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