MANAGING PAIN IN PATIENTS WITH SUBSTANCE USE DISORDER

MANAGING PAIN IN PATIENTS WITH SUBSTANCE USE DISORDER Melissa B. Weimer, DO, MCR Chief of Behavioral Health & Addiction Medicine St. Peter s Health Partners Grand Rounds October 11, 2017

Disclosures One time lecture sponsored by Indivior about overlap of pain and opioid dependence without mention of medication for which I received honorarium.

Learning Objectives 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

CASE 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.

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?

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.

What is the underlying neurobiological mechanism that explains the complex interaction between pain and opioid use disorder?

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

The Reward System in Pain & Substance Use Disorder A Quick Decision-Making Process: 1. Dopamine neurons from Ventral Tegmental Area (VTA) estimate value of reward/relief-seeking opportunity 2. Nucleus Accumbens (NAc) listens, makes decision to proceed 3. Frontal cortex also receives information from VTA, can inhibit NAc, but is slow and may be impaired https://www.oist.jp/news-center/photos/dopamine-pathways ** The larger the dopamine input, the more likely you are to do that behavior

So What s the Problem? The reward system is crucial for survival; if out of balance, it takes over: impulsivity, search for immediate gratification, unable to tolerate distress Addictive drugs and search for pain relief can dump tons of dopamine into these circuits Addictive drugs increase activity in these neurons, or prolong actions of neurotransmitters they release New research show pain relief activates these neurons to drive habitual pain relief seeking Trafton, 2015

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.

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.

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 In both SUD and chronic pain, the executive function of the pre-frontal cortex is impaired, unable to exert control over ventral striatum and limbic system, preventing activities that promote recovery

Implications for Chronic Pain All about dysregulated dopamine People with dysregulated dopamine systems are more likely to develop chronic pain: Acute injury chronic pain Drugs that increase dopamine (i.e. opioids) chronic pain Smokers and people given high dose opioids after injury chronic pain even after injury heals Trafton, 2015

Other Implications for Pain The addicted brain may amplify pain to justify a substance it craves Alternating withdrawal and intoxication can physiologically drive pain (sympathetic and psychomotor activation) Intoxication may mask pain and permit recurrent injury or overuse Intoxication impairs adherence to treatment plan

Learning Objectives 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

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;26:655-667.

Features of Opioid Use Disorder Inconsistent health care use patterns missed appointments, lack of engagement with non-medication treatments, lack of follow through with recommendations Illicit drug use Problematic medication behavior (escalating doses, early refills) Family concerns about use Functional stagnation, loss of roles Extreme difficulty with even a slow opioid taper Signs/symptoms of drug use (e.g., intoxication, overdose, track marks) Implications Concern comes from the pattern or the severity Differential diagnosis Butler et al. Pain. 2007

Learning Objectives 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 ways to improve pain treatment in patients with opioid use disorders

Pain Treatment in Opioid Use Disorder Engage patient General Principles Treat pain safely and effectively Address opioid use disorder Counseling and medication may be needed Address pain facilitators including substance withdrawal

Listen to and Engage Patient Past experiences can shape treatment choices Perceptions and expectations of treatment efficacy impacts outcomes Investment in plan facilitates cooperation Plan treatment when pain anticipated Engagement in self-management critical to chronic pain treatment, helpful for all pain Focus on non-medication modalities

Treat Pain Safely and Effectively Reduce or resolve underlying pain causes when possible Provide appropriate pain relief Non-medication approaches when effective, safe, easily available and acceptable to patient Less-rewarding meds when safe and effective Potentially rewarding medications when needed with appropriate limits on use Plan treatment when pain anticipated (eg for elective procedures or surgery)

Address Pain Facilitators Commonly: Acute pain Anxiety, PTSD, sleep disturbance, substance issues, substance withdrawal (particularly opioid withdrawal) Chronic non-cancer pain Anxiety, PTSD, sleep disturbance, substance issues, depression, functional losses, learning, and reward Terminal pain Anxiety, PTSD, sleep disturbance, substance issues, depression, functional losses, spiritual challenges, grief over impending losses

Address Opioid Use Disorder Acknowledge the challenge Assure not an obstacle to working for analgesia Encourage and support recovery Discuss what has been valuable for patient Identify or intensify psychosocial support Substance use counselor, self help groups, sponsor, faith-based interventions, mindfulness, etc. Continue or offer pharmacologic support like methadone or buprenorphine Assure safety: limited access and supply 3 to 5 day supply of opioids, if prescribed

Address Opioid Use Disorder Treat withdrawal as appropriate Recognize that if you do not treat withdrawal safely and effectively, pain will never be treated Options: Methadone or Buprenorphine in hospital Outpatient: Buprenorphine only Opioid Treatment Program: Methadone Anticipate opioid tolerance in opioid-dependent individuals Be aware of opioid reward effects

Address Opioid Use Disorder Use Medication Treatment Options methadone and buprenorphine Versus very careful monitoring of IR medication for a limited time In acute pain, focus on relief in the initial period* BEWARE the Opioid Debt Do not fall trap to the initial period that never ends. Transient reward won t likely affect long-term course of opioid use disorder

CASE 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 recurrent ED visits for nausea, vomiting, and severe migraine. The patient has a history of losing her opioid prescription, obtaining opioids from another provider, being allergic to most other pain medication options, missing appointments, and frequently asking for opioid dose increases.

Case: Thought Questions Does this patient have pain? Yes Does this patient have an opioid use disorder? Yes What factors place this patient at risk for an opioid use disorder? Young age, adverse childhood experience, mental illness, opioid exposure What can you do to help this patient? Provide referral for treatment and/or medication treatment, patient would likely respond well to medication treatment for her opioid use disorder

Same Case Patient gets referred for a Nissen fundoplication given severe gastritis and concern for ongoing ulcer disease. Patient is very concerned about pain relief after the procedure. Approach: Speak with treatment provider Plan pain management for a limited time per expected recovery Limit Rx at discharge and refer back to treatment Patient will very well need methadone or buprenorphine, if not already on the medication

Thank you! Melissa.Weimer@sphp.com www.pcss-o.org https://pcss-o.org/education-training/core-curriculum/