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Pain Management in Individuals with SUDs

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Pain Management in Individuals with Substance Use Disorders Jared W. Klein, MD, MPH Assistant Professor Division of General Internal Medicine University of Washington School of Medicine March 2, 2021 Panel Discussants James Darnton, MD Clinical Instructor Division of General Internal Medicine University of Washington School of Medicine Jocelyn James, MD Assistant Professor Division of General Internal Medicine University of Washington School of Medicine No conflicts of interest or relationships to discloseWe will discuss off-label use of medications Outline Chronic pain in patients taking medications for opioid use disorder (MOUD) Acute pain in patients taking MOUD Acute pain in patients with active OUD but not taking MOUD Pain in patients with OUD in prolonged remission Discussion / Q&A Definitions Acute Pain Weeks 0-6 Sub-acute Pain Weeks 6-12 Chronic Pain Weeks 12+ Definitions, cont. Moderate-Severe Pain Surgery Fractures Burns Mild-Moderate Pain Musculoskeletal Odontogenic Headaches Focus on function Case 1 52-year-old individual on methadone maintenance (110 mg/day) is seen in clinic for chronic low back pain. Pain has been present for over 15 years since a work-related injury. Has completed several courses of physical therapy, most recently was 2 years ago. Currently on permanent disability due to back pain and depression. Also has hypertension and chronic hepatitis C. Medications include: methadone (as above), sertraline 100 mg/day, acetaminophen (up to 2000 mg/day), HCTZ 25 mg daily. Case 1, cont. How would you manage this patient's chronic pain? Ask to split the methadone into 2 equal doses Start ibuprofen 600 mg TID Start oxycodone 5 mg QID PRN pain Start gabapentin 300 mg TID Another physical therapy referral % % % % % Chronic pain is common Drug Alcohol Depend. 2020 Apr 1;209:107902 Cross-sectional study of 950,000 patients at academic health system (Duke) from 2013-2018, examined rates of chronic non-cancer pain (CNCP) by SUD status, approximately 11% had any SUD, about 1.3% had OUD OUD + pain = worse outcomes? Journal of Pain Research 2020:13 PWUD with pain more likely to have difficulty accessing addiction treatment than those without pain Dose-response trend (more pain = more difficulty accessing treatment) Robust after adjusting for potential confounders Lower retention and increased likelihood of ongoing non-prescribed opioid use in patients with OUD who have pain Study of 1300 people who use drugs in Vancouver BC Adjusted for age, ethnicity, homelessness, incarceration, violence, mental illness, overdose, heroin use, prescription opioid use, methamphetamine use, and heavy alcohol use. Critical to evaluate for underlying causes Source: www.aans.org Evaluation may include careful physical exam, judicious ordering of diagnostic tests Both from American Association of Neurological Surgeons, aans.org Multimodal pain treatment is the foundation ALWAYS institute multimodal pain treatment strategies Non-opioid medications Non-pharmacologic approaches Acetaminophen Comfort measures (repositioning, ice/heat) NSAIDs Physical modalities (PT, splinting, TENS) Adjuvant agents (gabapentinoids, SNRIs) Behavioral strategies (mindfulness, CBT) Topicals Manual therapies (acupuncture, massage) Gabapentin in patients with OUD 1Addiction. 2016 Jul;111(7):1160-74. 2PLoS Med. 2017 Oct 3;14(10). Self-reported gabapentin & pregabalin misuse1 15-22% among patients with OUD (vs 1% general population) Association between combination gabapentin-opioid prescription and overdose, especially at high dose2 Emerging evidence of unhealthy gabapentin use Study of self-reported gabapentin misuse in patients with OUD compared to general population Case-control study of fatal opioid overdoses in Ontario from 1997-2013. After adjusting for confounders, odds of fatal overdose were 1.5 times higher in patients co-prescribed opioids and gabapentin, possible dose-response association Depression is common, likely undertreated 1J Am Board Fam Med. 2017 Jul-Aug;30(4):407-417. 2J Gen Intern Med. 2020 May 29. The 16% of Americans with mental illness receive >half of all opioid Rx 1 50% Most studies demonstrate at least half of patients with OUD have depression Treating depression in pts with OUD + pain OK to use SSRIs safe and modestly effective Possible preference for SNRIs Modulate pain experience in the CNS by boosting levels of serotonin and norepinephrine Duloxetine FDA approved for fibromyalgia, chronic low back pain and knee osteoarthritis Use TCAs with caution in patients on methadone Counseling should be offered and encouraged! Adjust MOUD, when possible Methadone and buprenorphine have short (~6 hours) duration of effect for pain control Increase dose or split dose of MOUD For patients on methadone who have take-home doses, they could consider splitting take-home dose BID For patients on buprenorphine, consider dosing BID-TID not always possible for patients dosed daily at opioid treatment program! Generally avoid full opioid agonists Full opioid agonists carry risk of over-sedation/overdose, diversion and disrupting recovery Exceptions for palliative care situations or end-stage diseases with substantial functional impairment If prescribe full opioid agonists: Ensure adequate shared decision-making about risks Institute close monitoring (urine toxicology, PMP checks) Establish functional endpoints Coordinate with opioid treatment program, if applicable Case 1, revisited How would you manage this patient's chronic pain? Ask to split the methadone into 2 equal doses Start ibuprofen 600 mg TID Start oxycodone 5 mg QID PRN pain Start gabapentin 300 mg TID Another physical therapy referral Case 2 26-year-old individual on buprenorphine presents with right maxillary dental pain Dentist said they need a root canal, which is scheduled for next week Has been stable on buprenorphine for 18 months Housed, lives with partner and 2 young children Case 2, cont. How would you manage this patient's buprenorphine? Stop buprenorphine 5 days before the procedure Stop buprenorphine the day before the procedure Increase buprenorphine dose after the procedure Continue buprenorphine and add oxycodone Risky time for patients with OUD 1 J Gen Intern Med. 2002 May;17(5):327-33. Acute pain Anticipate conflict over opioids1 anxiety Physicians Fear of deception Inconsistency Avoidance Patients with OUD Mistreatment Stigmatization Continue MOUD whenever possible Methadone easier to combine with full opioid agonists No preferred full opioid agonist Should coordinate with opioid treatment program Increasing evidence that full opioid agonists can be effectively added to buprenorphine to manage acute pain Theoretical preference for higher affinity full opioid agonists (e.g. hydromorphone, fentanyl) Naltrexone should be discontinued for moderate-severe acute pain requiring full opioid agonists Disrupting MOUD may destabilize recovery without improvements in acute pain management Multimodal pain treatment is still critical ALWAYS institute multimodal pain treatment strategies If available, consider involving anesthesia/pain medicine colleagues with complex cases for advanced techniques (regional blocks, ketamine, lidocaine infusions, etc.) Non-opioid medications Non-pharmacologic approaches Acetaminophen Comfort measures NSAIDs Physical modalities Adjuvant agents Behavioral strategies Topicals Manual approaches Adequately treat acute pain Anticipate tolerance Consider 50% increase above usual opioid dose Monitor closely for oversedation or undertreatment Opioid use disorder is a chronic disease Do not expect to worsen OUD by using opioids Do not expect to cure OUD by withholding opioids Institute safety measures Small quantities Frequent refills Ensure naloxone available Secure storage location Case 2, revisited How would you manage her buprenorphine? Stop buprenorphine 5 days before the procedure Stop buprenorphine the day before the procedure Increase buprenorphine dose after the procedure Continue buprenorphine and add oxycodone Case 3 32-year-old individual is admitted to the hospital with large deltoid abscess with surrounding cellulitis Started on IV vancomycin and taken to the OR for operative drainage 11-year history of opioid use, including daily heroin use for the past 6 years Previously on methadone 5 years ago but left treatment after about 6 months Case 3, cont. How would you manage this patient's withdrawal symptoms? Oxycodone 10 mg Q8 Hours Methadone 10 mg TID Loperamide, ibuprofen, clonidine Hydromorphone PCA (patient-controlled analgesia) Hospitalized patients with OUD: Key Principles Treat acute condition Manage withdrawal symptoms Address pain issues Initiate substance use treatment Maintain focus on treating the acute medical/surgical issue. To do this, it is necessary to aggressively manage withdrawal and pain. Opportunity to initiate and link with SUD treatment, but this is not necessary if patient hesitant. Important to ensure entire care team is on the same page, transparent discussions are key. Methadone for opioid withdrawal Start with 20 mg Reassess q2-3 hours, give additional 5-10 mg until withdrawal signs abate Do not exceed 40 mg in first 24 hours Next day, give total in one daily dose (may split dose for acute pain) Monitor QTc, sedation and respiratory depression Taper versus maintained dose No methadone Rx at discharge!!! Buprenorphine for opioid withdrawal OK to use buprenorphine for withdrawal Bup-nx 4-1 mg SL QID (or 8-2 mg SL BID) Low threshold to increase to 8-2 mg SL TID for pain Use may be limited by concurrent full opioid agonist use and severe acute pain Generally defer induction if anticipate need for full agonists in the near future (e.g. impending major surgery) Decision re: methadone versus buprenorphine Logistics Patient preference Harm reduction and safety measures Opioid-specific measures Use with others Carry naloxone Test for fentanyl Use a test dose first Advice around other depressants (benzos, alcohol) Cut back or avoid use while taking opioids Explore interest in treatment for other SUD As always, institute routine safety measures when prescribing Small quantities with more frequent refills Ensure naloxone available Secure storage location Be aware of opioid prescribing limits <7-day supply 7 days for non-op, 14 days for operative No specific limits 7-day supply 7-day supply 7-day supply Case 3, revisited How would you manage this patient's withdrawal symptoms? Oxycodone 10 mg Q8 Hours Methadone 10 mg TID Loperamide, ibuprofen, clonidine Hydromorphone PCA (patient-controlled analgesia) Case 4 48-year-old individual presents to clinic with right knee pain. Exam and MRI are consistent with meniscal tear and the surgeon advised arthroscopic repair. Has a history of opioid use disorder in prolonged remission, last use was over 10 years ago. Took buprenorphine-naloxone for 3 years, then gradually tapered off. Currently employed as a preschool teacher. Has a good relationship with their adult children. Case 4, cont. What advice would you give about peri-operative pain control? The risk of return to use by taking opioids post-operatively is increased. The risk of return to use by taking opioids post-operatively is similar to the general population. Higher doses of opioids might be necessary for adequate pain control given the history of opioid use disorder. The patient should reconnect with a sponsor or counselor if not already Limited data for patients in prolonged recovery Pain Med. 2018 Oct 1;19(10):1908-1915. Risk of return to use Mostly anecdotes and case reports Plausible given stress, anxiety and opioid exposure Potential protective factors Longer duration of recovery Higher engagement with recovery support (sponsor, mutual support groups, etc.) More stability of home and work environments Better adherence to mental health treatment, if applicable Recommendations for acute pain among patients in prolonged recovery Prim Care Companion J Clin Psychiatry. 2002 Aug;4(4):125-131. Proactive plan Maximize non-opioid, multimodal analgesia Enhance recovery supports Avoid former drug of choice, if possible Consider preemptively restarting MOUD, if patient amenable Clear, open communication about risks No longer physically dependent on opioids Communication: What is the patient's perspective? How worried are they? Any recent experience with opioids during recovery? Case 4, revisited What advice would you give about peri-operative pain control? The risk of return to use by taking opioids post-operatively is increased. The risk of return to use by taking opioids post-operatively is similar to the general population. Higher doses of opioids might be necessary for adequate pain control given the history of opioid use disorder. The patient should reconnect with a sponsor or counselor if not already Panel Discussion What challenges have you experienced in treating patients with OUD who present with acute or chronic pain? What are your practices for managing MOUD around the time of planned or unplanned pain episodes? What suggestions do you have for supporting patients with OUD in prolonged remission who are having pain issues? References John WS, Wu LT. Chronic non-cancer pain among adults with substance use disorders: Prevalence, characteristics, and association with opioid overdose and healthcare utilization. Drug Alcohol Depend. 2020 Apr 1;209:107902. Davis MA, Lin LA, Liu H, Sites BD. Prescription Opioid Use among Adults with Mental Health Disorders in the United States. J Am Board Fam Med. 2017 Jul-Aug;30(4):407-417. Voon P, Wang L, Nosova E, Hayashi K, Milloy MJ, Wood E, Kerr T. Greater Pain Severity is Associated with Inability to Access Addiction Treatment Among a Cohort of People Who Use Drugs. J Pain Res. 2020 Oct 1;13:2443-2449. Smith RV, Havens JR, Walsh SL. Gabapentin misuse, abuse and diversion: a systematic review. Addiction. 2016 Jul;111(7):1160-74. Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W. Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case-control study. PLoS Med. 2017 Oct 3;14(10):e1002396. References, cont. Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual mistrust in the medical care of drug users: the keys to the "narc" cabinet. J Gen Intern Med. 2002 May;17(5):327-33. Myers J, Compton P. Addressing the Potential for Perioperative Relapse in Those Recovering from Opioid Use Disorder. Pain Med. 2018 Oct 1;19(10):1908-1915. Prater CD, Zylstra RG, Miller KE. Successful Pain Management for the Recovering Addicted Patient. Prim Care Companion J Clin Psychiatry. 2002 Aug;4(4):125-131.