Take the pain out of pain management with clinical pearls from addiction medicine specialists Dr. Stefan Kertesz at the University of Alabama at Birmingham School of Medicine and Dr. Ajay Manhapra from the VA Hampton Medical Center in Hampton,Virginia. They walk us through an approach to pain management in the recovered addict, discuss treatment options for opioid use disorders, plus hot tips on how to interpret guidelines surrounding opioids, and more! What are you waiting for? Hit the play button! Special thanks to Elena Gibson and Carolyn Chan for writing and producing this show.
Mr. C is a 52 year-old male with a history of HTN, COPD, CKD, and a remote history of polysubstance abuse (cocaine, heroin), but has maintained sobriety for over 2 years. He presents to clinic with substantial worsening of right hip pain, that was being managed before with occasional NSAIDs and narcotics for a few days. An X-ray demonstrates severe avascular necrosis of the hip related to chronic steroid use. The orthopedic surgeons are planning a total hip replacement in 1 month, and are deferring his pain management to you, his primary care physician until then. P.S. Acetaminophen does not work.
- Hazardous Use: a pattern of substance use that increases the risk of harmful consequences for the user
- Alcohol Hazardous use thresholds: >14 drinks per week for men, > 7 drinks per week for women
- No clear definitions for illicit substances.
- Dependence: the patient has a predictable pattern of use and will have difficulty if the use stops.
- Simple Dependence: functioning well, but has tolerance and can’t stop easily.
- Complex dependence: borders on addiction. Patients have protracted withdrawals lasting weeks to months. Will often continue to have pain, sleep problems etc.
- Addiction: compulsive use with loss of control and use despite harm to oneself or others
- Opioid use disorder (OUD) is part of DSM-5 and replaced DSM-4 terms opioid abuse (mild OUD) and opioid dependence (moderate to severe OUD). OUD is a problematic pattern of opioid use leading to clinically significant impairment or distress (e.g. social/professional/legal problems, tolerance, withdrawal, etc.) within a 12 month period. Full diagnostic criteria here
- Screening tool for OUD: The Two-Item Conjoint Screen (TICS) -see figure.
- Patient risk factors for developing OUD when initiated on opioids include: history of substance use disorder, mental health disorder (especially PTSD), multiple comorbidities “multimorbidity”, polypharmacy
Opioids and Pain Management Pearls
- If initiating opioid therapy, the CDC guidelines recommend an initial prescription of only 3-7 days.
- Check out the CDC guideline for prescribing opioids for chronic pain, click here.
- When initiating opioids, start at the lowest effective dose, ie, trial tramadol before jumping to stronger agents such as oxycodone. Do not prescribe extended release formulations for acute pain.
- Long term receipt of opioids creates physiologic dependence, but does not mean a patient has an opioid use disorder by DSM-5 criteria.
Approach to Acute Pain Management in the Recovered Addict
- Trial nonpharmacologic (e.g. exercise, rest, CBT) and non-opioid treatments (e.g. NSAIDs).
- If conservative measures fail and opioid therapy being considered, then ask yourself these questions: How secure is this patient’s recovery? How stable is their life/living situation? What’s their risk of relapse? Is it moderate or high risk?
- Opioids are a last line therapy. Have an exit strategy before initiating, i.e. surgery.
- Initiate short acting therapy, counsel to focus on function and not pain control goals, and initiate at lowest dose possible.
- Utilize prescription drug monitoring programs and urine drug screens during this process.
Treatment Arms of OUD Medication and Behavior
- Medication Assisted Treatment (MAT) for OUD: Methadone or suboxone (buprenorphine/naloxone) are evidence based therapy (see UptoDate article MAT), and are often long term treatments.
- Behavior: Individuals should have a psychosocial assessment, with referrals to the appropriate resources. Not all patients with OUD will require professional counseling as a part of their treatment. Many patients can be counseled by their PCP.
Duration of Medical Treatment of OUD: How long does one stay on suboxone?
- Long term to lifelong therapy: Recommend one year of therapy with medical agent such as buprenorphine/naloxone, then reassessment to see if sobriety is stable enough to attempt taper. Some patients require lifelong therapy.
- Taper to abstinence: Limited data to support this as an effective treatment and not recommended by our experts. There are very high relapse rates with tapers ranging from 1 week to 3 months. Abstinence reduces tolerance increasing risk for overdose/death when relapse occurs e.g. heroin laced with fentanyl.
Harm Reduction Pearls
- There is no evidence that having access to naloxone leads to increased risk of addiction or overdose.
- Tapering chronic opioids is not risk free. Be aware of the risks, and have an open conversation with your patient.
- Tips to approaching opioids with your patients : Understand who your patient is, and calibrate risks vs. benefits. Do not interpret guidelines surrounding opioids as absolute rules. Instead, use them to help perform a risk assessment, and use your clinical judgement.
- Find out who in your area can prescribe OUD medical treatments (methadone or buprenorphine/naloxone).
Goal: Listeners will learn how approach acute pain management in patients who are recovered addicts and discuss evidence based treatments for opioid use disorders.
After listening to this episode listeners will…
- Define substance use, hazardous use, dependence, addiction, opioid use disorder
- Apply an evidence-based approach to screening for substance use disorders.
- Develop an approach to pain management in the recovered addict.
- Develop opioid harm reduction strategies to utilize in your clinical practice.
- Discuss the evidence behind the different different treatment strategies for opioid use disorder: taper to abstinence, medication assisted therapy, and long term or lifelong therapy.
Disclosures: Dr. Kertesz owns stock in Merck & Co. and Abbott Laboratories, amounting to less than 3% of assets, but has no other income, honoraria, consultancies or grants related to the health industry. Dr Manhapra reports no relevant financial disclosures.
- 00:00 Intro
- 01:58 Host picks of the week
- 04:10: Intro to the episode
- 04:35: Guest Bios
- 12:32: Case from Kashlak Memorial
- 13:40 Define substance dependence, substance abuse, hazardous use
- 17:42 Where to go next conversation about pain control
- 17:54: Assessing risk of relapse
- 19:35 Screening Tools
- 20:10 Risk factors for developing OUD when initiating opioids.
- 25:10: CDC Guidelines length of prescription and risk of substance use disorder (7)
- 27:00: Defining optimal length of opioid after common surgical procedures (6)
- 30:30: Long term receipt of opiates and addiction
- 33:50: OUD treatment options
- 37:30: Duration of buprenorphine/naloxone treatment, tapering risks (8)
- 38:50: POATs: Prescription opioids (9)
- 40:05 Social support and mental health services for addiction management
- 41:10 Risk of abstinence and adverse outcomes
- 42:35 Protracted withdrawal
- 43:35: Editorial BMJ Golden Month of Opioid use disorder (10)
- 44:00 Overdose risk in patients on long term opioids
- 44:40 Op-Ed on the Hill (11)
- 45:40 Example of protracted withdrawal syndrome
- 47:40 Reducing Harms: Naloxone, who to prescribe to?
- 50:30 Take home points
- 53:40 Outro
Links from the show:
- Paul’s picks – T.S. Eliot poems:
- Paul doesn’t recommend – Dark Tower Series Stephen King (books)
- Stuart’s pick The Wheel of Time Series (books) by James Oliver Rigney Jr.
- Matt’s pick Hospital and Internal Medicine Podcast- Urine Drug Testing
- Multipliers: How the Best Leaders Make Everyone Smarter (book) by Liz Wiseman and Greg McKeown
- Or just check out this Video about Multipliers
- Sapiens a Brief History of Humankind (book) Yuval Hirari
- Optimal length of opioid prescription after common surgical procedures – Scully, R. E., Schoenfeld, A. J., Jiang, W., Lipsitz, S., Chaudhary, M. A., Learn, P. A., . . . Nguyen, L. L. (2017). Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures. JAMA Surgery. doi:10.1001/jamasurg.2017.3132
- CDC Guidelines 2016 for prescribing opioid for chronic pain Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.
- Relapse rates after short taper of Buprenorphine: Ling, W., Hillhouse, M., Domier, C., Doraimani, G., Hunter, J., Thomas, C., . . . Bilangi, R. (2009). Buprenorphine tapering schedule and illicit opioid use. Addiction, 104(2), 256-265. doi:10.1111/j.1360-0443.2008.02455.x
- POATS: Prescription opioid addiction treatment study:
- Golden Month Editorial: Manhapra, A., Rosenheck, R., & Fiellin, D. A. (2017). Opioid substitution treatment is linked to reduced risk of death in opioid use disorder. Bmj. doi:10.1136/bmj.j1947
- The Hill Op-Ed: As a physician, I urge caution as we cut back opioids
- AAFP: A Primary Care approach to Substance Misuse
- Annals of IM: Beyond The Guidelines How Would You Manage Opioid Use in These Three Patients?
- Screening Two-Item Conjoint Screen Brown, R. L., Leonard, T., Saunders, L. A., & Papasouliotis, O. (2001). A two-item conjoint screen for alcohol and other drug problems. J Am Board Fam Pract, 14(2), 95-106.
- AAFP: Urine Drug Screening: A Valuable Office Procedure
- Mundkur, M, Kertesz, S, Gordon A. Will strict limits on opioid prescription duration prevent addiction? Advocating for evidence-based policymaking. Substance Abuse 2017.
- The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2016.16070792