PTSD, Chronic Pain, and Opioid Use Disorder: A Case Discussion

Transcription

1 PTSD, Chronic Pain, and Opioid Use Disorder: A Case Discussion Hosted by John A. Renner, Jr., MD, DLFAPA Professor of Psychiatry Boston University School of Medicine Director, Addiction Psychiatry Residency Training Boston University Medical Center and VA Boston Healthcare System August 22, 2017

2 PCSS-O Webinar Series Presented By: Providers Clinical Support System for Opioid Therapies Funding: Substance Abuse and Mental Health Services Administration PCSSMAT Partner Organizations: American Academy of Addiction Psychiatry (lead) American Psychiatric Association 11 other national medical specialty organizations Website: Funding for this initiative was made possible (in part) by Providers Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

3 PTSD, Prescription Chronic Pain, Medications and Opioid and Use Heroin: Disorder: A Changing Case Discussion Picture Jonathan Buchholz, MD Medical Director Inpatient Psychiatry VA Puget Sound Seattle, WA August 22, 2017

4 Learning Objectives At the end of the session, participants will be able to: State challenges and opportunities associated with transitions in care for both patients and health care providers generally and those specifically related to the use of opioids chronically Discuss non-pharmacologic and pharmacologic treatments for the management of chronic, non-malignant pain Discuss criteria for diagnosing opioid use disorder Discuss the experiencing transitions middle-range theory as a framework for understanding transitions between patients and their health care providers

5 PCSS-MAT Mentoring PCSS-MAT Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid addiction. PCSS-MAT Mentors comprise a national network of trained providers with expertise in medication-assisted treatment, addictions, and clinical education. A 3-tiered mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties. The mentoring program is available at no cost. For more information on requesting or becoming a mentor, visit

6 Session Evaluation and Certificates Instructions will be provided in an sent to participants an hour after the live session Certificates are available to those who complete an evaluation Recordings of all PCSS-O webinars can be accessed at and

7 Thank You! Please direct your comments, questions, and suggestions regarding future webinars to

8 PTSD, Chronic Pain and Opioid Use Disorder: A Case Discussion Jonathan Buchholz, MD VA Puget Sound Health Care System University of Washington Department of Psychiatry

9 Disclosures No financial disclosures

10 Goals and Objectives Understand the clinical complexity and overlapping symptoms for patients experiencing co-occurring disorders of chronic pain, opioid use disorder, and PTSD including how to assess these conditions and set expectations for care Describe evidence based approaches to the treatment of co-occurring PTSD, chronic pain, and opioid use disorders Observe strategies for supervision of trainees working with patients experiencing co-occurring PTSD, chronic pain, and opioid use disorders

11 Overview and Scope Lifetime Prevalence of PTSD % in the United States (US) and Canada, higher in Veterans % prevalence in Veterans 2 More than 100 million Americans suffer chronic pain 3 Lifetime prevalence of severe opioid use disorder is estimated to occur in 8-13% of patients on chronic opioid therapy 4,5 During the past decade, the number of patients seeking substance use treatment for the primary opioid use disorder has increased sixfold Chronic pain prevalence of 66% among veterans suffering from PTSD 6

12 Overview and Scope Continued Patients with PTSD have more risk factors for pain Higher rates of other psychiatric conditions Higher rates of substance use disorders Number of general medical conditions Patients with PTSD and Chronic Depression Greater pain severity Greater pain related impairment More likely to be prescribed opioid medications for chronic pain More likely to have opioid use disorders Morasco et al 7

13 The Case of Ms. L You are supervising the addiction psychiatry fellow on the addiction treatment consult service who presents the case history prior to seeing the patient in person. Ms. L is a 48 y.o. Navy veteran Military Sexual Trauma PTSD Depression Chronic low back pain Newly diagnosed severe opioid use disorder Presents to the inpatient psychiatry service following suicide attempt

14 Pain History Radiculopathy for more than 10 years Worsening symptoms in the last 6 years Reduced functioning in the last 2 years Multiple orthopedic surgeons have recommended against fusion or other procedures Subjective pain inconsistent with imaging

15 Pain History Continued Tried various combinations of pain regimens including various opioids 12-month history of overusing her opioids Broken her pain contract on several occasions during that time ER visit 3 weeks ago asking for more opioids, physician declined 2 days after the ER visit: suicide attempt via overdose of alcohol, alprazolam, and oxycodone

16 Recent History On inpatient psychiatry Detoxified from opioids Started on venlafaxine and prazosin Suicidal ideation reduced Complaints of pain, anxiety and depression remain Chronic pain service consulted and recommended that non-narcotic treatment options be considered patient declined PCP won t prescribe opioids Referred to addiction treatment The patient reluctantly agrees - If being in a methadone clinic is my only option, then I ll do it.

17 Honestly, I don t know where to begin? The fellow appropriately asks for some guidance prior to assessing the patient. What are the clinical considerations that you would advise the fellow to assess during this consultation?

18 Assessment of symptoms and proper diagnosis: Top Down vs Bottom Up Typical history obtained: Top Down CC, HPI, ROS, PMH/PPH/Substance history, Social, FH What brings you to the hospital today? Challenges to this approach with pts experiencing multiple co-occurring disorders Current symptoms for Ms. L Insomnia Physical pain low back, legs and feet Anxiety Dysphoria Irritability Feeling detached/wanting to detached Feelings of guilt Numbness physically and emotionally Anger Poor energy Constipation, nausea, low appetite Using opioids most all day (for various reasons: sleep, pain, anxiety, avoid withdrawal) Giving up on activities she once enjoyed

19 Assessment of symptoms and proper diagnosis: Top Down vs Bottom Up cont. Bottom Up Longitudinal life history Childhood development family history Educational history Relationship history social history over time Employment history Psychiatric, medical history chronologically Current presentation Tell me what you life looked like the last time you were feeling well both emotionally and physically Fellow: I don t want to sound like a pessimist but isn t that going to take hours?

20 Establishing Diagnosis of Opioid Use Disorder Goals for treatment of opioid use disorders Craving Withdrawal Illicit Use of Opioids Side effects Goals for treatment of pain Physical Comfort Emotional wellbeing Quality of life

21 Setting Expectations and Engaging in Treatment Shared therapeutic starting point Fellow: I want to help her but I m a psychiatrist, not a pain specialist

22 Working Together in Treatment What are the patient s goals? Is there a shared starting point? Explicit description of what the treatment setting will look like Negotiating this may take more than one visit Understand your resources, capabilities, and limitations Determine your own boundaries and be up front about those

23 Case Continued The Fellow assesses the patient on the psychiatry ward and has two good clinical encounters Diagnoses: Severe opioid use disorder, PTSD, MDD & chronic pain Patient wants comprehensive treatment Doctors give me mixed messages: My psychiatrist says I should see primary care for pain, my primary care doc says I should see psychiatry and go to addiction care. It feels like everyone is passing the buck. Interested in opioid replacement therapy but terrified about what will happen without some form of opioid Worried about relapse without replacement therapy Willing to consider alternative treatments for pain

24 Creating a plan Opioid use disorder Medication options Therapy options Pain Medication options Therapy options Alternative options PTSD Therapy options Medication options PTSD Opioid Use Disorder Chronic Pain

25 Creating a plan Opioid use disorder Medication options Therapy options Pain Medication options Therapy options Alternative options PTSD Therapy options Medication options PTSD Opioid Use Disorder Buprenorphine CBT Chronic Pain

26 Creating a plan Opioid use disorder Medication options Therapy options Pain Medication options Therapy options Alternative options PTSD Therapy options Medication options PTSD Opioid Use Disorder Chronic Pain

27 Creating a plan Opioid use disorder Medication options Therapy options Pain Medication options Therapy options Alternative options PTSD Therapy options Medication options PTSD Opioid Use Disorder Chronic Pain

28 Case Continued Patient agrees to treatment in Addiction Treatment Center Fellow medications for opioid use disorder and PTSD Psychologist therapy for pain, PTSD, OUD ARNP - chronic pain management, coordination of care with PCP Question for the fellow: What are your medication options for treatment of OUD and PTSD?

29 Opioid use disorder and Chronic Pain Benefits Drawbacks Buprenorphine - Flexibility in dosing (office based) - Safer - Easier to switch to methadone if bup. fails than other way around - Patient misconceptions about pain management with bup. - More complicated to add full mu agonists for pain relief Methadone - Potentially more robust engagement from OUD perspective - More dangerous - Cannot split doses as easily up front - Longer period of titration - Less flexibility (clinic dosing) IM Naltrexone - Generally Safe - Limited evidence for opioid use disorder - Will likely not address pain

30 PTSD and Chronic Pain Benefits SSRIs - Best evidence for treatment of PTSD - If PTSD improves, pain is likely to improve SNRIs - Evidence for treatment of PTSD and some pain symptoms Drawbacks - Limited evidence for treatment of pain - Potential side effects (HTN, withdrawal) Anticonvulsants (Gabapentin, pregabalin) - May help both anxiety and neuropathic pain - Limited evidence in treatment of PTSD Prazosin - Potentially helpful with nightmares related to PTSD - Improvement in sleep can significantly improve pain - Lack of evidence for cooccurring PTSD and chronic pain

31 Structure of Treatment Integrated care approaches Substance use disorders and chronic pain Pade PTSD and chronic pain Otis PTSD and substance use disorders Mills

32 Substance use disorders and chronic pain Pade et al 2012 integrated care models Retrospective review 143 pts engaged in care at the co-occurring disorder clinic embedded within the Primary Care Service at the Albuquerque VA. 65% retention rates for >6 months Mean pain score reduction after induction onto buprenorphine/naloxone Mean daily dose 16mg BID/TID Pain treated with adjunctive measures such as non-opioid pain medications and physical therapy

33 PTSD and Chronic Pain Otis 2012 Pilot no control group, RCT currently underway 12 sessions Session 1 - Education on chronic pain and PTSD, goal setting Session 2 - Making meaning of pain and PTSD Session 3 - Thoughts/feelings related to pain and PTSD, cognitive errors Session 4 - Cognitive restructuring Session 5 Diaphragmatic breathing and progressive muscle relaxation Session 6 Avoidance and interoceptive exposure Session 7 Pacing and pleasant activities Session 8 Sleep hygiene Session 9 Safety/trust (related to pain and PTSD) Session 10 Power/control/anger (related to pain and PTSD) Session 11 Esteem/intimacy (related to pain and PTSD) Session 12 Relapse prevention and flare-up planning

34 PTSD and Substance Use Disorders Mills 2012 RCT 103 pts Intervention group > control: PTSD symptoms at 9 months SUD outcomes equal Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) 13 individual 90-minute sessions Sessions 1-4 (and throughout) - Motivational enhancement and CBT for substance use + psychoeducation relating to both disorders and their interaction Sessions In vivo exposure Sessions Imaginal exposure and cognitive therapy for PTSD Session 13 Summary

35 Case Continued Fellow begins office based buprenorphine Safety profile, ability to split dosing, chronic pain and relapse prevention Venlafaxine and prazosin for PTSD Addition history of numbness, tingling, shooting pains in my legs/feet Gabapentin started for neuropathic pain and anxiety symptoms

36 Case Continued Patient stable for 2 months from OUD perspective CBT oriented treatment for OUD and pain Patient reluctant to engage in trauma focused therapy Still in good deal of pain Avoidant of leaving house Insomnia/nightmares Feels guilty that she avoids son s soccer matches Talks about letting son down regularly

37 Case Continued Current medication list: Gabapentin 400mg po TID Buprenorphine/naloxone 6mg sublingual TID Venlafaxine 150mg po qday Prazosin 4mg po qhs Desipramine 50mg po qhs Lidocaine patch 5% Ideas for next steps? Fellow: I feel like she really needs to engage in trauma focused therapy. Is it too soon?

38 Next steps Case continued No studies for treatment of PTSD, chronic pain, substance use disorder simultaneously occurring Case She engages in hybrid of CBT and PE over next 12 weeks Patient s pain increases subjectively She remains engaged well with ARNP for treatment of pain She is attending her son s soccer games, objectively functioning better

39 Current Medications Gabapentin 600mg po TID Buprenorphine/naloxone 6mg sublingual TID Venlafaxine 225mg po qday Prazosin 12 mg po qhs Desipramine 50mg po qhs Lidocaine patch 5% Fellow: Patient is asking for an increase in buprenorphine for pain, what do you think?

40 References 1. Resnick HS, et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol. 1993;61(6): Seal K, et al. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, Am J Public Health Sep;99(9): Epub 2009 Jul Dzau VJ, Pizzo PA. JAMA. Relieving pain in America: insights from an Institute of Medicine committee Oct;312(15): Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: Comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis 2011;30: Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain 2015; 156: Shipherd et al. Veterans seeking treatment for posttraumatic stress disorder: what about comorbid chronic pain? J Rehabil Res Dev. 2007;44(2): Morasco et al. The Relationship between PTSD and Chronic Pain: mediating Role of Coping Strategies and Depression. Pain 2013; 154(4): Pade PA, et al. Prescription opioid abuse, chronic pain, and primary care: a Co-occurring Disorders Clinic in the chronic disease model. J Subst Abuse Treat Dec;43(4): Otis JD, et al. The development of an integrated treatment for Veterans with comorbid chronic pain and post-traumatic stress disorder. Pain Medicine. 2009; 10 (7):