Chronic Pain and Opioid Management: Case-Based Discussion. Other acknowledgments

Transcription

1 Chronic Pain and Opioid Management: Case-Based Discussion Scott Steiger, MD, FACP, FASAM Assistant Professor of Clinical Medicine University of California San Francisco Consultant, Clinician Consultation Center Other acknowledgments I m not pro- or anti- opioid I used to (and will soon again) run a methadone maintenance treatment program Will Becker and Joe Frank 1

2 Learning Objectives Implement 2 new or modified strategies for reducing risk of complications from chronic opioid therapy for non-cancer pain in your practice Apply at least 2 strategies for reducing doses of chronic opioid therapy for non-cancer pain in a patient case Identify and treat patients with opioid use disorder Outline New patient on chronic opioid therapy Defining risks/benefits Opioids in chronic pain: evidence, guidelines, limitations Old patient on high dose opioids Risk reduction strategies Tapering options Chronic pain + substance use disorder Options for treatment 2

3 Case: 54 yo F chronic LBP 54 yo F presents for primary care after her previous PCP left the clinic where you work. PMH: HIV (VL<40, CD4 585), lumbago (DJD on Xray) Meds: Abacavir/dolutegravir/lamivudine 1 daily MS-Contin 60 mg bid #60 per month Oxy/APAP 10/325 mg tid PRN #90 per month 54 yo F chronic LBP Pain better with Massage Time away from mother Pain worse with too much activity Stress 3

4 Checklist for new patient Start non-pharmacologic interventions Patient-Provider Agreement P/E/G U tox Check PDMP ( CURES report ) Discuss with previous/current providers Consent to discuss with one family member/friend Discuss safe storage Complexity of chronic pain Deardorff, WW. APA

5 Biopsychosocial assessment Diagnose underlying pain-generating disease process Curable/reversible or life-threatening Degenerative, irreversible, nonlife-threatening Requires focal and/or rapid intervention Requires chronic disease management Co-morbid chronic disease Coping skills/ resilience Social support Pain interference Values/beliefs Evidenced-based approach to chronic pain treatment SELF MANAGEMENT Rational pharmaco therapy Behavioral therapies Physical activation SELF EFFICACY Promotion of Healthy Behaviors Addressing Co-Morbidities Integrated Health System 5

6 Evidence-based non-pharmacologic treatments for chronic pain Physical activation aerobic exercise Physical therapy Yoga Tai Chi Aquatherapy Behavioral treatments Cognitive behavioral therapy Mindfulness/meditation PMR Guided imagery Other techniques Massage Chiropractic Acupuncture Trigger point injections Botox injections IA steroid injection TENS Nerve blocks Chronic pain in 5 minutes B93rvI 6

7 54 yo F low back pain I can watch the video I ll try to take a walk 5 days a week but what do I gotta do to get my meds refilled? 7

8 Building a Patient Provider Agreement Set expectations for benefits Outline the risks Describe a process for management The benefits of opioids for CNCP Cochrane: n>4800 show reduction in pain* 50-66% report reducing pain scores by at least half Caveats Max dose 180 mg MED Few studies longer than 6 months. *Noble 2010 **Chou 2009; Reuben 2015) 8

9 The benefits of opioids for CNCP AHRQ/CDC 2014/2016: insufficient evidence to determine long-term benefits versus no opioid therapy The benefits of opioids for CNCP in HIV Care? Increase in ART no improvement in viral suppression Silverberg et al., Clin J Pain 2012 Edelman et al., JGIM, 2013 Koeppe et al., Clin J Pain,

10 On a scale of 0-10, over the last week: What has your average pain been? (0-10) How much has your pain interfered with your enjoyment of life? (0-10) How much has your pain interfered with your general activity? (0-10) Krebs, 2009 Building a Patient-Provider Agreement 10

11 Special risks in HIV+ patients Immunosuppression Trend toward lower CD4 Overdose Higher rates of substance use in HIV+ pts Difficulty with health care providers Ethnic and sexual minorities overrepresented in HIV Building a Patient-Provider Agreement 11

12 54 yo F low back pain Provides a urine sample +morphine, oxycodone Negative amphetamine, benzo, cocaine, codeine, hydrocodone, hydromorphone CURES 26 fills in last 12 months, all 1 provider Review of records/discuss with old PCP 1 early refill Take home: Checklist Start non-pharmacologic interventions Patient-Provider Agreement P/E/G U tox Check PDMP ( CURES report ) Discuss with previous/current providers Consent to discuss with one family member/friend Discuss safe storage 12

13 54 yo low back pain Should we continue MS-Contin 60 bid and oxycodone/apap 10/325 mg tid? 54 yo low back pain How can we make this patient s chronic opioid therapy safer (and more effective)? 13

14 Improving safety of chronic opioid therapy 1) Prevent overdose 2) Reduce dose Odds of overdose by increasing dose Dose* (mg/day) Dunn Gomes Bohnert HR (95% CI) OR (95% CI) HR (95% CI) 1-< (REF) 1.00 (REF) 1.00 (REF) 20-< ( ) 1.3 ( ) 1.9 ( ) 50-< ( ) 1.9 ( ) 4.6 ( ) 100 or ( ) 2.0 ( ) 7.2 ( ) ( ) *morphine equivalent Dunn et al. Annals IM 2010; Gomes et al. Archives IM 2011; Bohnert et al. JAMA

15 What is a high dose of an opioid? MSO4 50 mg is about the same as. Codeine 60 mg q4h Oxycodone/APAP 10/325 tid Hydrocodone/APAP 10/500 5 times a day Methadone 5 mg tid Hydromorphone 4 mg tid Oxymorphone ER 7.5 mg bid Fentanyl 12 mcg/hr patch Opioidcalculator.practicalpainmanagement.com agencymeddirectors.wa.gov/mobile.html 15

16 Naloxone comes in 3 forms 1) Generic intranasal requires counseling (adaptor) 2) IM autoinjector variably covered (Pt assistance) 3) Branded Narcan intranasal 16

17 54 yo F low back pain, follow up Thanks for talking to me about that and prescribing that. Worried about teenage granddaughter I ve been thinking: maybe I should come off of these pills. But I sure don t want any more pain, and every time I try to stop, the pain just comes back. Ambivalence toward opioids Among a sample of adults on LTOT, 80% reported that opioids were at least moderately helpful (and 20% did not) Among those who found opioids helpful, 43% reported a desire to cut down or stop LTOT Among a sample of adults on high dose LTOT, 42% reported side effects as at least moderately bothersome Howe et al. Clin J Pain 2012; Thielke et al. Clin J Pain

18 Completely off opioids is unlikely Discontinuation is uncommon 8 35% in observational studies Following non fatal overdose, 9 in 10 receive subsequent opioids Discontinuation may improve pain and function Two published systematic reviews included 5 small randomized trials Systematic review included 45 controlled and uncontrolled studies Martin et al. JGIM 2011; Vanderlip et al. PAIN 2014; Larochelle et al. Annals 2015; Chou et al Annals 2015; Windmill et al. Cochrane Review 2013; Frank et al., in press Taper by 20% 50% per week for patients who are not addicted. The rapid detoxification literature indicates that a patient needs 20% of the previous day s dose to prevent withdrawal symptoms 18

19 Goals of opioid dose reduction or discontinuation: Slow enough to minimize symptoms and signs of opioid withdrawal should be used Individualized based on patient goals/concerns Rate of tapering: 10% of the original dose per week as a starting point Slower tapers (eg, 10% per month) might be appropriate, particularly when patients have been taking opioids for years More rapid tapers might be needed for patients at highrisk of adverse events Dowell et al. JAMA 2016 Short term risks include withdrawal, increased pain, and loss to follow up A plan that an individual patient can embrace with a significant degree of personal engagement more important than a specific protocol Dowell et al. JAMA

20 In person interviews with 24 adults with experience with LTOT & opioid tapering Opioid tapering is anxiety provoking, unpleasant and logistically challenging Frank et al. Pain Medicine The nuts & bolts 1. Non opioid pain care 2. Medication management 3. Patient engagement While we re making some medication changes, it s very important that we also work on Adjunctive medications Non pharmacologic modalities Self management strategies Psychosocial support Clear, written instructions 20

21 Evidence-based non-pharmacologic treatments for chronic pain Physical activation aerobic exercise Physical therapy Yoga Tai Chi Aquatherapy Behavioral treatments Cognitive behavioral therapy Mindfulness/meditation PMR Guided imagery Other techniques Massage Chiropractic Acupuncture Trigger point injections Botox injections IA steroid injection TENS Nerve blocks The nuts & bolts of tapering 1. Non opioid pain care 2. Medication management 3. Patient engagement I still recommend decreasing your dose. Have you thought about whether you re ready to make a change today? Just one baby step at a time I ll ask my nurse to give you a call in 3 weeks to check in Opioid medication order Rate & duration Symptomatic medications? Clear, written instructions Follow up plan Refill policy 21

22 Study sample: Veterans on LTOT undergoing voluntary opioid dose reduction (N=50) Results: Average dose decreased by 46% over 12 months Discontinuation in only 6 patients Dose reduction paused for at least 3 months in 25 patients Steady dose reduction in 10 patients, and readjusted higher in 6 patients 70% experienced a decrease or no change in pain intensity Harden et al. Pain Medicine The nuts & bolts of tapering 1. Non opioid pain care 2. Medication management 3. Patient engagement We re learning that many people actually feel better on lower doses of these medications. What concerns you most about decreasing your dose? There is no right way to go about this How about I offer you a couple of options? Goals Function/Quality of life Opioid dose Concerns, risks Shared decision making? Clear, written instructions Contingency management Provider/team access plan 22

23 Case: 54 yo F low back pain MSContin 60 bid + oxy/apap 10/325 tid = 165 mg morphine equivalents daily 15 mg MED = 9% Two tapering options: ~10%/mo Reduce long-acting first Reduce short-acting first Month MS-Contin OXY/APAP 10/325 mg Base 60 bid 3 tabs daily 1 30 qam, 4 tabs daily 60 qhs 2 30 bid 5 tabs daily 3 30 qhs 6 tabs daily 4 15 qhs 6 tabs daily 5 NONE 6 tabs daily 6 NONE 5 tabs daily Month MS-Contin OXY/APAP 10/325 mg 1 60 bid 2 tabs daily 2 60 bid 1 tab daily 3 60 bid NONE 4 30 qam 15 qpm 30 qhs NONE 5 30 bid NONE 6 30 qam, NONE 15 qhs 23

24 Tapering Opioids Take Home INDIVIDUALIZE Think 10% per month A pause can refresh Anticipate at 33-50% of original dose Tapering Opioids Take Home INDIVIDUALIZE Think 10% per month A pause can refresh Anticipate at 33-50% of original dose TALK TO YOUR PATIENTS ABOUT WHAT ADDICTION LOOKS LIKE AND HOW IT CHANGES THEIR TREATMENT 24

25 54 yo F low back pain Is it chronic pain or opioid use disorder? (decreased dose may reveal) Diagnosis of opioid use disorder 25

26 Opioid use disorder or pain treated with opioids? Tolerance? Withdrawal? Lots of time/effort spent obtaining drugs? Loss of control over use? Use despite negative consequences? The 4 C s of Addiction craving loss of control of amount or frequency of use compulsion to use use despite consequences 26

27 Treatment of opioid use disorder Abstinence only * Naltrexone Methadone maintenance Buprenorphine maintenance** *Arnato et al, Cochrane 2013, Weiss et al Arch Gen Psych 2011, Fiellin et al JAMA Int Med 2014 **Mattick et al., Cochrrane 2014 Bup/nx treats chronic pain and opioid use disorder VA retrospective cohort of 143 pts 67% retention APS scores improved MI Pain Clinic case series of 95 pts 86% patients had improvement in pain, mood, function Pade et al. JSAT 2012 Malinoff, Am J Ther

28 OUD treatment necessary but insufficient Whether MMTP or bup 31-46% mod-severe chronic pain Tsui et al Pain 2011 Mark et al J Subst Abuse Treat 2013 Barry Am J Addict 2013 Stein et al JGIM 2015 Dunn Drug Alc Dep yo tapering opioids Reduce long-acting first Reactions at Follow up Month MS-Contin OXY/APAP 10/325 mg Base 60 bid 3 tabs daily 1 30 qam, 4 tabs daily 60 qhs 2 30 bid 5 tabs daily 3 30 qhs 6 tabs daily 4 15 qhs 6 tabs daily 5 NONE 6 tabs daily 6 NONE 5 tabs daily 1: Not too bad 2: Great! 3: Shoulda done it sooner 4: no show, RF anyway 5: 2 weeks early, Tox +ccc, admits to buying extra oxy 28

29 54 yo high risk opioid vs OUD? I can get this back, it s just the pain got so bad. Give me one more chance, doc I ll just go buy more on the street 54 yo high risk opioid vs OUD? Reluctantly, you prescribe 2 week supply: MS-Contin 30 qhs + oxy/apap 6 tabs/day 8 days later, she s back in the office asking for help Induced to buprenorphine 18 mo later: stable on bup/nx 16/4 mg VL still undetectable 29

30 Part 3 Take home points Talk to patients on chronic opioid therapy about substance use disorder before it s required If opioid use disorder, stop prescribing chronic opioids and treat with buprenorphine or refer to methadone maintenance. Get your X-waiver and USE IT How do I get my X? SAMHSA list: 30

31 Resources for Clinical Support PCSS-O.ORG 31

32 Substance Use Warmline: Providing clinician-to-clinician consultation on managing substance use disorders 10 am 6 pm EST, Monday Friday The Clinician Consultation Center is pleased to offer free and confidential telephone consultation focusing on substance use evaluation and management for primary care clinicians. With special expertise in pharmacotherapy options for opioid use, our addiction medicine-certified physicians, clinical pharmacists, and nurses provide advice based on Federal treatment guidelines, up-to-date evidence, and clinical best practices. Learn more at 32