pain and addiction: where we’ve been and where we’re going! · pain and addiction: where...

June 16, 2020

Era Kryzhanovskaya, MD

Pain and Addiction: where we’ve been and where we’re going!UCSF Continuing Medical Education

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Learning Objectives

Describe morphologies of pain and multi-modal treatment options

Develop an approach to screening for concomitant opioid use disorder (OUD) in patients on controlled substances

Identify treatment options for patients with OUD and consider COVID-19 impacts on current practices

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Roadmap

BackgroundPain

‐Definition‐Multi-modal management

Addiction‐Opioid use disorder (OUD)‐Treatment options

COVID impact Reflections and next steps

No conflicts or disclosures

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Case

TM is a 47M h/o depression and moderate lumbar spinal stenosis s/p remote L4-5 laminectomy who comes in for follow up of his back pain. His regimen for the last year has been duloxetine 30mg daily and hydrocodone-APAP 10-325mg q6hr prn pain of which he uses 3-4 pills a day. He reports no other substance use. Able to manage his job as glass blower and painter, but recently noted increased back pain at night.

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Case: Polling question

What would you suggest next for TM? A) Refer for Orthopedics for surgical evaluation B) Start morphine ER 60mg BID C) Start gabapentin 100mg qHS D) Order total spine MRI; you don’t know until you know! E) Up-titrate his duloxetine

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Background

In 20 years, we went from this…

to…

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Opioid Epidemic

New York Times, 2018

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Three Waves of Opioid Overdose Deaths

CDC 2017

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Opioid Use, Chronic pain

100 million people with chronic pain (1/3 of US population) 191 million opioid prescriptions written in 2017 Overlap of chronic pain and addiction

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Pain: Definitions!

Nociceptive pain: due to tissue injury or harmful stimulus

Neuropathic pain: due to injury of the nervous system itself

Central sensitization pain: occurs in the absence of injury, caused by overactivation of the nervous system that leads to hyperalgesia

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Multimodal Pain Treatment

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https://thecurbsiders.com/podcast/156-chronic-painGarland 2020

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Multimodal Pain Treatment: Non-opioid Rx

Finnerup 2019

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Case

TM is currently prescribed duloxetine 30mg daily and hydrocodone-APAP 10-325mg q6hr prn pain of which he uses 3-4 pills a day. For his neuropathic pain, which medication class is missing from his regimen and may be most helpful to him?

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Case: Polling question

What medication class would you suggest next for TM? A) Vitamins (specifically Vit D) B) Partial opioid agonists C) TCAs D) Gabapentinoids E) SSRIs

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Where meds work:

https://www.slideshare.net/drdhriti/opioid-analgesicVolkow 2016

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Opioids?!

Source: http://masstapp.edc.org/opioid-misuse

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Do opioids work for chronic non-cancer pain?

Few randomized controlled trials Generally short-term trials Exclusion: patients w/ mood disorders, multiple pain

conditions, SUD, use of sedatives/hypnotics Cochrane: low quality evidence suggests about 10-15%

improvement on a 10-point scale *clinically significant? SPACE trial: is there space for more than opioids in OA

management?

Presentation Title19

https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdfSource: CDC 2016

“Although opioids can reduce pain during short-term use, the clinical evidence review found INSUFFICIENT EVIDENCE to determine whether pain relief is sustained and whether function or quality of life improves with long-term opioid therapy”

Presentation Title20

Guidelines for opioid therapy

Establish and measure goals for pain and function Discuss a trial and an exit plan if/when the risks outweigh the benefits

CDC 2016 https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdfWood 2019 https://jamanetwork.com/journals/jama/fullarticle/2753128mytopcare.org

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Why do we care about doses?

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Why do we care about doses?

One factor in connection to addiction

Risk of addiction from chronic opioids is hard to define: 3-26%

Volkow 2016Soran 2018

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Roadmap

BackgroundPain

‐Definition‐Multi-modal management

Addiction‐Opioid use disorder (OUD)‐Treatment options

COVID impactReflections and next steps

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Case Continued: Polling question

TM misses a few appointments. He’s on your schedule for tomorrow, and during pre-rounding, you notice his utox from that last visit shows hydrocodone, hydromorphone, and oxycodone. Additionally, he recently requested an early refill, reported missing an art exhibition that was supposed to feature his work last month, and told another provider he stopped taking his duloxetine.

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Case: Polling question

What would you do next for TM? A) Refer to CBT: no time like the present to start! B) Stop hydrocodone-APAP, start Morphine ER 60mg BID C) Start Gabapentin 300mg qHS with uptitration to TID D) Recommend he restart duloxetine; that NNT is so good! E) Identify aberrant medication taking behaviors and

screen for substance use disorders

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Dependence vs Addiction

Physical dependence‐ Biological adaptation‐ Withdrawal, Tolerance

Addiction‐ Behavioral maladaptation (loss of control, craving, continued use

despite harm)

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Overlap

Soran 2018

Chronic Pain

Opioids

OUD

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Opioid Use Disorder (OUD)

How to diagnose‐ DSM-5‐ 4R’s, 4C’s‐ Use + consequences of use

What you may see in clinic or hospitalWithdrawal Uncontrolled pain (10% of patient with chronic pain have OUD) Skin and Soft Tissue Infections, Endocarditis, Osteomyelitis TraumaOverdose

The 4R’s-Role failure-Relationship trouble-Risk of bodily harm-Repeated attempts to cut back

The 4C’s-Control (loss of it)-Craving-Compulsion to use-Consequences of use

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Why treat OUD?

Decrease mortality Chronic disease requiring chronic medication Reduce cravings Detox doesn’t last

Chutuape 2001Sordo 2017

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Medications for OUD

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Medications for OUD

, OTP

Evidence based tx options: methadone, buprenorphine, IM naltrexone

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Medications for OUD: Methadone

Agonist therapy At licensed OTP w/ counseling, frequent UDS Observed ingestion of Methadone (until ready for take homes) Peak level in 4 hours, wide variability in half-life Metabolized in liver Doses individualized EKG for QTc

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Medications for OUD: Buprenorphine

Partial mu and delta opioid agonist Ceiling effect on respiratory

depression Poor oral bioavailability Half life >24h, high affinity Mono or combo product DATA 2000 Waiver needed Start at home or in-office

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Medications for OUD: How to choose?

Co-morbidities? Ability to take daily medication? Start on inpatient? Whatever the patient is willing to take!

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Case Continued: Polling question

TM returns to clinic interested in buprenorphine treatment after thinking about your last visit together. You had discussed your concern for the development of opioid use disorder (OUD). He is worried about his pain being addressed if he’s on treatment for OUD.

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Case: Polling question

What would you tell TM next? A) He will not need extra pain medication on top of

buprenorphine B) Buprenorphine is an effective analgesic, and if he has

new pain, full opioid agonists can be added C) TCA can be up-titrated if needed for his pain, but no

other opioids will be added D) Regional nerve blocks and interventional approaches

will be considered as mainstay of treatment for his pain E) Oxycodone 5mg daily prn can be added to

buprenorphine to help his pain

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Pain and medication for OUD

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Harm Reduction

Prescribe Naloxone for all! Safe injection practices

(and facilities), needle exchanges

Vaccinations Treat infectious dz PrEP

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Roadmap

Background Pain

‐Definition‐Multi-modal management

Addiction‐Opioid use disorder (OUD)‐Treatment options

COVID impact Reflections and next steps

Presentation Title43

COVID-19 effects

Patient:‐ Increased susceptibility?‐ Increased overdose events‐ Functional assessments

Environment:‐ Safe places to self-isolate‐ OTP, prescribing changes‐ Telehealth: exacerbating disparities in

care? Opportunities

Slat 2020

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Reflection

• One change you plan on implementing in your own practice.

• One take-home point that will help you empower your home institution to understand, diagnose, and promote treatment of pain and addiction for patients locally.

Take 1 minute…

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Thank You!

irina.kryzhanovskaya@ucsf.edu

Questions? Collaboration?

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Additional resources

Real time support/questions: UCSF Substance use warmline: (855) 300‐3595, 6am‐5pm PST

Bup and methadone guide: SAMHSA, TIP 63: Medications for OUD

Bup protocols, ordersets, guides: www.bridgetotreatment.org

Bup telemedicine/guide for rural areas: www.oregonechonetwork.org

Bup and pain: www.ncbi.nlm.nih.gov/pubmed/31433765 ‐PMID: 31433765

Bup DATA2000 X Waiver PCSS: www.pcssnow.org/medication‐assisted‐treatment OR

Bup DATA2000 X Waiver ASAM: elearning.asam.org/buprenorphine‐waiver‐course

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Opioid Use

>50% obtained from friend, relative