managing patients with pain, psychiatric co … · disorders and addiction in ... managing patients...

Managing Patients with Pain, Psychiatric Co-Morbidity &

Addiction

October 23, 2010

John A. Renner Jr., MD, CAS Division of Psychiatry

Boston University School of Medicine

Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction

Managing Patients with Pain,

Psychiatric Co-Morbidity &

Addiction

John A. Renner Jr., MD, CAS

Division of Psychiatry

Boston University School of Medicine

October 23, 2010

Renner Psych Co-Morbidity

DR. JOHN RENNER: Good morning. By way of disclosure, I just want to mention that I have some stock

in Johnson & Johnson. This is the material that we’re going to cover with the talk today.


Roadmap

• Prevalence of Co-Occurring Psychiatric

Disorders and Addiction in Chronic Pain

Patients

• Treating Co-Occurring Psychiatric Disorders in

Chronic Pain Patients

• Diagnosing Addiction and Substance Abuse in


• Treating Co-Occurring Addiction in Chronic Pain

Patients

We’ll begin by discussing the prevalence of co-occurring psychiatric disorders and addiction in chronic

pain patients; then talk a little bit about how you treat co-occurring psychiatric disorders; then shift to

diagnosing addiction and substance abuse in chronic pain patients; and finally, treating co-occurring

addiction in chronic pain.

Start with prevalence.


Psychiatric Co-Morbidity &

Chronic PainCONDITION Current Incidence in


Incidence in the General

Population

Depression 45 % 5 %

Anxiety Disorders 16.5 % to 50 % 3 % to 8 %

Personality Disorders 31 % to 81 % 10 % to 18 %

PTSD 20 % to 34 % 1 % general population

20 % combat veterans

3.5 % to 15 % in civilians

with trauma

Substance Use Disorders 15 % to 28 % 10 %

Somatoform Disorders 97 % in CLBP patients in

inpatient rehab program

unknown

This slide captures some of the more common psychiatric disorders and gives you some indication of

how common this is in chronic pain patients. You’ll see with depression, significantly more depression

than in the general population, similarly in anxiety disorders, personality disorders, PTSD the range can

be from 20% to 34%. There you have to look at the populations that you’re comparing this to. Only 1%

of the general population has PTSD, but if you work at the VA where I am, 20% of combat vets are going

to have PTSD, and civilians with trauma the range is 3% to 15%, so it can be a common problem.

Substance use disorders, it ranges to about 10% in the general population but almost three times as high

in individuals with chronic pain problems. Somatoform disorders, we really don’t have good data for the

incidents in the general population, but in chronic low back pain patients and in-patient rehab, it goes as

high as 97%, so there’s really an undetermined range with somatoform disorders.


Pain & Depression

• Among patients with Major Depressive Disorder

(MDD), a significantly higher proportion reported

chronic (i.e., non-disabling or disabling) pain than

those without MDD (66% versus 43%, respectively).

• Disabling chronic pain was present in 41% of those

with MDD versus 10% of those without MDD.

Arnow BA et al Psychosomatic Medicine 2006;68:262-268

This slide captures some of the data on pain and depression. Among patients with major depressive

disorder, significantly higher proportion reported chronic pain than those without that. They’re at 66%

versus 43%. Disabling chronic pain was present in 41% of those with major depression versus only 10%

of those without major depression, so again, you can see the higher risk in the chronic pain patients.


Pain, Depression & Anxiety

Compared to pain patients without MDD,

patients with co-morbid MDD and disabling

chronic pain had

• significantly poorer quality of life,

• greater somatic symptom severity,

• a higher prevalence of panic disorder and

• a six-fold greater prevalence of anxiety

Arnow BA et al Psychosomatic Medicine 2006;68:262-268

The other point that I want to make is that there’s a very high co-morbidity between depression and

anxiety disorders. People with chronic pain, major depression, have poor quality of life, increased

somatic symptoms, higher prevalence of panic disorder, and more than six-fold greater prevalence of

anxiety disorders, so very high co-occurring incidents of depression and anxiety disorders.

The depression may be more obvious to you, but if you get any sense that your patient is depressed, you

need to screen them for that and then you need to also ask questions about anxiety disorders. They are

going to be very common in the same patients.


Psychiatric Co-Morbidity & Chronic Pain

Summary

• There is a high incidence of depression, anxiety

disorders and substance abuse disorders in

chronic pain patients

• Depression and various anxiety disorders are

often seen in the same patient

• Attention to assessment and treatment of chronic

pain and concurrent depression/anxiety and

substance use disorders seems necessary for

the best outcomes

I think if you have any suspicion at all, particularly about depression in chronic pain patients, I think it’s

really important as part of your standard management that you screen them for depression and anxiety

disorders and substance use disorders.


Roadmap


Disorders and Addiction in Chronic Pain Patients

• Treating Co-Occurring Psychiatric Disorders

in Chronic Pain Patients

• Diagnosing Addiction and substance Abuse in



Patients

How do you treat co-occurring psychiatric disorders in chronic pain patients?


Optimized Antidepressant Therapy and Pain

Self-management in Primary Care Patients

with Depression and Musculoskeletal Pain: A

Randomized Controlled Trial

• Optimized antidepressant therapy along with a pain self-management program produced significant reductions in depression severity and moderate reductions in pain severity and disability at 12 months

• Reductions in depression and pain were seen

early (1 month) and sustained

Kroenke K, Bair M, Damush T et al. JAMA 2009; 301(20): 2099-2110.

First of all is that you really want to optimize self-management of the pain and depression. This looks at

one trial where they optimized antidepressant therapy by combining it with the pain self-management

program. That produced significant reduction in the depression severity, moderate reduction in the

pain severity; so interestingly enough, you’re probably going to see better response to depression than

you are necessarily to see improvement with the pain. If you do see improvement with depression,

you’ll probably see it relatively early within the first or second months of treatment.


Comparing Antidepressants

Nefazodone Fluoxetine Sertraline Paroxetine Citalopram Venlafaxine Bupropion

Efficacy yes yes yes yes yes yes yes

+ Sleep helps

Anxiety helps helps

Sexual

Dysfct

Min. 58% 61% 68% 69% Min.

Weight none yes yes yes yes yes none

The second point I would want to make is that for treating both the depression and co-occurring anxiety,

you’re most common pharmacotherapy is probably going to be the SSRIs. Though this slide compares a

variety of antidepressants, you’ll see that the efficacy across this range of antidepressants is fairly

comparable. They’re all effective. Nefazodone, or Serzone, probably works best in terms of improving

sleep. It works best in terms of reducing anxiety. Paroxetine is the only other SSRI that has a very

specific benefit for anxiety. One of the problems with nefazodone is panic damage. There is a black box

warning with this drug, but in patients who can tolerate it; it may be a very effective drug to use.

As you can see with all of these drugs, there are problems with sexual dysfunction, problems with

weight gain, except for bupropion and nefazodone, so there are side effects that you need to be

concerned with all of these medications, but I’d look particularly at using paroxetine and nefazodone as

medications that maybe helpful with patients with co-occurring pain, depression, and anxiety.


General Principles:

Management of Psychiatric Co-Morbidity in


• Standard pharmacotherapy for depression and anxiety

– Choose non-abusable medications

–Adequate doses for adequate time

• Refer for Cognitive Behavioral Therapy

• Caution with benzodiazepines

– State low; go slow

–Non-refillable prescriptions

– Monitor carefully

Pick standard antidepressant meds that you’re comfortable with. Make sure you’re using adequate

doses and patients need to be on them for at least a month if you’re going to see an adequate response.

You always, whenever possible, want to combine antidepressant therapy with cognitive behavior

therapy. There’s no question that the treatment outcome is improved if you combine cognitive

behavior therapy, plus the antidepressant. In some cases, you may want to use benzodiazepines, but

here because of the risk benefit you want to start with low doses, go carefully. Monitor their

prescriptions more carefully, and just be aware that there may be a higher risk for abuse.


Anxiety Disorders:

The Role of Benzodiazepines

• Comprehensive literature review

• Efficacy demonstrated for: Generalized Anxiety

Disorder, Panic Disorder and Agoraphobia

• Probably efficacy for: Social Phobia, Alcohol-induced

anxiety disorders

• Little evidence of added risk for medication abuse or

increased relapsed BUT avoid use in primary sedative-

hypnotic addicts

Posternak, Mueller. Am J Addict. 2001;10:48-68

If you look at the questions about when should you consider benzodiazepines, there is efficacy for

treating general anxiety disorder, panic disorder, and agoraphobia. There’s probable efficacy for social

phobia. Alcohol-induced anxiety disorders and there’s really little added risk for medication abuse or

increased relapse, except in individuals who are primary sedative-hypnotic addicts.

If you’ve got any individual with a clear cut history of prior benzo abuse, those are the people you really

have to be extremely careful about and avoid use; otherwise, the increased abuse of benzos is not very

different in psychiatric patients or in addicted patients. It is slightly higher in those two groups than in

the general population, but not dramatically so. I think there’s some over exaggerated concern about

using benzodiazepines. By and large, they should never be your first choice with pain patients, and they

should only be considered if patients have failed to respond to less abuse able medications.


Treatment RecommendationsPsychiatric Treatment in Patients with

Chronic Pain

• Psychiatric medications

Depression – SSRIs; Nefazodone

Generalized Anxiety Disorder – Buspirone; SSRIs

Panic Disorder – SSRIs; Nefazodone

Social Anxiety – Paroxetine

PTSD – SSRIs & Prazosin

Bipolar – Valproate

This slide just lists the variety of psychiatric conditions and the most common medications that we

would recommend for their use. There certainly are other options but these are the most common: For

depression, start with the SSRIs. If they don’t work, I would consider nefazodone; with generalized

anxiety disorder, buspirone in higher doses than is normally prescribed and SSRIs; panic disorder, again,

SSRIs and nefazodone; social anxiety, paroxetine; for PTSD, paroxetine and citalopram. Prazosin is very

effective for PTSD-induced nightmares*; and for bipolar disorder, my first choice would be valproate.

*Off-label use.


Treatment RecommendationsPsychiatric Treatment in Patients with

Chronic Pain

• Counseling

Cognitive Behavioral Therapy (CBT)

Motivational Enhancement Therapy (MET)

Twelve Step Facilitation (TSF)

Cognitive Processing Therapy (CPT)

• Self health groups (i.e., AA, NA)

I would also, again, emphasize the importance of adding cognitive behavior therapy. Cognitive

processing therapy is a new approach that we’re using for PTSD and that’s of particular benefit in that

subset of patients. Also, if you have any concerns about potential abuse or people with prior addiction

histories, I would make sure they’re still connected with AA or NA.


Roadmap





• Diagnosing Addiction and Substance Abuse

in Chronic Pain Patients


Patients

Let’s move more specifically to diagnosing addiction and substance abuse in chronic pain patients.


Hierarchy of Risk for Abuse of

Opioids

• Active opioid dependence

• History of opioid dependence

• Abuse of other drugs or alcohol

• Inadequately treated pain symptoms

• Other psychiatric co-morbidity

• Family history of drug/alcohol dependence

First of all, you need to be aware of what your risks are. First of all, any active opioid dependence is

obviously a situation where you’re going to get concerned, but that doesn’t mean that you’re really

going to deny treatment to people. You just need to be much more cautious. If someone has a history

of opioid dependence though they’re not currently in trouble, that just puts them at higher risk. Risk of

any other classes of drugs puts them at risk.

Inadequately treated pain syndromes; this I think is something that physicians often don’t consider and

sometimes while they’re well intended, they are overly conservative in treating pain in individuals with

addiction histories. I think the reality is that by under treating pain in these patients, you’re actually

more likely to precipitate new drug abuse. I think that you need to really be sure that despite their

history they get adequate treatment for current and existing pain problems. Any other psychiatric co-

morbidity will simply increase the risks, and any family history of drug or alcohol dependence will

increase the risk.


Diagnostic Challenges:Opioid Addiction in Pain Patients on Opioid Therapy

“Opioid Dependence”

3 or more criteria occurring over 12 months

• Tolerance – YES

• Withdrawal/physical dependence – YES

• Taken in larger amounts or over longer period – MAYBE

• Unsuccessful efforts to cut down or control – MAYBE

• Great deal of time spent to obtain substance – MAYBE

• Important activities given up or reduced – MAYBE

• Continued use despite harm – MAYBE

APA DSM IV-TR 2000

This slide lists the requirements, according to DSM IV, for the diagnosis of substance abuse and in this

case opiate dependence. There are seven criteria. You have to have three criteria present at the same

time during one 12-month period. Tolerance and withdrawal are going to be present in all of these

patients if they are on chronic opiate treatment. The other behaviors all are sort of various reflections

of the loss of control that was mentioned earlier, so you only need one of these other behaviors plus

tolerance and withdrawal in order to meet the criteria for opiate dependence.


Diagnostic Challenges:Opioid Addiction in Pain Patients on Opioid Therapy

The 4 C’s of “Addiction”

• Loss of Control

• Use Despite Consequences

• Compulsive use

• Craving

Savage SR 2002

This is the same slide that you saw earlier.


Roadmap





• Diagnosing Addiction and Substance Abuse in


• Treating Co-Occurring Addiction in Chronic

Pain Patients

For the latter part of this talk, I want to look at managing co-occurring addiction in chronic pain patients.

Here, I just want to stress again the fact that someone is addicted does not mean they’re ineligible for

pain treatment. We certainly see lots of people in our addiction programs that have a great deal of

difficulty getting adequate medical care because many physicians really avoid treating them. I think you

really need to learn how to manage these patients because the problems are often legitimate and the

treatment need is quite real.


You do have to consider how you’re going to adapt the care for the patient if there is a risk for addiction.

Some of the next slides sort of generously borrowed from Jeff Baxter so he was helpful in putting this

information together. First of all, you have to consider the setting, whether you can manage them in a

primary care setting or where they need to be referred to a specialty care or pain management

program.

Team care is always helpful. If you have a mental health consultant, a psychiatrist, a psychologist,

someone who can provide ancillary therapy, you’re probably going to do better by coordinating that

care. As has been mentioned, many times you want to do risk-benefits analysis as you assess for

opiates. You want to really look first if there’s any real risk and history, are there non-pharmacological

ways to treat the problem? If non-pharmacological treatments don’t work, move up to pharmacological

treatments but don’t begin with opiates. You want to have a clear risk hierarchy in terms of how you

choose the approach for treatment.

You always want to be careful with the supply of medications. As was discussed earlier, in some cases

weekly meds are best but that may not be realistic. You do want to monitor them and make sure that

they are secured. If there is any real history for addiction, you should consider whether or not you want

to refer the patient back for addiction treatment, or at least make sure you know that that’s available,

and they know it’s acceptable for them to participate in that treatment. Finally, as mentioned before,

direct supervision pill counts, monitoring them, prescription monitoring program.

Adapting Care for Patients at Risk for

Addiction

• Setting of care• primary vs. specialty care; team care

• Selection of Treatment• Risk/benefit assessment for opioids

• Adjuvant meds and modalities

• Supply of Medications• Weekly? Secured? Supervised?

• Refer for Addiction Treatment• Sponsor, family, addiction treatment program

• Supervision and Monitoring• Pill counts, drug screens, collateral info.


There are various ways that you can approach managing these patients. In one situation you want to

continue the current modality, but you really want to change the structure of care that you’re providing.

In that case, you may want to add other pain therapists. You may want to add physical therapy, other

approaches to managing the pain. You may want to add mental health treatment and look for a

psychiatrist who has experience with addiction and pain. They are not always available, but I think if you

can find someone with that experience, it will be more helpful.

Lastly, you might want to consider a pain specialty provider, but as was discussed earlier, that can often

be complicated, so you need to be sure what it is you’re looking for and that you’ve accessed someone

who’s going to help you manage the patient.


Addiction







Continue Modality, Change Structure

Require treatment with:

•Adjuvant pain therapy providers

• physical therapy, chiropractic

•Mental health/psychiatry

•Addiction specialty provider

•Pain specialty providers


You may need to consider simply increasing the level of care. This slide describes one program that’s

been available in one VA where they developed an opiate renewal clinic. Here, this model has actually

been quite successful. It’s pharmacy run. They have pain management as part of a team. Patients are

educated about pain management and there’s a strong connection to primary care providers. They had

over 300 patients who were referred to this clinic in a 2-year period. Over 50% at the time of referral

had aberrant behaviors related to their control of pain meds. As you’ll see, over the course of those two

years, at least half of those patients improved, so this clinic was really beneficial for the patients who

were having difficulty controlling their meds.

About half of the patients that were referred to the clinic did not have aberrant behaviors and they

continued to do well over the course of two years. This is a specialized program that certainly any

facility that deals with large numbers of pain patients should consider.


Addiction







Continue Modality, Change Level of Care

Opioid Renewal Clinic (Urban VA setting)• Pharmacist-run prescription management clinic

• Pain Specialty NP supported by pain team

• Education on opioid management

• “Support primary care providers”

335 pts. referred over 2 years

• 51% (171) had aberrant behaviors on referral• 45% (77) improved adherence, behaviors resolved

• 38% (65) self discharged

• 13% (22) referred for addiction treatment

• 4% (7) tapered

• 49% (164) w/out aberrant behaviors did fine

Weidemer NL Pain Medicine 2007


You also can look at what you might do with sort of existing programs to try and beef them up in a sense

to make them more adequate to manage this type of patient. In a primary care setting, you may want

to really increase the M.D. time because you can’t manage these patients with sort of rapid in and out

visits. They do take time, and they need to know that you’re concerned about them. That’s very

difficult to do if you’re feeling very rushed.

You may want to add nurse care managers. You may want to add psychology care managers; sort of

increase your team. You want to make sure that all the providers are well educated about chronic pain

management; that you’re all working from the same agenda, that there are treatment plans that

everyone is comfortable with. For the patients, they need phone contact information. They need to be

educated too about what it is you’re trying to do, what’s the best way to manage chronic pain. You

need to make sure that you talk with them about the risks. If they have any psychiatric history or if

they’re presenting any psychiatric pathology, you make sure that they understand the appropriateness

of screening for depression or anxiety disorders.

If you can integrate group treatment activities or workshops into your general program, that’s

particularly helpful and sometimes groups of chronic pain patients are quite useful as ways of expanding

the care available to patients and helping them live with their problems and understand how you best

can manage the medications. In most of these case settings, I think that this type of increased level of

care will result in better outcome, less disability, and improved mental health.

Continue Modality, Change level of Care

Primary care based collaborative treatment enhanced with

• 20% FTE internal medicine physician

• Full-time psychologist care manager

For providers:

• 2 educational sessions

• Develop treatment recommendations

For patients:

• Phone contact + print materials

• Assessment with care manager

• Mental health co-morbidity screenings

• Goal setting and review of expectations/fears

• Group treatment/workshops

• Pain specialty care/consults with team internist

• Improvements in pain, disability, mental health

Dobscha SK JAMA 2009


The next few slides are going to talk about managing patients when you decide you have to terminate

opiate treatment. There can be a whole range of reasons for this consideration. In some cases, the

patient simply is physically better, but they may be physically dependent and you may need to taper

them off the medication. In other cases, as Jane described, I think inadequate pain control, lack of

efficacy, you finally reach the decision that in a risk-benefit assessment, the risks now outweigh the

benefits.

If there is clear loss of control; are there abuse or opiate dependence; and if there is out of control of

other drugs. You cannot really safely continue prescribing potent opiates to individuals whose

alcoholism is totally out of control or whose benzodiazepine abuse is out of control.

Change in Treatment Modality

Consider termination of opioid treatment:

• Opioid treatment no longer required

• Inadequate pain control – lack of efficacy

• Out of control opioid use/abuse

• Out of control abuse of alcohol, benzodiazepines or

cocaine


These are categories where you decide you really want to terminate treatment. This may happen

involuntarily or it may happen on a voluntary basis. Even with an involuntary withdrawal, I would go

slow, stick to a regular schedule, and make sure the patient understands it, and that you really go with

it.

In some emergency situations, you may actually have to hospitalize a patient. If the patient is

threatening, as was mentioned before, you may want to immediately terminate care. If there is

recurrence of pain, and here, I think the most critical thing for the patient and you to understand is

terminating the treatment with opiates does not necessarily translate into terminating your treatment;

in fact, this will go much better if the patient understands that this is just one element of care that you

are planning to change.

If the patient understands that you still have a commitment to work with them, and that there are other

ways of managing their pain, and that you’re going to continue to do that, I think you will find it much

easier to get them off the opiates. I think the degree to which the patient feels like they’re being

abandoned, that is just going to up their level of problems that you’re going to have as you try to taper

the opiates. It’s really important that they understand that if pain recurs, you’re going to reconsider

things, but there are other approaches for the pain, and that you’re approaching all of this in a more

rational way.

I’ll show you an opiate withdrawal scale in a second. I think patients need to know that you’re going to

use scales, that you’re going to have a rational way of managing their meds, and that you’re not just

doing this in an arbitrary way because you don’t like them and you want to get rid of them, or you want

to get them off the meds. I think if they understand that there’s logic to what you’re doing, I think they

will relax a little and you’ll find it easier to do.

Challenges

• Involuntary Withdrawal• Set a reasonable schedule and stick to it

• Emergency Termination

• Recurrence of pain• Overlap of pain and withdrawal symptoms

• Assess withdrawal intensity with scale

• Psychiatric instability• Overlap of pain and psychiatric symptoms

• Threatening behavior• “if you don’t prescribe it I will just have to get it on the street”

• “I’m calling my lawyer”

I think you may expect an increase in psychiatric symptoms as you bring them off of opiates. Opiates in

particular are very good antidepressants, and it’s not surprising to see an increase in depression and you

may want to consider increasing psychiatric treatment at that time. You also need to understand you

don’t tolerate threatening behavior. My experience, however, with most patients, when you begin to

get that edge, don’t overreact. I think the more you can be laid back and just make it very clear that

threatening, screaming, yelling, is not going to achieve the goals they have and that I can work with you,

you don’t need to do that. I think you’ll find that patients are going to be more reasonable.


You want to be very clear that you’re not abandoning the patient. If you do need to terminate

treatment, you really need to make sure you’ve clearly documented the reasons. I think you clearly

need to document other options where the patient’s been referred for addiction treatment or to other

appropriate changes. Make sure you put all of that in writing. As you’re continuing to proceed,

particularly if you’re simply just stopping the opiates, again, clearly make sure the patient understands

that coming off of meds is not the end of treatment and does not represent your denial of treatment to

them.

You may need to see the patient actually more frequently and monitor how you’re doing and being

more careful with them. In some sense, I think in the worst case scenarios, giving people lots of pills is

an excuse not to see them. In the best case scenario, eliminating the pills and reducing the pills may

translate into more care and more frequent care and better attention; that may be the best way to do it,

but I think you have to understand that they will interpret that in a way and they’ll understand what

you’re doing.

Avoiding “Abandonment”

• Documentation of risk/benefit discussion and why treatment

discontinued

– Allow for medically appropriate taper

• Restate commitment to continue to work with patient on

pain and addiction if needed

– Refer to specialty pain treatment providers

– Alert patient to addiction treatment resources

• See patient frequently and monitor for progress and safety

• Copy to patient and to chart

Fishbain DA Pain Medicine 2009


If you’re trying to withdraw someone from opiates, you need to have some sense of which patients are

going to have the most difficulty, and you can predict in some cases the severity of withdrawal. Patients

who have been on high potency opiates for long periods of time are more likely to have symptoms.

Patients who have been on shorter acting opiates are more likely to have symptoms, so you can predict

that to some degree.

Determination of Withdrawal Risk

• Exposure to steady state level of

medication

– Neuro-adaptation to opioids

• Higher intensity withdrawal from:

– Higher steady state levels

– Longer term exposure

– Faster rate of medication clearance

• Long vs. short half life agents


This slide gives you a sense of the intensity of opiate withdrawal. Here you’re comparing heroin to

buprenorphine to Methadone, and you can see that heroin withdrawal, abrupt withdrawal, much more

severe, but relatively short acting. Methadone is much longer but less severe. So longer acting opiates

are not going to be as severe as the short-acting opiates in terms of withdrawal symptoms, but they will

last longer.

For patients who are truly addicted, not just physically dependent, but addicted in the more pathological

sense, you’ll find that the slow gradual withdrawal may be the most difficult thing for them to tolerate.

Even though symptoms aren’t severe, the lengths of the symptoms are often difficult for them, and they

need a lot of support during that time period.

Opioid Withdrawal Timing/Intensity

Kosten and O’Connor, 2003


One way to do this is to use clinical opiate withdrawal scales. This is an example of the COWS. This is

probably the most commonly used scale. Here, the benefit of this is that it: (1) Gives you a very

objective way of measuring severity; (2) It gives you a way of deciding whether you need to treat

patients at all; (3) Whether you need to increase the dose; (4) It gives you a target of where you’re going

in terms of reducing the severity of symptoms. The major benefit, here again, it’s reassuring to the

patient. They know you care. They know you’re tracking things. They know you’re making decisions

based on objective evidence rather than just I’m trying to get rid of you and get you out of my office. I

would recommend learning how to use scales like this if you’re going to withdraw people and they are

complaining of ongoing symptoms.

Clinical Opioid Withdrawal Scale

(COWS)

• Pulse rate

• Sweating

• Restlessness

• Pupil Size

• Bone/joint aches

• Runny nose/tearing

• GI upset

• Tremor

• Yawning

• Anxiety/irritability

• Gooseflesh

5-12 Mild

13-24 Moderate

25-36 Moderately severe

≥ 36 Severe

Wesson DR, Ling W 2003


This slide looks at tapering long-acting opiates. One model is to reduce the medication by 10% to 20%

each week. Depending on the formulation of the meds, this may be a little bit more difficult. The rate

of decrease may really be determined by how severe their withdrawal symptoms are. You may want to

add a supply of short-acting meds for some sort of breakthrough symptoms, so you’re gradually tapering

the long-acting opiates and giving them a small supply of short-acting opiates, or give them comfort

meds. I’ll show you that in a second.

Tapering Long-acting Opioids

• Decrease by 10-20% each week

–Pill formulations may dictate amount of drop

in dose

–Rate of decrease determined by

circumstances of withdrawal

• Allow supply of short acting medications to

treat “breakthrough” symptoms

–Build up alternative pain treatment modalities

–Comfort medications


For tapering individuals who are on short-acting opiates, first of all, you have to consider whether you

need to taper at all. The symptoms may be relatively short-lived and you may be able to get them off

quite quickly, particularly if there is physiologic presence at all, if there’s physiologic dependence. You

may want to decrease the strength of tablets over every week. You may want to do this simply by pill

count just to eliminate one pill on a particular schedule.

One option may be to transfer them to a longer-acting opiate. This becomes more complicated. You

will have less intense withdrawal symptoms with longer acting opiates, but if you haven’t had a lot of

experience doing this, it may be complicated to try and do that.

Tapering Short-acting Opioids

• Decide if you need a taper at all (is there

physiological dependence?)

• Decrease strength of tablets each week

• Decrease by a specific number of tablets each week

• Consider substitution with long acting medication,

then taper???

• Rate of decrease determined by circumstances of

withdrawal

• Build up alternative pain treatment modalities

• Comfort medications


Another option is to add Clonidine. Clonidine can be used to moderate some of the opiate withdrawal

symptoms. Understand that it works best with the physiologic symptoms associated with opiate

withdrawal. Clonidine is not particularly effective with psychological symptoms or with craving. So you

may have a patient where you’re reducing the physiologic symptoms with Clonidine, yet they still have a

lot of cravings, so you need to be prepared for that.

You need to be concerned by hypotensive effects, particularly on an outpatient basis, initial dose of 0.1

mg p.o., monitor blood pressure. I would not go over these recommended limits over 24 hours, so you

just need to be careful to not get into difficulty with that. It’s a little easier to manage with the

transdermal patch.

Treatment: Clonidine

Oral Dosing

• Initial dosing: 0.1 mg po

Watch BP carefully

• Titrate up to 0.1 to 0.3 mg

po q4-6 hours, then taper

• Risk: HYPOTENSION

• Effective adjuvant to other

meds listed

Transdermal (Patch)

• More steady levels of med;

avoid cyclic hypotension

and rebound.

• Dosed one patch per week

($10/patch).

• Dose range: 0.1-0.4 mg

• 24-48 hours to start to

work-- can use oral

clonidine initially while

waiting for effect.


This is a list of comfort meds. I won’t go through all of this. I think you’re all familiar with these things,

but these are all medications that you can add to help the secondary symptoms of opiate withdrawal.

The only things that I would be concerned about are the sleep aids and the benzodiazepines. It’s safe to

use them, but you just need to make sure, particularly with the antidepressants for sleep, that the

patients are aware that they should not increase the dose beyond what you are recommending. I would

really try to avoid benzodiazepines as add-ons at this point in care. I think that could be quite risky to

add that in at this stage.

“Comfort Meds”

• Ibuprofen 600 QID

• Dicyclomine (Bentyl) 20 mg

QID for stomach cramping

• Pseudoephedrine 30-60

mg QID

• Antiemetics: Tigan 250 mg

po/ 200 mg IM q6-8 hours

• Muscle relaxants: Robaxin

500-750 mg up to QID

• Antidiarrheals:

– Kaolin with Pectin;

– PeptoBismol (Bismuth HCL)

– Loperamide (immodium)

less effective

• Sleep aids

– Trazodone 50-100 mg

– Doxepin 25-50 mg

– Amitriptyline 50mg

• ??? Benzodiazepines


Again, sort of the psychological aspects of managing outpatient opiate withdrawal. The patient’s going

to be distressed. They are going to need extra support, extra time, extra attention, but you may be

surprised in some circumstances to see that their function actually improves as you lower the dose.

Reinforce the notion that you’re going to continue to work with the patient. You have other options

besides opiates and that you’re not going to abandon them. See the patient regularly to monitor their

progress.

Clinical Approach to

Outpatient Opioid Withdrawal

• Anticipate the patient’s distress

• Function may improve on lower dose

• Reinforce commitment to work with patient

• Describe steps to minimize withdrawal symptoms

• Describe safer pain management you will pursue

• Maximize non-opioid modalities

• Refer to specialty pain treatment

• Describe options if withdrawal doesn’t work

• See patient frequently to evaluate progress and

monitor for safety


Inpatient detox may be an option for some patients, but the current reality is it’s usually relatively short

term. It may not have long term benefits. I think that it’s easy to get people off drugs; like opiates, you

can do it very quickly in a hospital but the real problem is how they do after they get out of the hospital

in preventing relapse. So I would reserve this only for very unsafe patients or patients who are quite

unstable.

Inpatient Detoxification

• Usually patient initiated and voluntary

• Short length of stay: 4-5 days

• Insurance coverage varies

• Diagnosis of opioid addiction, not just physiological

dependence

• Addiction focused, not pain

• Nursing managed

• No labs/Xrays/Pharmacy

• Reserve for the most unstable or unsafe

–May be difficult to place patients with serious mental health or

medical co-morbidities


The last few slides, I want to talk about the option of referring patients to long-term opiate treatment,

either Methadone or buprenorphine. In Methadone, you have to get daily doses in the clinic. It’s

important to understand that a single daily dose of Methadone is very adequate for controlling

withdrawal symptoms and craving, but it does not control pain or no more than 6-8 hours as Dr. Alford

went over in his earlier presentation.

Opioid Agonist Treatment (OAT)Methadone Program

• Daily observed dosing of opioid medication

• Single daily dose - inadequate for pain control

• Monitoring for drug and alcohol use

• Dosing titrated to withdrawal symptoms

• Gradual taper over time

• Mandated behavioral tx

• May be long waits for admission


Dosing is monitored very carefully. There may be long waits for admission. It may be very disruptive to

the patient to attend the clinic every day. Why do we do it? We do it because it works. It’s the most

effective control and treatment that we have for opiate dependence. It prevents relapse, reduces extra

drug use, shows significant improvement in mental and physical health, and greatly reduces the death

rate associated with opiate addiction.

Why Methadone Maintenance?Because it Works…

• 80-90% relapse to drug use

without it

• Increased treatment retention

• 80% decreases in drug use,

crime

• 70% decrease all cause death

rate

• 50% + reduction in health

care costs

NIH Consensus Statement JAMA 1998


Another option, particularly for chronic pain patients, this may prove to be the more effective option is

buprenorphine*. It can be available in an office based setting. It’s a partial opiate agonist. The main

advantage with buprenorphine is your ability to fine tune the dose and to divide the dose during the

day. Under standard buprenorphine maintenance treatment, patients get a single dose in the morning;

however, since they are taking the dose home, they can divide that dose during the day. We’ve

discovered with a number of chronic pain patients that buprenorphine provides adequate control of

both their pain symptoms and it eliminates the addiction symptoms.

I think that over the next few years, we’re probably going to see an expanded practice role for

buprenorphine for dealing particular with the more difficult patients with legitimate chronic pain and

clear cut history of addiction. It’s available in sublingual tablets, and now a sublingual film strip only in

two doses, 8 mg and 2 mg. Providers need 8 hours of training in order to prescribe buprenorphine, but

it’s been highly effective in a large number of difficult patients. I would strongly encourage any of the

primary care physicians here who work with these patients to get the training to use buprenorphine. I

think you’ll find it’s worthwhile.

*Off-label use.

Opioid Agonist Therapy (OAT) Buprenorphine

• Partial opioid agonist

– Lower overdose risk

– ? Lower intensity withdrawal

• Formulated with naloxone

• Office-based treatment

• Patients control dosing

times

• No “take home” restrictions

• Maintain or detox

• Split dosing may provide

adequate pain control

• Weaker agonist activity

• Blocks out other opioids

• 8 mg and 2 mg doses only

• Sublingual formulation only

• Limited prescriber availability

• Limited insurance coverage

• Must be in withdrawal to

initiate treatment


Just a few caveats; if you’re referring patients to opiate agonist therapy, either Methadone or

buprenorphine, as standard practice, that is single doses of Methadone, single daily doses of

buprenorphine; that is not adequate for patients with real pain control. The legal constraints on

Methadone dispensing in clinics makes it very difficult to manage pain patients in that particular setting.

It’s important to recognize that neither of these drugs treats other addictions besides opiate

dependence.

They don’t treat alcoholism. They don’t treat cocaine dependence. They don’t treat benzo dependence.

You may need to supplement with other opiates if patients are on buprenorphine or Methadone.

Patients on Methadone and buprenorphine develop tolerance. They may develop new pain syndromes.

They may need extra management of those symptoms for conditions that occur. It’s not easy to directly

transfer patients. From buprenorphine, you have to be in opiate withdrawal before you get the first

dose, and with methadone you have to build up the Methadone dose very slowly and there may be a

long wait before you can get into a Methadone treatment.

Transitioning pain patients to OAT other caveats

Not pain treatment

• Patients should not expect analgesia

• Addiction recovery focused, not pain focused treatment

environment

• Must meet DSM IV criteria for opioid addiction

• not just abuse of other drugs

• Required behavioral treatment/drug testing

• Concomitant opioid pain meds not allowed

No direct transfer of care or dosing

• Most patients must be in withdrawal to start (Bup)

• Must start from low dose and gradually build up (methadone)


This slide just gives you some references for finding treatment. SAMHSA has a treatment facility locator

on their website; Massachusetts State Hotline; Buprenorphine Treatment, sort of references of

Massachusetts Hotline there and the SAMHSA Hotline and lastly, the National Alliance of Advocates for

Buprenorphine Treatment, that final website also has referral information and information for patients.

I think we’ll stop now for questions. Thank you.

[Applause]

Finding Treatment

• SAMHSA Treatment Facility Locator

–http://dasis3.samhsa.gov/

• Massachusetts State Helpline 800-327-5050

–www.helpline-online.com

• Buprenorphine Treatment

–MA State hotline: 617-414-6926

–http://buprenorphine.samhsa.gov/

–www.naabt.org

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