDUCED ABNORMAL PAIN SENSITIVITY

Narcotics Eliminate production of your own body s ENDORPHINS Shut the endorphin system down Lead to HYPERalgesia and HYPERsensitivity to pain

Journal of Opioid Management Significant pain reduction in chronic pain patients after detoxification from high-dose opioids Sept/Oct 2006 21 of the 23 patients showed marked decrease in pain following tapering from narcotics!!

Publications Opioid-induced hyperalgesia: pathophysiology & clinical implications: Journal of Opioid Management 2008 Opioid induced abnormal pain sensitivity Current Pain Headache Report 2006 Adverse effects of chronic opioid therapy for chronic musculoskeletal pain National Rev of Rheumatology 2010 Hyperalgesia in opioid-managed chronic pain and opioid-dependent patients Journal of Pain 2009

SERIOUS SIDE EFFECTS Narcotics slow down the action of the bowel / intestines resulting in severe constipation almost always requiring another medication to help relieve this symptom Urinary retention inability to empty bladder most often in males Hypogonadism decreased sex drive, erectile dysfunction often requires need for additional meds Testosterone therapy

What is the Solution?

MYOFASCIAL SYNDROME Sciatica Neuropathy Sinus problems / dental pain Carpal Tunnel Migraine Leads to misdiagnosis & incorrect tx J. Travell, 1976

Goals of Treatment Improve quality of life Restore optimum levels of function Reduce or eliminate pain Reduce or eliminate addictive pain medications Enable become independent of the healthcare system (related to pain)

EFFECTIVE TREATMENT Return to the basics: Physical and Psychological Rehabilitation Physical Medicine True Multidisciplinary Approach What is the definition of insanity? "The definition of insanity is doing the same thing over and over and expecting a different result. Benjamin Franklin, Albert Einstein, Chinese Anonymous

Outpatient Weaning Setting s Office Outpatient drug detox program Outpatient Comprehensive Pain Management Program (community weaning) Patient Characteristics On lower opioid dose, simpler medication plan (1-2 meds), more gradual wean Motivated Low to medium psychosocial issues Community social support for plan Weaning Process Speed of weaning: dose decrease by 20-25% every 10-14 days Monitoring: Urinary drug screen, pain behaviors, drug use and seeking, functional status Support: Meds for withdrawal (temporary), physical rehabilitation (functional approach), follow-up every 1-2 weeks, but available by phone daily, proactive check-in; cognitive behavioral approach Case Management Red flags: Increased pain complaints: Can t bear it, Carrier did not approve X, Equipment did not arrive, pharmacy issues, worrisome symptoms. Actions: contact injured worker in person if possible, review treatment recommendations and symptoms management, contact treating team, return to provider if not able to assure compliance, do not approve increase in meds or new diagnostic evaluations or treatment changes unless recommended by current treatment team; disallow return to prior prescribers.

Inpatient Weaning Setting s Residential drug detox program Weaning as part of Comprehensive Pain Management Program* Rapid detox (addressed later) Patient Characteristics On high doses of opioids and/or complex drug regimens or needs more rapid detox Not motivated or resistant to weaning Medium to high psychosocial issues; history of psychiatric diagnosis, prior failed detox Poor community social support for plan Weaning Process Speed of weaning: dose decrease by 20-25% every 3 days Monitoring: Urinary drug screen, pain behaviors, drug use and seeking, functional status Support: Meds for withdrawal (temporary), physical rehabilitation (functional approach), follow-up every day, available by phone daily, proactive check-in, onsite problem resolution; aggressive physical rehabilitation to separate physical from drug issues; multiple modalities to treat withdrawal Case Management Red flags: Increased pain complaints, limited participation, desire to quit program, family support not adequate or detrimental, core beliefs unchanged, anger at carrier, multiple addiction issues. Post-discharge issues. Actions: Family engagement, clear-cut discharge pre-planning regarding pharmacy limitation, approved physicians, day-to-day problem resolution using providers from pain program. Urine drug screens. Onsite psychological support, cognitive behavioral approach.

Replacement Therapies Setting s Outpatient: bridge to detoxification Methadone, Buprenorphine products Patient Characteristics On high doses of opioids predominantly Indicated for addiction; very limited as a pain solution Motivated wean off current meds, agrees to terms of process or case who will not wean, out of control Low to medium psychosocial issues Good community social support for plan Weaning Process Speed of weaning: induction requires care, but is relatively quick; subsequent taper is slow Monitoring: Urinary drug screen, pain behaviors, drug use and seeking, functional status Support: Functional restoration, cognitive behavioral therapies, support groups (AA, NA) Case Management Red flags: Lower risk of abuse if no other meds prescribed; pain complaints likely to continue. Patient may advocate to go back on pain medications. Control. Actions: Consider inpatient or outpatient detoxification.

Rapid Detoxification Not proven safe or effective Indications: Few, if any. Low doses of narcotics. Claims: Painless, cheaper, safe. Realities: Very risky (high death rate) from coma detoxification, does not treat root of the problem, severe withdrawals and craving on discharge without any support. Risks: Death, suicide due to severe withdrawals, pain not addressed, immediately resuming use of narcotics. Ideal candidate: Maybe patient with no addiction history who medically needs to be off meds ASAP. The data supporting the safety and effectiveness of opioid antagonist agent detoxification under sedation or general anesthesia is limited, and adequate safety has not been established. Given that the adverse events are potentially life threatening, the value of antagonist-induced withdrawal under heavy sedation or anesthesia is not supported.

Possible Symptoms of Withdrawal Flu-like aches and pains Sweating, tearing, runny nose Chills, flushing Goose bumps Ants crawling on your skin Loss of appetite Headache Anxiety Restlessness / Restless legs Severe insomnia Nausea, vomiting, diarrhea, abdominal pain

PHYSICAL THERAPY

S T R E ACTIVE T C H I N PASSIVE G

ICE HEAT

NEUROMUSCULAR MASSAGE

PAIN RELIEF AIDS SELF CARE

P R E V E N T I N J U R Y OCCUPATIONAL THERAPY

OCCUPATIONAL THERAPY POSTURE BALANCE

ERGONOMICS Human Performance Testing Workplace Design / Analysis Job Simulation

WORKPLACE ANALYSIS AND DESIGN

BIOFEEDBACK THERAPY Relaxation Re-education Body Mechanics Posture

MOTOR DYSFUNCTION EVALUATION ABNORMAL

PSYCHOLOGY SERVICES Evaluation Manage behavioral crises. Support during Tx Individual, group, family Self Hypnosis Training Relaxation & Stress Management

QUESTIONS??