Chronic Pain, Opioids, & Addiction: Assessing and Managing Risk Randy Brown MD, PhD, FASAM Associate Professor, Dept of Family Medicine Director, Center for Addictive Disorders, UWHC Director, UW Addiction Medicine Fellowship Program 1
Objectives Review potential indications for opioids Review assessment & monitoring of risk Standardized instruments Aberrant behaviors Urine drug testing Managing pain + addiction 2
BUT FIRST, SOME DEFINITIONS
Opioids and Opiates Natural Morphine Codeine Opiates Opioids Semi-synthetic Heroin Oxycodone Hydrocodone Buprenorphine Synthetic Methadone Fentanyl Tramadol
Opioid Abuse = 1+ repetitively over 1 yr Use despite harm/risk Occupational impairment Legal problems Social consequences Amer Psych Assn. DSM-IV, 1994. 5
Opioid Dependence = 3+ repetitively over 1 yr Tolerance Withdrawal Physical dependence addiction Using more/longer than intended Time spent obtaining/recovering Inability to cut down/control use Use despite consequences Activities Reduced Amer Psych Assn. DSM-IV, 1994. 6
DSM-V Use Disorder 11 criteria Legal consequences replaced by craving criterion Severity modifier 2-3 criteria = mild 4-5 = moderate 6+ = severe Course modifiers Sustained/early Full/partial
INDICATIONS & INITIAL VISIT ISSUES
Mr. P 9
Indications for Considering Opioids Mod-severe pain (nociceptive > neuropathic) Functional Failure of non-opioid Tx Low-mod risk?? Alcohol/drug screening Psychiatric hx (bipolar, anti-social, trauma) Opioid-specific risk 10
Treatment Goals Goals/expectations = negotiated, realistic, measurable Realms to consider: Pain relief Function Sleep Affective distress Work/vocational retraining 11
Patient Prescriber Agreements (PPA) Informed Consent Establishes targeted benefits or goals of care Educational re: potential risks Plan of Care Documents mutual understanding of clinical care plan Articulates monitoring procedures and responses to unexpected findings o Efficacy not well established o No standard or validated form o Printed copy, signed by both patient and prescriber, given to the patient may serve as a Patient Counseling Document Cheatle MD, Savage SR. J Pain Symptom Manage. 2012 Jul;44(1):105-16. Alford D et al. www.scopeofpain.com
Primary Agent = Long-Acting (?) Because: withdrawal, euphoria, misuse misuse w/ fentanyl, methadone pain control tolerance to adverse fx Consider ceiling of 100-120mg equivalents of morphine Consider naloxone! Short-acting agent for breakthrough pain 13
Odd Short-Acting Opioids Codeine 10-15% don t convert to morphine Tramadol (Ultram)/meperidine (Demerol) Lowers Sz threshold Dilaudid Highest street value/mg ($5-10) http://streetrx.com/ 14
RISK ASSESSMENT ISSUES & TOOLS
Risk Assessment: Substance Use Screening Alcohol CAGE Single item Alcohol Use Disorders Identification Test (AUDIT, AUDIT- C) Other drugs CAGE-AID Drug Abuse Screening Test (DAST-10) NM ASSIST Opioid Risk Tool 1 /DIRE 2 1 Belgrade et al. J Pain 2006. 2 Webster et al. Pain Medicine 2005. 16
Risk Assessment: Mental Health Screening Bipolar spectrum disorders Mood Disorders Questionnaire Bipolar Spectrum Diagnostic Scale Antisocial personality disorder CCAP Depression/anxiety MDQ/PHQ-9 17
Predictors of Incident Addiction Sample = 36,605 private payor, 9,651 Medicaid; 12-54 mo observation Younger age, 18-30 (OR 5-10, pvt vs MCaid) 2+ mental health Dx (OR 2.3) Pre-index opioid dependence (OR 5.6) Dose > 120mg morphine equivalents daily (OR 2.1) Edlund et al. Drug Alcohol Dep, 2010
FOLLOW-UP ISSUES
Follow-Up: The 4 A s Analgesia Activity Adverse effects Aberrant Behaviors 20
Adherence Attending visits not related to opioids? Loss of control over opioid use? ( 2 early fill requests over 12 mo) Took opioids for indication other than pain (anxiety, stress, depression, or nonrestorative sleep)? Other substance use? 21
Aberrant Behaviors: What Do They Mean? Mrs. O Medication mishandling Inappropriate storage Overtaking Loss/theft Pseudoaddiction Aberrant behaviors due to inadequately controlled pain NOT use disorder Use disorder Diversion 22 Weissman, Haddux. Pain, 1989.
Aberrant Behaviors: Misuse Indicators Overly focused on medication rather than pain relief x 3+ visits Multiple Rx losses ( 2 /yr) Frequent calls/requests for narcotics Supplemental sources Functional deterioration Chabal et al. Clin J Pain, 1997. Ballantyne, LaForge. Pain, 2007. 23
Aberrant Behaviors: Pseudoaddiction vs. Misuse Name-brand requests (?) Aggressive complaining about need for analgesia Drug hoarding when symptoms Openly acquiring narcotics from other medical sources Unsanctioned dose COMM 24
Urine Drug Testing Identifies other substance use NOT use disorder MAY aid in detecting diversion Ms. L need to specifically order synthetic opioid testing urine dip for ph, SG, plus urine Cr & temp. results should be discussed with patient Any unexpected result should be confirmed DON T FORGET ABOUT ALCOHOL!!!25
Urine Drug Testing GC/MS confirmation Identifies specific molecules Sensitive and specific More expensive Must be aware of opioid metabolism to interpret Codeine Morphine 6-MAM Heroin 6-monoacetylmorphine Hydrocodone Hydromorphone Oxycodone Oxymorphone
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Opioid Use Disorder + CNMP AODA consultation (diagnose/treat) Treatment program Methadone treatment facility Buprenorphine Detox/taper 1. Opioid analgesic taper 2. Tramadol detox 3. Clonidine + adjuncts 28
Managing Concurrent Pain/Addiction Ensure control of substance use disorder and ongoing recovery engagement Minimize short-acting opioids, sedatives Consider buprenorphine preparations Multidisciplinary care plan Monitoring Urine drug testing Pill counts/shorter-term fills Appropriate ROIs
Some Take-Home Points Opioids effectively relieve pain, but effectiveness over long-term is unknown Use a risk/benefit framework to judge advisability of opioids Judge the treatment, not the patient Standardized instruments can facilitate visits, but are NOT diagnostic Always try to be transparent in discussions