Chronic Pain in Patients with Substance Use Disorders

Chronic Pain in Patients with Substance Use Disorders Edward S. Lee MD

Disclosure

Nothing to Disclose

Learning Objectives Describe the scope of the problem of hazardous opioid use Identify patients at high risk for opioid-related adverse events Develop pain management practices with universal precautions in mind

VA Pittsburgh Services Substance Abuse Assessment Team Opioid Renewal Clinic Acupuncture Clinic Interdisciplinary Pain Rehabilitation Program Pain Clinic (anesthesia)

Scope of Problem Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic Use, Abuse, and Nonmedical Use of Opioids: A Ten-Year Perspective Pain Physician 2010; 13:401-435 Americans constitute 4.6% of the world’s population, but consume 80% of the global opioid supply, 99% of the global hydrocodone supply and 66% of the world’s illegal drugs

Scope of Problem Average sales of opioids per person increased from 74 milligrams in 1997 to 369 milligrams in 2007, a 402% increase In 2010, enough hydrocodone and oxycodone was prescribed to give 45 Percocet (5mg) and 24 Vicodin (5mg) tablets to every American (Hawley C, “Painkiller sales soar around US, fuel addiction 4/5/12, Associated Press)

CDC: Morbidity and Mortality 14,800 prescription opioid-related deaths in 2008 475,000 opioid-related emergency room visits in 2009 100 overdose fatalities daily

http://www.cdc.gov/homeandrecreationalsafety/rxbrief/index.html

Public Health Crisis  May 8, 2012 – US Senate launched inquiry into the relationship between pharmaceutical and medical device manufacturers and pain treatment advocacy groups  The American Pain Foundation, which received 90% of its $5 billion budget from industry immediately dissolved itself

Paradigm Shift  1990’s: Pain as 5th vital sign, concern about undertreatment of pain drove escalation of doses of opioids with no upper limits.

Addiction was not considered to be a risk in patients with genuine pain conditions  Today: prioritizing safety, understanding limited efficacy of chronic opioid therapy, balancing treatment of pain with alternatives

Effect of Substance Use Disorders on Pain Management  Non-adherence to pharmacologic and non-pharmacologic treatments  Higher risks of medication interactions, adverse events  Ineffective analgesia

Differential Diagnosis Addiction: loss of control, compulsive drug use Pseudo-addiction: inadequate analgesia Other psychiatric diagnosis –Cognitive disorders –Personality disorders –Mood disorders

Diversion

ASAM Definition of Addiction, 2011 Brain disease characterized –Inability to consistently Abstain –Impaired Behavioral control –Craving –Diminished recognition of significant problems with one’s behaviors and interpersonal relationships –Dysfunctional Emotional response

Addiction vs. Pseudoaddiction More predictive of addiction: –Theft, forgery, purchasing or selling opioids illegally.

–Injection of oral medications.

–Illicit use of other psychoactive drugs.

–Recurrent unsanctioned dose escalation –Recurrent reports of lost or stolen medications

Addiction vs. Pseudoaddiction Less predictive of addiction –Requests for dose increase –Drug “hoarding” when pain is less severe –Few unsanctioned dose escalations –Obtaining opioids from multiple medical providers

Chronic Pain Syndrome  ICD-9 338.4  Pain for at least three months and: – Extreme focus on pain and/or amplification of pain – Major inactivity and/or deconditioning – Disrupted sleep – Multiple work ups and/or failed treatments – Depression and irritability – Significant reduction in social activities

Chronic Pain Syndrome  Patients are less likely to benefit from chronic opioid therapy  More appropriately treated in an Interdisciplinary Pain Rehabilitation Program

Comorbidities in Veteran Population PTSD Post-concussive syndrome Polytrauma Chronic pain Substance Use Disorders

Tobacco Nicotine is highly addictive Nicotine has analgesic properties Smoking is associated with increased pain Smoking is associated with use of illicit drugs and alcohol Carbon monoxide is associated with inflammatory state Impaired wound healing

Caffeine May trigger headaches directly Withdrawal may cause headache Impaired sleep can exacerbate pain

Alcohol Alcoholic Neuropathy “Self-medication” for pain Dysregulated sleep Increased functional capacity among heavy alcohol users with chronic pain

Benzodiazepines Higher risk of mortality Decreased pain tolerance Limited efficacy for treatment of anxiety or insomnia

Marijuana  No significant analgesic properties  Significant adverse effects including: – Cognitive impairment – Anxiety – Depression – Association with psychosis – Suicidality

Cocaine Topical anesthetic Antinociceptive Sleep disorder Association with headaches: relief of migraine, followed by rebound headache Angina due to coronary vasospasm

Heroin Effective analgesic Rapid tolerance Withdrawal reinforces continued use Detected as an opioid on standard urine drug test: 6methyl acetyl morphine metabolite confirms heroin use (dimethyl acetyl morphine)

Other Drugs Stimulants Hallucinogens Inhalants Dissociatives

Universal Precautions Patients with substance use disorders can be of any race, class, gender, or religion Financial incentives for diversion of medications can be high; oxycodone 30 mg tabs $15 to $30 each Assume that all candidates for chronic opioid therapy are susceptible to aberrant behavior

Universal Precautions: Diagnosis Form treatment plan based on diagnosis of pain source as well as comorbid physical and mental health conditions (depression, substance use disorders, etc.) Documentation of diagnostic procedures and previous treatment

Universal Precautions: Addiction Risks Assess risk of substance use disorders based on family history, current environment, personal history of addiction, and urine drug testing

Universal Precautions: Informed Consent  Adverse effects (sedation, GI effects, respiratory depression, hypogonadism)  Alternatives to opioid therapy  Risks due to impairment (driving, care-giving, etc.)  Pregnancy risks  Medication interactions  Explanation of tolerance, withdrawal, abuse, and dependence

Universal Precautions: Opioid Analgesic Agreement Explain renewal process - prohibit early refills Monitoring by drug testing and pill counts Single provider, single pharmacy Abstinence from illicit drugs and alcohol Secure medications

Universal Precautions: Document efficacy Effective analgesia 2 point decrease in pain rating Improvement in social, physical and mental function

Universal Precautions: Trial of Opioid Therapy Initiation of opioids does not mean lifetime commitment to opioid treatment Opioid rotation or holidays may be indicated Continual requests to escalate dose are an indication that pain is opioid resistant

Universal Precautions: Corroboration of Safe Use  Family members  Random pill counts  Random drug testing  State Prescription Monitoring Programs – VA requires informed consent for access to programs – VA does not permit sharing of prescription information with these programs – Pennsylvania program is only available for law enforcement purposes

Universal Precautions: Four A’s Analgesia Activities of Daily Living Adverse Effects Aberrant Behaviors 5th A: Affect

Universal Precautions: Reassess Patient Reassess underlying condition and co-morbid conditions on a regular basis –Change in pain rating –Change in character and location of pain –Change in physcial exam

Universal Precautions: Documentation Use SOAPP, PADT, COMM Have consents and opioid agreements on file Consider annual renewal of consents and agreements Urine Drug test results www.PainEDU.org

Chronic Opioid Therapy Prefer long-acting formulations Limit dose: morphine equivalent between 100 and 120 mg, higher doses only if absolutely no adverse effects Rational polypharmacy –TCA’s, anticonvulsants, NSAIDs –Does not include stimulants and sedatives

Buprenorphine  Partial opioid agonist  Sublingual form appoved only for the treatment of opioid dependence  Preliminary data that divided doses of buprenoprhine may be effective for managing pain in patients with co-morbid opioid dependence. Lower doses may be sufficient  Transdermal approved for chronic pain treatment: lower dose than typically used for treating opioid dependence

Methadone Long half-life Risk of overdose Effective for neuropathic pain Potential for QT prolongation (consider discontinuing if >500ms)

New Opioid Formulations Embeda: morphine with Naltrexone – recalled by Pfizer Acurox: oxycodone with niacin. FDA approval pending Oxeta: immediate release oxycodone, tamper resistant Remoxy: long-acting oxycodone – was not FDA approved

Urine Drug Testing Facility-specific –SAMHSA 5: amphetamine, cannabinoids, cocaine, opioids, PCP –VAPHS screen includes barbiturates, methadone, benzodiazepines, ethanol –Recommend checking for oxycodone –Fentanyl is not detected as an opioid

Urine Drug Testing Diluted Creatinine

< 20

pH Specific Gravity Nitrite

Adulterated

< 3 or > 11 < 1.003 > 500

Inappropriate Results Positive for illicit drugs Negative for prescribed drugs Confirm by gas chromatography/mass spectroscopy

Detection Limits  Alcohol  Amphetamine  Barbiturate  Benzodiazepines  Cocaine  Marijuana  Opioids

= = = = = = =

7-24 hours 48 hours 24 hours to 3 weeks 3 days to 1 month 3 days 3 days to over 1 month 48 hours to 4 days

False Positives Analytes Amphetamine and/or Methamphetamine Barbiturates Benzodiazepins Cannabinoids Cocaine Methadone Opiates PCP Tricyclics

Cutoff (EMIT II) 1000 ng/mL 200 ng/mL 300 ng/mL 200 ng/mL 300 ng/mL 20 ng/mL 50 ng/mL 100 ng/mL 150 ng/mL 300 ng/mL 150 ng/mL 300 ng/mL 300 ng/mL 2000 ng/mL 25 ng/mL N/A

EMIT II (Syva) Ranitidine Chlorpromazine* Bupropion* Oxaprozin

Cutoff (Triage) 1000 ng/mL

Triage (Biosite)

300 ng/mL 300 ng/mL 50 ng/mL

Pantoprazole

300 ng/mL N/A Ofloxacin Levofloxacin Dextromethorphan Dextrophan Mesoridazine

300 ng/mL 25 ng/mL 300 ng/mL 1000 ng/mL

Cyclobenzaprine

Detection of Diversion Pill counts Random drug testing, with confirmation Oxycodone at high doses should be detected as opioid due to oxymorphone metabolite State prescription monitoring programs

Pain Clinic Referral When diagnosis is unclear Unclear if chronic opioid are appropriate Consider alternatives, including interventions, surgery, and devices

Opioid Renewal Clinic Permits intensive monitoring Opportunity for patient and provider education Team approach to high-need patients

Substance Abuse Consultants Current or prior abuse of opioid and non-opioid drugs or alcohol Reinforce safety Treatment with buprenorphine or naltrexone if appropriate Methadone maintenance with possible “supplemental” opioids

Behavioral Approaches to Pain Management Cognitive Behavioral Therapy Acceptance and Commitment Therapy Mindfulness Based Stress Reduction

Non-Opioid Therapy Pharmacologic Non-pharmacologic –Behavioral Health –Exercise, including yoga, tai chi –Consider complementary and alternative medicine when available

Acknowledgements            

Ilene Robeck MD Michael Mangione MD Timothy Burke MD David MacPherson MD Debra Weiner MD Elizabeth Hakas MD Adam Gordon MD Cynthia Kirsh PhD Mary Pat Acquaviva PA Kim Banks CRNP Mary Lou Bossio CRNP Julie Smith RN

 Rachael Ondersma MSW  Maggie Casteel VRS  Vicky Andrew  Alan Petrazzi PT  Sue Delanko KT  Mark Smallwood PT  Gail Becker  Jean Yavorski RN

References  Blondell RD, Ashrafioun L et al. A Clinical Trial Comparing Tapering Doses of Buprenorphine With Steady Doses for Chronic Pain and Coexistent Opioid Addiction. J Addict Med 2010; 4: 140-146  Chou R, Fanciullo GJ, Fine PG, et al.: Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. Journal of Pain, 2009; 10(2):113130  Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic Use, Abuse, and Nonmedical Use of Opioids: A Ten-Year Perspective Pain Physician 2010; 13:401-435  Martín-Sánchez E, Furukawa TA, Taylor J, Martin JL. Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Med. 2009; 10(8):1353-68  Melanson SEF, Magnani B. False-positive urine drug screens: What clinicians should know and when the laboratory should be consulted. NewsPath. Jan 2006  Gourlay DL, Heitt HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med 6(2):107–12, 2005