Opiate Use Disorders and Pain in the elderly: Integrating care with the pain specialist Gabriel Paulian M.D Christopher Ong, M.D Yuliet Sanchez, M.D Uma Suryadevara, M.D No disclosures for any of the speakers! 1
Where s the pain? 2
Algorithm for a general approach to the assessment of chronic nonmalignant pain ROBERT P. JACKMAN, MD, JANEY M. PURVIS, MD, Cascades East Family Medicine Residency Program, Oregon Health and Science University, Klamath Falls, Oregon BARBARA S. MALLETT, MD, Spinal Diagnostics, Tualatin, Oregon Am Fam Physician. 2008 Nov 15;78(10):1155-1162. WHO Step Ladder Approach 3
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Are opiates indicated in my patient? Influences on therapeutic decisions: Outcomes during prior therapies Pain severity and course Age and medical comorbidities Reasonable alternatives Likelihood of addiction/abuse/diversion If they are indicated: what are the possible outcomes Critical outcomes Pain relief Function - physical and psychosocial Side effects Drug-related behaviors: abuse, addiction, pseudoaddiction, diversion 5
Barriers to Opioid Therapy Patient-related factors Fear of addiction System factors Availability in pharmacies Clinician-related factors Poor knowledge of pain management, opioid pharmacology and chemical dependency Fear of regulatory oversight 6
Opioid Therapy: what are my options? Immediate-release preparations Used mainly : opioid naïve patients acute pain dose finding during initial treatment of chronic pain rescue dosing (breakthrough pain ) Can be used for long-term management in select patients Opioid Therapy: what else do I need to know? Dose limit? Duration of opioid therapy lifetime? Tolerance Hyperalgesia 7
Opioid Therapy: Side Effects Common Constipation Somnolence, mental clouding Less common Nausea Myoclonus Pruritus Urinary retention -Sweating -Amenorrhea -Sexual dysfunction -Headache Opioid Therapy Scenario 1: 67 y/o F with PMHx of chronic knee pain secondary to severe DJD managed with OXYCODONE/APAP 5/325 1 tab po QID 8
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Opioid Therapy Scenario 2: 72 y/o M with PMHx of low back pain secondary to failed back surgery managed with METHADONE 10 mg po Q 8 hrs Opioid Therapy 10
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Psychiatric Comorbidities Depression is present in more than 50% of patients with chronic pain. Severity of pain is a strong predictor of worsening depression and health-related quality of life outcomes. Treatment options in the context of pain: Medications (SSRIs, anxiolytics, TCAs), CBT, Complementary and alternative treatment, Lifestyle changes Psychiatric Comorbidities: Depression Chronic pain is an important risk factor for suicide. Suicide Risk assessment tools in patients with pain. Consider other treatment options if patient is at a higher risk for suicide or depression: A delicate balance! 12
Psychiatric comorbidities: Anxiety Treatment in the context of pain: Antidepressants (SNRIs, TCAs) psychological treatments, other anxiolytics. Benzodiazepines: The main actions are hypnotic, anxiolytic, anticonvulsant, myorelaxant, and amnesic. Adverse effects in elderly from Benzodiazepines: psychomotor impairment, occasionally paradoxical excitement, falls and fractures, intellectual and cognitive impairment. Some Important Data: 2004 to 2008: 111% increase in the estimated number of emergency department visits involving nonmedical use of opioid analgesics. 2004 to 2008: 89% increase in such visits for benzodiazepines. From 2007-2011: Opioid prescribing rates increased 32 percent. 2010 data: Opioid analgesics were involved in 75% of pharmaceutical overdose deaths. cdc.gov 13
Benzodiazepines Data from the National Vital Statistics System multiple cause-of-death file: Benzodiazepines were involved in 31% of opioid-analgesic poisoning deaths in 2011, up from 13% in 1999. Prescribing Benzodiazepines with Opiates is DANGEROUS! Alternatives for Benzodiazepines Pain Substance Use Disorders: Another Comorbidity Chronic pain Physical dependence Tolerance Addiction Pseudoaddiction Hyperalgesia Opioid induced hyperalgesia 14
Addiction Substance Use Disorder Chronic pain and depression can predispose to benzo abuse and dependence Risk increases with age and more common among patients on multiple medications Commonly used questionnaires are less sensitive in the elderly Opioid Use screening tools SOAPP (Screener and Opioid Assessment for Patients with Pain-Revised) ORT (Opioid Risk Tool) DIRE (Diagnosis, Intractability, Risk, Efficacy Tool) SISAP (Screening Instrument for Substance Abuse Potential) 15
Ongoing assessment tools: COMM (Current Opioid Misuse Measure) ABC (Addiction Behaviors Checklist) Chabal 5-Point Checklist PMQ (Pain Medication Questionnaire) PDUQ (Prescription Drug Use Questionnaire) PADT (Pain Assessment and Documentation Tool) Working together Treatment options like CBT, Relaxation therapy and group therapy. Treat pain and psychiatric comorbidities together. Multidisciplinary treatment approach: best approach for pain management. 16