Management of Chronic Pain: Why the U-turn in Opioid Prescribing?

Transcription

1 Management of Chronic Pain: Why the U-turn in Opioid Prescribing? Launette Rieb, MD, MSc, FCFP, DABAM, FASAM Clinical Associate Professor, Department of Family Practice, University of British Columbia Medical Consultant, Department of Family and Community Medicine, St. Paul s Hospital, Vancouver Nanaimo Division of Family Practice, April 20, 2017

2 Faculty/Presenter Disclosure Faculty: Launette Rieb Relationship with commercial interests: None No pharmaceutical, medical device or communications company: No commercial bias

3 Disclosure of Commercial Support No financial support or in-kind support for this program No potential conflicts of interest for Dr. Rieb

4 Learning Objectives Review risks associated with opioid use, including pain, to understand the U-turn Name key CPSBC opioid guidelines and standards for acute and chronic pain List techniques for opioid and benzo tapering, including the use of adjuvant medications, especially in the legacy patient Reflect on who may benefit from changes in opioid dose, monitoring, or dispensing

5 Non-pharmacological Therapies Cochrane Reviews Psychological therapies CBT Mild-mod effect: depression, disability, +/- pain (Williams, 2012) Physical therapy Some evidence for shoulder (Green, 2003) TENS Conflicting evidence (Khadilkar, 2008) Prolotherapy Not effective alone, unclear with cointerventions (Dagenaise 2007) Spinal manipulation for CLBP No better/worse than tx like PT/exercise, unclear compared to sham (Rubinstein 2011) Massage Beneficial, especially combined with stretching and education (Furlan 2008)

6 Mindfulness Meditation Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic LowBackPain A Randomized Clinical Trial Daniel C. Cherkin, PhD; Karen J. Sherman, PhD; Benjamin H. Balderson, PhD; Andrea J. Cook, PhD; Melissa L. Anderson, MS; Rene J. Hawkes, BS; Kelly E. Hansen, BS; Judith A. Turner, PhD JAMA. 2016;315(12): doi: /jama randomized participants - clinically meaningful (30%) improvement from baseline in functional limitations (modified Roland Disability Questionnaire [RDQ]; range, 0-23) and in self-reported back pain bothersomeness (scale, 0-10) at 26weeks MBSR or CBT, compared with usual care, resulted in greater improvement in back pain and functional limitations

7 Opioids for chronic low-back pain. Cochrane Review (Chaparro 2013) 15 trials which included 5540 participants More pain relief and fxn in short term No information from RCTs supporting the efficacy and safety of opioids used for more than four months The current literature does not support that opioids are more effective than other groups of analgesics for LBP such as antiinflammatories or antidepressants

8 Oxycodone for neuropathic pain and fibromyalgia. Cochrane Review(Gaskell 2014) Oxycodone was not convincingly shown to help relieve the pain (very low quality evidence) Compared with placebo, fewer people stopped taking oxycodone because they felt it was not effective, but more people experienced adverse effects (very low quality evidence) Oxycodone has not been shown to work as a pain medicine in diabetic neuropathy or postherpetic neuralgia. No studies have examined its use in other types of neuropathic pain, or in fibromyalgia

9 Analgesic Efficacy of Opioids (Chou, 2015) Some evidence for opioid use acutely and under 6 months, lack of studies on benefits > 1 yr Long term harms of LOT vs non opioid tx for CNCP: Increased risk of overdose, substance abuse and dependence, fractures, myocardial infarction, and use of medication to treat erectile dysfunction Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports dose dependent risk for serious harms

10 US CDC 2016 Summary No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later Extensive evidence shows the possible harms of opioids Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacologic treatments compared with long-term opioid therapy, with less harm

11 CDC Guidelines for Prescribing Opioids for Chronic Pain (Dowell 2016) Establish tx goals and function Non-opioid therapies preferred Only use when benefit outweighs risk Lowest effective dose <50 MEDD<<90 mg Avoid concurrent benzodiazepines Re-evaluate every 3 months If an OUD develops offer methadone or buprenorphine Used for many CPSBC standards/guidelines

12 Analgesic Efficacy of Opioids (Ballantyne, 2006) Only 1 out of every 4 patients get some pain relief with opioids initially, the others should be taken off right away, not left on with other medications added Average just 20-30% analgesia Fantasy that endless dose escalations will provide further reductions in pain

13 Factors Associated with OD Aberrant behaviors Recent initiation of opioids Methadone Concomitant use of benzodiazepines Obtaining opioid prescriptions from multiple providers Substance abuse and other psychological comorbidities Higher dose

14 Dose-related risk of opioid overdose 10 Risk of adverse event Risk Ratio Dunn 2010 Bohnert 2011 Gomes 2011 Zedler <20 mg/day mg/day mg/day >=100 mg/day Dose in mg MED Courtesy Gary Franklin

15 *

16 Opioid Abuse and Addiction is Dose Dependent Long-term prescribed opioid use (>90 days supply) associated with increased risk of an opioid abuse or dependence diagnosis vs. no opioid treatment Low dose (1-36 mg MED/day): OR 15 Moderate dose ( mg MED/day): OR 29 High dose ( 120 mg MEDD): OR 122 (Edlund 2014)

17 SUD in patients on LOT Systematic review and meta analysis Based on history and physician suspicion alone rates of substance dependence with opioid therapy was under 5%, under 1% if no past hx SUD However 5 studies did UDS as well: 21% of patients had either no prescribed opioid and/or a non-prescribed opioid in their UDS 15% had illicit drugs (Fishbain 2008)

18 Prescription Opioid Misuse and Addiction Opioid misuse in literature 4% to 26% + This study of opioid use behavior in patients (n=801) with CNCP based on standardized interviews 26% purposeful oversedation 39% increased dose without prescription 8% obtained extra opioids from other doctors 18% used for purposes other than pain 12% hoarded pain medications (Fleming et al. J Pain 2007)

19 Opioid Adverse Effects Death Overdose Sleep apnea PAIN Myocardial Infarction MVAs Testosterone Addiction (Chou et al., 2015; Dowell et al., 2016; Ballantyne, 2015; )

20 Opioids Causing Pain Opium use causes internal rheumatism (Quincey TD, 1821) Morphine tends to encourage the very pain it pretends to relieve (Albutt, 1870)

21

22 (Mao, 2008)

23 Opioid-induced Pain Sensitization (Ravat and Ballantyne, 2016)

24 OIH Mechanisms - Microglia (Arout, 2015)

25 Significant Pain Reduction in Chronic Pain Patients after Detoxification from High Dose Opioids Baron and MacDonald, 2006 Retrospective study of opioid detoxification 21/23 patients had significant decrease in pain after detoxification

26 Withdrawal-induced hyperalgesia (WIH) Unmasking OIH with opioid cessation PAIN AND release of catecholamines due to withdrawal Causes neuroinflammatory and neuroimmune response PAIN

27

28 Higher starting dose = more hyperalgesia, AND Tapering from higher doses was associated with lower values of Heat Pain (i.e. more hyperalgesia) in a dose dependent manner N= 109

29 Possible OIH/WIH Mitigators pre/clinical NMDA antagonists (ketamine, etc.) NSAIDs (ketorolac, ibuprofen, etc.) Gabapentinoids (gabapentin, pregabalin) Alpha and beta blockers Cannabinoids? Melatonin Microglia TLR-4 antagonists, e.g. (+)-naloxone, (+)-naltrexone, ibudilast Opioid tapering, or rotation then tapering, instead of abrupt stop (Arout, 2015; Chu, 2012; Mao, 2006; Grace, 2014; Xin 2012; Hutchinson. 2012)

30 December 2016, 157(12) Open access: ticle=00028&type=abstract

31 WISP descriptive case series Mixed methods study of patients on opioids for CNCP or addiction 5 screening Q option to do full survey of 35 Qs 58 screened, 47 confirmed WISP, of these 34 completed the full surveys (21 by interview) WISP median pain intensity 8/10 (original injury 10/10), more painful than general withdrawal WISP median duration 2 wks, but 18% > 1 mo. WISP can be a risk factor for opioid reinitiation Mitigators included gabapentin and NSAIDS

32 WISP VS original injury & w/d pain God, it felt just like it did when it was healing when it was broken, yeah. I don t know how any other way to describe it. Participant #2, 53 year-old white male, original injury - fractured arm at age 12 I was pounding my legs old injury sites are horrendous. So, like it s more severe in those spots. The other part you can like go, get through with a hot cloth, or whatever, with Gravol and stuff, but old injury sites come back with like, severe severity. Participant #17, 58 year old Indigenous female, original injury foot fractures requiring plating and lower leg injuries requiring fasciotomies after a home invasion, capture, and repeated assault with a hammer

33 WISP - Emotional Aspects There s also not just physical pain I was run over by a semi so I suffered some physical injuries that come up in withdrawal, but also there s anxiety from it too It s like PTSD from that big time Participant #8, 38 year old white male with previous multiple bilateral lower leg and foot fractures after being struck and pulled underneath a semi-trailer

34 WISP Theories all part of the drug withdrawal I don t think it healed right might be psychological I thought, okay, it s such a strong pull to do the drugs that my brain figured out that because I started taking opiates when I sprained my ankle, it s going to start kicking the pain out at the ankle to get more opiates... Participant # 5, 35 year old white male, original injury right ankle tendon tear requiring casting

35 CPSBC - Opioid Use Guidelines Do complete Hx + Px, meds/otc/illicit drugs, DDx Screen SUD, mood disorders, family Hx Opioid Manager, PharmaNet, UDS, contracts Not for headache, fibromyalgia, axial LBP MEDD > 50 mg re-assess, >90 mg document exceptional need and benefit Short course for acute pain exit strategy Avoid co-prescribing benzos and stimulants FUNCTION must change to continue Rx

36 Functional Assessment Universal Precautions The 5 As (Gourley, 2005) 1. Activities of daily living - Work, self care, mobility, leisure, sport, sleep 2. Analgesia 3. Adverse effects 4. Affect 5. Aberrant drug-related behaviors

37 Screening tools Substance Use Disorders AUDIT alcohol (free from WHO) DAST drugs, or CAGE-AID COMM current opioid misuse measure Mood BDI - Beck Depression Inventory PHQ9 Various sleep, anxiety, bipolar, and PTSD screens Pain and function PDI Pain Disability Index AREBRO catastrophizing and predictor of return to work

38 Opioid Issues - Pearls Generally avoid caffeinated products No clear advantage of long acting over short unless for opioid use disorder treatment Use ONLY ONE opioid for both short and long, do not mix (unless patch used) Lack of literature supporting adding another opioid to methadone and buprenorphine/nx

39 Reduce Risk when Prescribing Random UDS, PharmaNet, opioid agreement Random call backs for pill counts to pharmacy Bubble pack medications Patch return to pharmacy for next dispense Shorten dispensing frequency/amount Change to OD formulation with daily witnessed ingestion Taper off or send to detox/treatment facility if continued alcohol, benzo or illicit substance use

40 When to Suggest Opioid Taper? Patient on opioids without significant improvement in pain and function Safety sensitive position Spread of pain in the absence of disease progression allodynia and hyperalgesia Active substance abuse/dependence where harm reduction not viable Patient requests to come off

41 Typically opioid tapering is not an emergency! As out patients most can drop 5-10% every 1-2 weeks, sometimes slowing to every 2-4 weeks for the last 20-30% of the opioid For patients on LOT for many years who have failed more rapid tapering, just slow it down to drop every 1-3 months Even if you drop the dose 5% every 3 months, in a year they will be down 20%, and by 2 years 40%. But this is ridiculously slow if they are on extremely high doses or have only been on a couple of years or less

42 Helping with Opioid Tapering Education: Go over what opioids DO in the body Explain WITHDRAWAL symptoms, incl. pain Normalize and temporalize go slow in legacy pts Medication adjuvants: Decrease catecholamines: α-blockers, breathing exercises, mindfulness, etc. Regulate sleep: TCAs, tetracyclics, melatonin Treat pain and w/d: NSAIDS, gabapentinoids, etc. Opioid rotate then taper (eg. to bup/nx or methadone if you have experience doing this)

43 Opioid Lowering Options 1. Convert to long acting opioid taper 2. Taper with short acting opioid 3. Withdrawal symptom management 4. Opioid substitution/rotation - taper

44 Opioid Short > Long Conversion Long acting can provide smoother control But beware of high peak of some long acting formulations which can produce euphoria Change 50-75% of the total dose over to the long acting formulation provide the rest in short acting with a warning for sedation Review in 1 week and convert more to long Ideally very little to no breakthrough

45 Opioid Dose Adjustments - Pearls Physician adjusts dose as required: Increase or decrease by 5-10% at a time The earliest dose change should be after 5 half lives of that particular drug Morphine (1/2 life 3 hr) daily adjust in hospital Methadone (1/2 life 24-36h) adjust q5+ days Comfortable change is every 1-4 weeks PT input If unsuccessful (no change pain + function) taper off, might try a diff opioid, or not Go slower at the end of a taper last 20%

46 Opioid Tapering Example Pt taking hydromorphone (short) 200 mg/d 1 st conversion: Hydromorphone (long) 75 mg q12 h plus hydromorphone (short) 4mg 1-2 q4h prn warn about driving, sedation 2 nd week: see if prn doses needed if so add in as long acting, e.g. 100 mg q12h 3 rd week on taper 5-10%, typically faster at first and slower at the end of the taper Taper until lowest dose strength long: 3mg q12h Then re-introduce short to complete weekly taper, e.g. hydromorphone (short) 2mg q8h; 1mg q6h; 1mg q8h; 1mg am and hs; 1mg hs; off

47 Opioid Tapering Short Sometimes easiest to simply taper what the patient is currently using E.g. Percocet 16-20/d, taken 6 tid +/- 2/d If it is a dual agent first switch to eliminate the ASA or acetaminophen (bloodwork?) E.g. Oxycodone 5 mg 18/d Next spread out the daily dose evenly based on the ½ life of the medication E.g. Oxycodone 5 mg 5/4/4/5 spread q6h

48 Opioid Tapering Example Next taper the medication depending on the patient s symptoms the drop can be ever 4-14 days, always dropping nighttime dose last Oxycodone 5 mg 4/4/4/5 spread q6h Oxycodone 5 mg 4/4/4/4 spread q6h Oxycodone 5 mg 4/3/4/4 spread q6h Oxycodone 5 mg 4/3/3/4 spread q6h Oxycodone 5 mg 3/3/3/4 spread q6h Oxycodone 5 mg 3/3/3/3 spread q6h Continue this pattern until 0/0/0/1, then off

49 Opioid Tapering Combo If patient using a combination of short and long acting conventional wisdom is to taper short first, but since often this is what patients feel and are attached to you can taper it last Oxycodone ER 80 mg q12 h plus oxycodone 10mg 1-2 prn 4/d max Taper Oxycodone ER first by 10 mg every 4-14 days dropping morning dose, then evening dose Hold the oxycodone short 10 mg at q6h until off the Oxycodone ER then taper by 5 mg as per previous schedule leaving the hs to be last off

50 Helping with Opioid Tapering Education: Go over what opioids DO in the body Explain WITHDRAWAL symptoms, incl. pain Normalize and temporalize go slow in legacy pts Medication adjuvants: Decrease catecholamines: α-blockers, breathing exercises, mindfulness, etc. Regulate sleep: TCAs, tetracyclics, melatonin Treat pain: NSAIDS, gabapentinoids, etc. Opioid rotate then taper (eg. to bup/nx or methadone if you have experience doing this)

51 Bup/nx and Pain Daitch D et al. Pain Medicine Retrospective chart review of CNCP patients on over 200 MEDD - converted from other opioids to bup/nx - pain scores averaged 8/10 pre-conversion, 4/10 post conversion

52 Daitch D et al. Pain Medicine. 2014

53 Bup/nx Induction Bup/nx classic induction: COWS score >13 2 mg q 2-4 h up to 8 mg day 1, mg day 2 If induction for detox, taper 2 mg q 1-2 d Bup/nx kind induction: The day primary opioid is stopped put on buprenorphine patch 20 mcg/hr take off when oral bup/nx initiated Next day once COWS give bup/nx 1 mg if no precipitated withdrawal in 1 hr give 2 mg as above, etc. Bup/nx cowboy induction: COWS >13 give bup/nx 8mg then 4 mg q2 up to 16 day 1

54 Case Escalating Opioids & LBP Mr. D = 47 year old married at home father, degree is psychology, No family history of SUD, dad a gambler late in life Age 19: L4-5 discectomy for prolapse Post-op give Tylenol #3 He mixed these with ETOH to get high 10 years later recurrent disc surgery Initially successful then increasing low back pain over the next year

55 Mr. D, con t GP managed Tried different medications, low dose at 1st Hydromorphone short acting up to 80 mg/d Would run out early, would crush and smoke Fluoxetine 60 mg/d Lorazepam 4 mg/d Pain still unmanageable on above regime Referred on

56 Mr. D., con t Multidisciplinary hospital based pain clinic Medications altered, various medications combined Opioids were increased over time to the level below: Fentanyl Patch 150 mcg/h q2 d (prescribed q3d) +/- fentanyl solution 100 mcg/2ml vile 3-5/d Fentanyl film 600 mcg bid = 1200 mcg/d Tramadol (24h) 50 mg ii bid = 6 tabs/d = 300 mg/d Methadone tablets 60 mg bid = 120 mg/d Hydromorphone - short acting 80 mg/d (snorting) Morphine equivalent dose = 1,830+ mg/d

57 Mr. D., con t Other medications Fluoxetine 80 mg/d (adverse rxn - duloxetine) Diazepam 2.5 mg bid (+still using lorazepam) Decongestant with pseudoefedrine 2 tabs/d Caffeine pills and energy drinks He still felt pain, otherwise felt Great! Function: ran triathlons, others see sedation Total cost to wife s insurance = $3,000/wk

58 Mr. D., con t Voluntary admission to a medically supervised residential treatment facility: education, 12 step, group, 1:1, CBT, etc. Methadone and fluoxetine same dose at 1st Stopped tramadol on admission Stopped all fentanyl after 2 d taper Added quetiapine 25 mg q6h No withdrawal seen

59 Mr. D., con t Tapered the methadone over 3 weeks to 5 mg tid Dose held until in withdrawal Switched to buprenorphine patch 10 mcg initially not quite enough Then over to sublingual bup/nx titrated to 6 mg/d where he has been maintained successfully

60 Mr. D., followup Follow-up 12 months post admission to recovery Meds Bup/nx 6 mg/d Fluoxetine 60 mg/d and tapering Quetiapine 125 mg/d and tapering Has attended 12 step daily, has a sponsor No relapses or slips, despite divorcing No more pain issues GAF 95/100

61 Mr. D., Reflections Primary pain disorder or substance use disorder? Opioid induced hyperalgesia? How can the opioids besides methadone be stopped abruptly without withdrawal? How can bup/nx and 12 step combined control both the pain and addiction issues?

62 Co-management of SUD and Pain When an Substance Use Disorder is active, pain is much harder to treat due to dysregulation of all pathways involved with mood, pain, and behavioral reinforcement Must co-manage pain and addiction issues be it alcohol, cocaine or opioid use disorder No take home opioid doses if any active SUD No opioid prescribing if any alcohol use may need to taper off.

63 Opiate Addiction Abstinence Medications Counseling Agonist Antagonist Peer Support Methadone Naltrexone Residential Treatment Buprenorphine

64 One example: Stop other opioids Methadone mg on day 1 as per physician orders If 30 mg then taper by 5 mg per day until off If 10 mg taper by 2mg per day until off Methadone for detox Course needed, and authorization Clinical judgment required for starting dose Use only in those highly tolerant to opioids

65 Pain and OUD Typically conversion to medication assisted treatment (MATx) with buprenorphine, or methadone is done to stabilize Buprenorphine had the same or better pain relieving effect as morphine No evidence to add a 2 nd opioid for CNCP

66 Naltrexone opioid antagonist In those with an opioid use disorder (OUD) committed to abstinence based Tx use naltrexone 50 mg/d po can of heroin block 0.5+ gm IV or equivalent Start 1-2 wks after last short acting opioid (3-4 wks post methadone) ¼ pill day 1; ½ pill day 2; 1 pill day 3 onwards Witnessed ingestion is best or injectable once here Contraindicated cirrhosis, OD risk high once d/c Use for first 6-12 months of sobriety from OUD Analgesia with non-opioids or get consult Injectable on federal special authorization - $$$$

67 Take Home Naloxone Towardstheheart.com

68 No Benzos For patients with chronic non-cancer pain (CNCP) and/or SUDs on/off opioid therapy - benzodiazepines are contraindicated No help with pain Helps with sleep initiation but not maintenance Rebound insomnia Withdrawal anxiety Increased risk of unintentional OD, MVA, falls Opioids + benzos + alcohol especially lethal Advisable to taper off benzos prior to opioid start

69 Ashton Protocol Dr. Heather Ashton from the UK Protocol for very slow benzo conversion and taper of diazepam Conversion to diazepam in steps 5mg at a time & then very slow taper over 6-12 months Use for highly sensitive patients Those on for many years Elderly Failed conventional tapering

70 Benzodiazepine Tapering Strategies Taper with the same benzo, drop q1-4 wks: Eg. Zopiclone 7.5mg ii hs Taper: 7.5+5, 5 ii, 7.5, 5, 7.5 ½ (3.5), 5 ½ (2.5) Can also put into a suspension and taper 1mg/mo. Taper using a different long acting benzo: Diazepam 10mg, decrease by 2mg q1-4 wks Fast taper or eliminate using another med: Gabapentin 300 mg tid titrated to symptoms up to mg tid then taper over 1-3 months

71 Benzo Taper - Short If the person has been on a short acting benzo for a long time, can taper this If highly sensitive/symptomatic, consider compounding the medication in a liquid vehicle as an inpatient: E.g. Lorazepam 1 mg/ml 1 ml hs x 1d 0.9 mg/ml 1 ml hs x 1 d 0.8 mg/ml 1 ml hs x 1 d, etc. until off Note same volume taken each night As an out patient can go slower

72 Benzo Withdrawal Management Some medications have been tried in withdrawal for symptomatic therapy: SSRI for depressive symptoms TCAs, melatonin, trazodone for insomnia Propranolol for severe palpitations, gastric upset?muscle relaxants No real good evidence for this but is clinically relevant in engaging patients in withdrawal Novel studies being done with pregabalin, gabapentin, and other antiepileptics

73 Pharmacological assisted benzodiazepine discontinuation 1 st line: Phenobarbital Acts as a weak agonist at GABA receptor Long t1/2, minimal withdrawal, generally welltolerated and effective Dosing: mg bid qid 2 nd line: Gabapentin mg tid Pregabalin mg qhs tid (Dr Mark Weiner, Ann Arbor, Mich., Pain Recovery Solutions)

74 Case Mr. B 48 yr old HIV+ HCV+ male with peripheral neuropathy, sleep disturbance, cocaine & alcohol use disorders now both in sustained abstinence (6 years), pain 8/10 Meds: Oxycodone/acetaminophen (5/325) 6 q6h no evidence of current OUD, no pain relief Thus oxy 120 mg = 180 mg MEDD Temazepam 60mg hs 2-3x/wk (from his wife) Intolerable experience in the past with duloxetine, venlafaxine, and amitriptyline

75 Mr. B, cont d Treatment: 1. Taper off oxycodone/acetaminophen 5/325: Lower by 1 tablet q4 days until at 1 q6h Then lower by ½ tab q4 days until off 2. Titrate onto gabapentin Begin with HS dose mg, incr. q4d until at 300mg hs Titrate up daytime doses by 100 mg until 300 tid - qid, then by 300mg weekly until 600 tid (2400 mg/d) If no pain relief in 6 weeks at 2400 mg/d then taper off If 2400 mg/d helpful can push the dose further to 3600 Neuromodulators can help ameliorate opioid withdrawal symptoms too which can help Mr. C.

76 Mr. B, cont d Treatment, cont d: 3. Taper temazepam Stabilize nightly benzo to half current episodic dose Slowly taper, or can use diazepam, remembering that neuromodulators can also help benzo withdrawal Ashton protocol for benzo tapering may be needed 4. Nortiptyline may be better tolerated for sleep but he declined, can try quetiapine 25 mg hs and titrate up 5. Sleep hygiene/relaxation/anger mgt

77 Mr. B, cont d Result: Pain better controlled, sleep still a challenge but improving with time Good result!

78 Mr. B, cont d Q: What if he was binging on alcohol and benzos?

79 Mr. B, cont d Offer residential detox. Not eligible for opioids stop (or fast taper 10% per day).

80 Mr. B, cont d Q: What if he had requested more opioids instead of less?

81 Mr. B, cont d Explain that other medications are first line and need to be tried in sufficient doses. Explain that opioids have risks associated with use outline them. Explain why this is considered a failed treatment attempt = opioids are no longer indicated

82 Mr. B, cont d Q: What if he had some pain relief and increased function with oxy/acetaminophen and was unresponsive to all other med categories?

83 Mr. B, cont d Once daily oral morphine formulation which could go to a daily witnessed ingestion (DWI) if needed during initial monitoring, and be reverted back to DWI if there is cocaine or other drugs in the UDS NOT eligible for carry doses of opioids if using cocaine or other illicit drugs

84 Medications are a fantastic tool, they are not working but if Review the diagnosis Repeat Hx/Px Screen for depression, anxiety, and PTSD Explore perception of disability & meaning Screen for a Substance Use Disorder Expand non-pharmacological treatments Ensure your prescribing is safe, effective, and cannot possibly do more harm than good Take an empathetic, consistent approach

85 Summary 1. Use non-opioid medications and therapies primarily 2. Rare use of opioids beyond acute setting 3. If restores function, use opioids with screening and monitoring and informed consent 4. Have an opioid exit strategy and recall these techniques of tapering and rotation

86 Thank you!

87 Key References on hyperalgesia Arout CA, Edens E, Petrakis IL, Sofuoglu M. Targeting Opioid-Induced Hyperalgesia in Clinical Treatment: Neurobiological Considerations. CNS Drugs 2015;29(6): Hooten WM, Mantilla CB, Sandroni P, Townsend CO. Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering. Pain Med 2010;11(11): Hooten WM, Lamer TJ, Twyner C. Opioid-induced hyperalgesia in community-dwelling adults with chronic pain. Pain 2015;156(6): Hutchinson MR, et al. Opioid-induced glial activation: mechanisms of activation and implications for analgesia, dependence and reward. The Scientific World Journal 2007;7(S2)

88 Key References on Hyperalgesia Mao J. Opioid-induced abnormal pain sensitivity: implications in clinical opioid therapy. Pain 2002;100(3): Rieb, L. Spreading pain with neuropathic features may be induced by opioid medications. This Changed My Practice. UBC CPD, Sept. 13, Rieb L, Norman W, Martin R, Wood E, McNeil R, Milloy MJ. Withdrawalassociated injury site pain (WISP): A descriptive case series of an opioid cessation phenomenon. PAIN. December 2016, 157(12) Open access: &article=00028&type=abstract Rivat C, Ballantyne J. The dark side of opioids in pain management: basic science explains clinical observation. PAIN Reports. 1(2016)e opioids_in_pain_management.3.aspx

89 Key References on Screening Pain Catastrophizing Survey Tripp DA, VanDenKerhof EG, McAlister M. Prevalence and determinants of pain and pain-related disability in urban and rural settings in southeastern Ontario. Pain Res Manag Winter;11(4): Brief Pain Inventory short formhttp:// Butler SF, Budman SH, Fanciullo G, Jamison N. Cross Validation of the Current Opioid Misuse Measure (COMM) to Monitor Chronic Pain Patients on Opioid Therapy Clin J Pain Nov Dec; 26(9): doi: /AJP.0b013e3181f195ba

90 References Screening & mngt Alcohol use disorder identification test from WHO, free Moulin DE, et al. Pharmacological management of chronic neuropathic pain: Revised consensus statement from the Canadian Pain Society. Pain Res Manag. Vol 19; No 6 (Nov/Dec) 2014; p Kahan M, Srivastava A, Spithoff S, Bromly L. Prescribing smoked cannabis for chronic noncancer pain: Preliminary recommendations. Can Fam Phys. 2014: vol 60:Dec; p Derry P, Derry S, Moore RA, McQuay HJ. Single dose oral diclofenac for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD DOI: / CD pub2

91 References - Management Ziegler P. Safe Treatment of Pain in the Patient With a Substance Use Disorder. Psychiatric Times (CMP Medica), 24(1), 2007 Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD DOI: / CD pub2 Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T. Antipsychotics for acute and chronic pain in adults. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD DOI: / CD pub3

92 References - Management Duehmke RM, Hollingshead J, Cornblath DR. Tramadol for neuropathic pain. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD DOI: / CD pub3 Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD DOI: / CD pub2 Wiffen PJ, Derry S, Moore R, Aldington D, Cole P, Rice AS C, Lunn MPT, Hamunen K, Haanpaa M, Kalso EA. Antiepileptic drugs for neuropathic pain and fibromyalgia - an overview of Cochrane reviews. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD DOI: / CD pub2

93 References - Management Eccleston C, Palermo TM, Williams AC de C, Lewandowski A, Morley S, Fisher E, Law E. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD DOI: / CD pub3 Martin-Sanchez et al. Systemic Review and Meta-analysis of Cannabis Treatment for Chronic Pain. Pain Medicine Vol 10 (8) 2009: Lunn MPT, Hughes RAC, Wiffen PJ. Duloxetine for treating painful neuropathy or chronic pain. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD DOI: / CD pub2

94 References non-pharm Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD DOI: / CD Dunn KM et al. Ann Intern Med 2010;152:85-92 Gomes T et al. Arch Intern Med 2011;171: Bohnert A et al. JAMA 2011;305: Zedler B et al Pain Medicine 2014; 15: