MAT for Opioid Dependence. MAT and Pain Management. Epidemiology. Epidemiology. Factors Impacting Pain Perception 9/23/2014

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1 MAT for Opioid Dependence Methadone maintenance treatment (MMT) Buprenorphine/naloxone (suboxone) Buprenorhine/naloxone (BupNX) Buprenorphine SL Parenteral naltrexone (P-ntx) Oral naltrexone (ntx) MAT and Pain Management Epidemiology Minimal published research as basis for practice Incomplete understanding of opioid pharmacology in humans Treatment protocols rely on expert opinion for appropriate practice Expert opinion may differ across treatment settings Prevalence of pain and pain disorders for people with addiction varies between 30% to 60% of people in treatment settings, thus is common Rosenblum et al reported survey data suggesting 24-37% of patients in MAT have chronic severe pain (JAMA 2003) Epidemiology Factors Impacting Pain Perception Pain is primarily chronic noncancer pain (CNCP) which may persist for years Not life-threatening Unlikely to resolve with tissue healing EX: Traumatic injury, degenerative joint disease, inflammatory tissue disorders, chronic pancreatitis, ischemic disorders, fibromyalgia, low back pain Pain is often associated with depression, anxiety, bipolar disorder and personality disorders Sensitive vs. non-sensitive Population: 1:14 ratio Addiction: 1:5.4 ratio Cytochrome p450 variation Rapid metabolizers vs slow metabolizers 1

2 Factors Impacting Pain Perception Chronic Pain Disorders Anxiety, depression exacerbate pain Disability impairs self-esteem, causes dependence on others Dependence may be associated with anger and irritability, which increase pain Distrust of medical profession may produce over-report of pain symptoms Pain disorder may not have identified structural or physiological source Neural sensitization may evolve to hyperalgesia, allodynia, spontaneous neural activity Continuous neural signaling results in pain perception in absence of tissue alterations Chronic pain is likely different pathophysiology, not extension of acute pain PATIENT ASSESSMENT Patient Assessment Documentation! Pt personal history, history from SO, family Thorough physical and laboratory exam Appropriate radiology studies Consultations: orthopedic surgeon, neurologist, anesthesiologist, pain clinic Careful documentation of medical decision-making Impact of pain on functional status Exacerbating & palliative factors Response to previous treatments Expectations for pain relief Contingencies of pain and coping Vocational, financial, legal and insurance incentives, disincentives Family support and expectations Patient Assessment PAIN ASSESSMENT History and current status of comorbid disorders Depression, anxiety, PTSD, somatoform Medical conditions, medications prescribed Cognitive impairment Mental status exam Affect, attention and interaction with clinician, suicidal ideation, assessment of future Patients often believe physicians don t understand or accept severity of pain, thus often over-report Physicians often believe patient s pain level is less than patient reports and worry about drug-seeking behavior, manipulation 2

3 PAIN ASSESSMENT Pain Assessment Instruments BE AWARE THAT CLINICIANS TEND TO UNDERESTIMATE PAIN IN ELDERLY MINORITIES WOMEN POOR PEOPLE Green, Baker, Smith & Sato 2003 Rupp & Delaney 2004 Use scales within, but not across, patients Faces pain scale, visual analog scale, numeric rating scale Brief Pain Inventory, McGill Pain Questionnaire assess multiple pain dimensions Katz Basic Activities of Daily Living, Pain Disability Index, Roland Morris Disability Questionnaire, WOMAC Index for functional assessments Establish a multidisciplinary pain treatment team whenever possible Physician/psychiatrist addiction therapist nurse pharmacist social work Emphasis on non-opioid analgesics and adjunctive medications NSAID with adequate dose acetaminophen, topical analgesics SSRI, SNRI, trazodone, mirtazapine Anticonvulsants: gabapentin, depakote, topiramate, zonisamide MMT and Acute Pain Aggressively manage insomnia Trazodone, mirtazapine Doxepin, amitriptyline avoid benzos whenever possible Complementary and alternative treatments, and exercise interventions Acupuncture, massage, yoga, relaxation, meditation, tai chi MAT methadone is not effective for analgesia For acute pain, ADD a short-acting oral opioid Variable response to opioids: ask pt what has been effective in the past Expect to use higher dose because of pt s tolerance Provide one-week max supply Notify MMT program of prescription status 3

4 MMT & Chronic Pain Buprenorphine & Opioids Assess if pain responds to methadone vs craving reduction only: Does pt get any pain reduction with MMT? (MAT methadone dose does not provide sufficient analgesia for pain control) Time-limited pain reduction suggests methadone dose increase may be helpful for chronic pain condition No pain decrement post-dosing suggests pain condition may be non-responsive to opioids Buprenorphine is partial agonist for mu receptor High affinity for mu receptor leads to displacement and blockade of full agonists Unclear if buprenorphine has an analgesic ceiling Respiratory depression ceiling protects from overdose lethality Buprenorphine with Acute Pain How does bup blockade of mu receptor alter pain control? How to provide acute pain control for emergent conditions? Recommendations for elective surgery prep? Bup/NX with Acute Pain Bup/NX and Chronic Pain Michigan 5-day rule: stop bup 5 days before surgery; high relapse risk Boston University rule: hold bup day prior to surgery; less relapse risk, no adverse outcome Clinician reports: continue bup through surgery and/or delivery without apparent loss of pain control Prescribe MAT Bup/NX in divided doses, every 8 hrs Trial of increasing total dose, max is unknown May consider trial addition of a short-duration opioid Some patients report good response No systematic data is available Need to talk to patient s pharmacy re goal 4

5 Bup/NX for pain? NALTREXONE Buprenorphine as Butrans is widely used as a parenteral analgesic Bup/Nx is a similar opioid parenteral preparation, reported by Heit and Malinoff to be effective for pain, in split doses Bup/Nx may be prescribed for pain without a DEA DATA 2000 number, BUT insurance won t pay for it Naltrexone is mu receptor antagonist blockades receptor for hrs reduces craving for opioids and alcohol Pts often non-compliant Also marketed as Vivitrol monthly injection to enhance compliance Naltrexone pharmacology Naltrexone & Acute Pain Generic oral dose = 100mg daily Duration of activity about 3 days 50% loss at receptor by day 2 Vivitrol monthly extended-release injection 96% blockade first week Gradual dissociation over 2-3 weeks Resolution of blockade at one month Elective surgery should be scheduled at least one month after injection to maximize availability of opioid receptors If emergent need for pain control Consider regional anesthesia, nerve blocks Anesthesiology consult to control airway during administration of very high dose opioids to displace naltrexone at mu receptor Summary Resources Presence of acute and chronic pain is not a contraindication for MAT MAT may be successfully combined with treatment for acute and chronic pain SAMHSA TIP 54, Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders order or download SAMHSA sponsored website for ongoing webinars focused on MAT: American Society of Addiction Medicine Adequate pain control reduces relapse risk associated with chronic, persistent pain American Academy of Addiction Psychiatry 5