MANAGING PAIN IN PATIENTS WITH SUBSTANCE USE DISORDER Melissa B. Weimer, DO, MCR Chief of Behavioral Health & Addiction Medicine St.

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1 MANAGING PAIN IN PATIENTS WITH SUBSTANCE USE DISORDER Melissa B. Weimer, DO, MCR Chief of Behavioral Health & Addiction Medicine St. Peter s Health Partners, Albany, NY Assistant Professor of Medicine, OHSU May 1, 2018

2 Disclosures Speaker Melissa Weimer, DO, has nothing to disclose Planning Committee: The members of the planning committee (Jessica Gregg, Todd Korthuis, Melissa Weimer, John Mahan, Laura Heesacker, O Nesha Cochran, and Chris Colasurdo) have nothing to disclose.

3 Learning Objectives Discuss 3 cases that review the following Explain how pain and opioid use disorder (OUD) activate the same neurobiological pathways in the brain Recognize that differentiating opioid use disorder from pain is a complex task Identify key features of opioid use disorder Identify ways to improve pain treatment in patients with opioid use disorders

4 CASE 1 35 yo female with chronic daily migraine and diffuse myofascial pain who has been prescribed opioids for 5 years after the birth of her daughter. The patient has severe depression and anxiety, chronic nausea, history of adverse childhood experience (neglect as a child), and obesity. She is a stay at home mother to her 2 children, but frequently has to put the children in daycare because she can not care for them when she has severe migraines. She is also prescribed chronic high dose benzodiazepines by a psychiatrist. She has been cited by the hospital as a frequent utilizer of services due to >10 ED visits in a year for nausea, vomiting, and severe migraine. The patient has a history of losing her opioid prescription, obtaining opioids from more than one provider, being allergic to most other pain medication options, missing appointments with her outpatient providers, and frequently asking for opioid dose increases.

5 Case: Thought Questions Does this patient have pain? Does this patient have an opioid use disorder? What factors place this patient at risk for an opioid use disorder? What can you do to help this patient?

6 Sleep Disturbance Secondary Physical Problems Substance Misuse Pain OUD Anxiety Depression PTSD Functional Disabilities Cognitive Distortions Increased Stresses When Opioid use disorder and pain co-occur they may reinforce one another. Need to address both to successfully treat pain, but OUD will always prevail.

7 Understanding Reward and Emotion in Chronic Pain Reward learning processes may contribute to persistence and amplification of pain SBP = subacute back pain CBP = chronic back pain Hashmi JA et al, 2013

8 The Reward System in Pain & Substance Use Disorder -Pain RELIEF seeking, like addictive substances, can activate the reward pathway through dopamine -Over time, pain relief seeking behaviors can mirror substance use disorder -Adding opioids, which inherently activate dopamine in the brain, to an already imbalanced reward system can facilitate opioid use disorder in some people

9 Reward Transmitters Implicated in the Motivational Effects of Drugs of Abuse Positive Hedonic Effects Dopamine Opioid Peptides Serotonin GABA Negative Hedonic Effects of Withdrawal Dopamine dysphoria Opioid Peptides pain Serotonin dysphoria GABA anxiety, panic attacks Koob, Volkow, Neuropsychopharmacology, 2010.

10 Anti-Reward Transmitters Implicated in the Motivation Effects of Drugs of Abuse Positive Hedonic Effects: The Dark Side of Addiction Dynorphin dysphoria Corticotropin-Releasing Factor (CRF) stress Norepinephrine stress These are ACTIVATED in amygdala and ventral striatum during withdrawal Koob, Volkow, Neuropsychopharmacology, 2010.

11 Who is primed to potentially develop OUD? Younger patients (<45) History of mental illness History of substance use disorder or Family Hx of substance use disorder Tobacco, alcohol History of childhood abuse or neglect Higher dose opioid exposure Possible that certain pain issues are more likely to develop (nonspecific pain, headaches) Edlund MJ, Martin BC, Devries A, Fan MY, Braden JB, Sullivan MD. Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J Pain Jan;26(1):1-8.

12 Opioid Prescription Behaviors Inconsistent health care use patterns missed appointments, lack of engagement with non medication treatments, lack of follow through with recommendations Problematic medication behavior (escalating doses, early refills) Functional stagnation, loss of roles Multiple Prescribers Extreme difficulty with even a slow opioid taper Family or friend concerns Correlating DSM-5 criteria -Given up or reduced important activities -Withdrawal -Tolerance -Possible Craving -Inability to fulfill role obligations -Great deal of time spent to obtain substance -Unsuccessful efforts to cut down or control -Taken in larger amounts or over longer period of time than intended -Social or interpersonal problems due to use TOTAL = 8 out of 11, SEVERE OUD

13 Opioid Use Disorder in Clinical Practice The 4 C s Loss of Control Compulsive use Continued use despite harms Craving Savage SR, et al. J Pain Symptom Manage. 2003;26:

14 Case: Thought Questions Does this patient have pain? YES Does this patient have an opioid use disorder? YES loss of roles, continued use despite harms, tolerance, withdrawal, great deal of time spent to use, pain relief craving What factors place this patient at risk for an opioid use disorder? Personality traits Young age of opioid initiation Concomitant use of benzodiazepines, possible synergism or cross addiction/dependency Mental illness placing at greater vulnerability for chemical coping Adverse childhood experiences History of medication non-adherence (lost prescriptions, possible compulsive use or medication) Possible frequent bouts of opioid withdrawal from overuse of opioids causing negative affective motivation and craving 14

15 Case: Thought Questions What can you do to help this patient? Identify underlying biopsychosocial and spiritual factors that are contributing to her pain Guide her toward activities and treatment modalities that increase pain coping Limit use of addictive drugs or medications, tobacco, fast-acting analgesics, etc. Social reinforcement, problem-solving, effective emotional coping, small goal achievement, quality of life activities Offer her safe and effective treatment for her pain and opioid use disorder Buprenorphine turned out to be highly effective for her pain and OUD treatment OUTCOME = patient successfully inducted onto buprenorphine, started caring more for her kids, and started a small business, no longer using opioid analgesics, ED visits stopped 15

16 Case 2 46 yo man with history of IV heroin use 25 years ago (in long term remission), panic disorder, and chronic knee osteoarthritis. He is a patient of one of your colleagues who is on vacation. The patient is prescribed oxycodone IR 15mg up to 6 tabs per day for the last 5 years. He works full time as a supervisor at a call center. He states he attends water aerobics on the weekends, but he remains overweight. He comes to see you because he needs an urgent medication refill due to a documented error with the prescription on your colleague s part. He has not had his medication for 2 days when you see him. He denies overuse of his medication and appears to take his medication appropriately per the PDMP. There is no mention of misuse in your colleague s notes. The patient reports that the oxycodone no longer works very well and he finds that his pain is increasing. Urine drug test is negative for all substances but oxycodone. The patient is in opioid withdrawal when you see him.

17 Case: Thought Questions Does this patient have pain? Does this patient have an opioid use disorder? What factors place this patient at risk for an opioid use disorder? What can you do to help this patient?

18 Case: Thought Questions Does this patient have pain? YES Does this patient have an opioid use disorder? Not based on DSM-5 criteria, self-report, or documented report. Tolerance and withdrawal criteria are not met for opioids taken as prescribed. What factors place this patient at risk for an opioid use disorder? Panic Disorder, History of substance use disorder, Age What can you do to help this patient? Evaluate risk vs benefit Provide a limited quantity refill of his prescription until your colleague is back Encourage adjuvant treatments, weight loss

19 Case 3 Josh is a 32 yo man with history of opioid use disorder (IV heroin) x 10 years and anxiety who presents to the hospital for resection of a sarcoma of the left thigh. He states he has been using illicit buprenorphine for the last 1 year and has been abstinent from opioids. Urine drug test confirms abstinence from opioids other than buprenorphine. He begs you to continue his buprenorphine despite having a surgery scheduled in 2 days. What do you do?? 19

20 Continue buprenorphine/naloxone! Get patient stabilized on buprenorphine/naloxone Consider dosing BID or TID Use PCA vs IR opioids for pain from surgery Competitive binding of hydromorphone and fentanyl Add adjuvant meds Pre-surgery gabapentin, NSAIDS, acetaminophen Taper opioids prior to discharge or monitor closely after discharge, limited supply Refer for ongoing buprenorphine/naloxone treatment 20

21 Alternative treatment Switch to methadone Do not exceed 30-40mg on day 1 of treatment Dose BID or TID for pain relief Increase dose by 5mg every 3-5 days PRN Use additional opioids for pain relief Use adjuvants Consider re-induction of buprenorphine/naloxone after surgery* OR continue methadone with referral to methadone treatment program 21*would need to be off of methadone a minimum of hours prior to switching to buprenorphine/naloxone

22 Summary Coupled with complex social, psychological, and biological stresses, certain people can be primed for development of severe chronic, complex pain and opioid use disorder Both substance use disorder (SUD) and pain-relief seeking behaviors activate, and over-stress, the reward system In both SUD and pain, when the reward system is over-activated, anti-reward neurotransmitters in the limbic system are enhanced, causing stress, negative affect, impulsivity, inducing compulsive behaviors to alleviate feeling lousy

23 Thank you! treating-chronic-pain-core-curriculum/

24 Pain Treatment in Opioid Use Disorder Engage patient General Principles Comprehensively evaluate the pain Treat pain safely and effectively with evidence based treatments Address pain facilitators including substance withdrawal Address opioid use disorder Obtain your buprenorphine waiver!

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