#156 Chronic Pain, Opioids, Tapers

June 24, 2019 | By Nora Taranto

Pain Management Pearls & Updates from Doctors Soraya Azari and Phoebe Cushman

Rethink how you’re diagnosing and managing chronic pain with high-yield tips from pain experts and primary care doctors Soraya Azari MD @azarimugs (UCSF), and Phoebe Cushman MD, MS (UMass Memorial). Because let’s face it, managing chronic pain can be very difficult. Expand your toolbox for management– including the importance of activity, empowering your patient, risk stratification for patients prior to opioid initiation, how to identify opioid use disorder, and how to taper opioids. Plus, updates on recent practice changing articles in chronic pain.

Full show notes at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

Written and produced by: Nora Taranto MD

Hosts: Nora Taranto MD, Paul Williams MD, Matthew Watto MD

Edited by: Emi Okamoto MD, Matthew Watto MD

Guests: Soraya Azari MD; Phoebe Cushman MD, MS

Sponsor

This episodes was recorded LIVE at #SGIM19 in Washington DC! Join the Society for General Internal Medicine today!

Time Stamps

• 00:00 Intro, disclaimer, guest bios
• 04:50 Guest one-liners, book recommendations, picks of the week, career advice
• 14:50 A case of chronic pain; Group pain into 1 of 3 buckets
• 18:48 Use of pain scales; and taking a pain history; affirming positive behaviors surrounding pain
• 23:13 Nonpharmacologic measures for chronic pain
• 26:30 Cognitive behavior therapy (CBT) for chronic pain; remote CBT vs traditional CBT
• 30:32 Apps for Meditation, Affirmations
• 31:53 Back to the case: Should we trial opioids for our patient’s chronic pain? Our guests give their recommendations
• 34:55 Counseling about risk of opioids
• 37:42 Risk stratifying patients requesting opioids; Some risk tools (COMM, Opioid Risk Tool, DIRE); Don’t forget to screen for mood disorders
• 42:10 What to do if pain is not improved on high dose opioids; How to identify an opioid use disorder
• 45:13  How to taper patients off opioids; Forced tapers and the CDC guidelines; How to taper the right way
• 50:34 Buprenorphine for opioid use disorder and/or chronic pain
• 57:38 Gabapentin and risk for misuse and/or unintentional overdose in patients also using opioids
• 61:42 Plugs: Get your x-waiver, or better yet advocate for getting rid of the waiver

Chronic Pain Pearls

Ask how the patient is managing his or her pain at home. Reinforce and affirm those self-driven management behaviors.

Patients with chronic pain often feel out of control and unempowered. One of our jobs is to be their cheerleader, and to build them up in their coping style.   

The diagnosis is not chronic pain syndrome, but chronic pain syndrome due to X, Y, or Z. Don’t forget the underlying condition, which can help guide treatment.

Screen for mental health and substance use disorders before initiating opioids. Risk calculators (Opioid Risk Tool, DIRE score, and COMM tool) offer objective measures to consider.

We prescribe opioids so we should also be ready to treat opioid use disorder! Get your free buprenorphine waiver today: https://pcssnow.org/.

Tapering opioids should be done consistently and slowly, continually checking in with the patient. Expert recommendation is 2 to 10% decrease per month.

Opioid replacement: There’s no wear-off effect from buprenorphine, it has a long half life, and it has a good safety profile. Its analgesic properties are better when it is taken more frequently (3-4 times per day) than the once or twice daily dosing often given to prevent withdrawal.

Managing Chronic Pain Show Notes

Pain in the Bu(cke)t: Let’s break it down with a few definitions

We think about pain and pain management differently, depending on its origin, since “pain” can be such a nebulous thing.

Nociceptive pain: due to tissue injury or harmful stimulus that is detected by pain receptors in the nervous system.

Neuropathic pain: due to injury of the nervous system itself (somatosensory, in general) which can cause allodynia (pain from sensory stimuli that is not normally painful).

Central sensitization pain: occurs in the absence of injury, caused by overactivation of the nervous system that leads to hyperalgesia (pain out of proportion to the stimulus causing it) in addition to allodynia. Common examples are complex regional pain syndrome and fibromyalgia.

The patient evaluation

It is important to recognize that often, even when you are seeing a patient for the first time, he or she will have multiple sources of pain, and be on scads of medications for their management. Dealing with the polypharmacy and figuring out what is working and what isn’t is a huge challenge in and of itself.

Should we be using pain scales?

Maybe the PEG Scale (if you have the time), but the qualitative questions may be more important.

The typical pain scale (1-10) is notorious for its subjectivity, and its meaning for patient care and outcomes is questionable. There are some scales that attempt to give a more meaningful numerical rating to scale the pain. The PEG Scale measures patient pain and its interference with their enjoyment of life and general activities (Krebs, 2009). This is ideally tracked over time, which is more helpful than a one-time assessment. And, in practice, physicians don’t always have time to do this (especially since upwards of 40% of patients are coming in to primary care with pain complaints Kroenke, 2003. Also see Barriers and Facilitators to Chronic Non Cancer Pain Management -Lincoln, 2013).

The Qualitative questions are important to ask, including How is it affecting your function? and How are you controlling your pain at home? Effective pain management is reliant on patients feeling empowered and in control (Lincoln, 2013). It is essential in primary care visits to help foster some of that resilience. We can affirm the patient behaviors that are mitigating the pain and empower our patients that they can help control and lessen their pain.  

It’s not all about the drugs: Non-pharmacologic interventions

Activity, activity, activity! (+ RICE)

Being as active as possible is key to pain management, and can be useful in the management of chronic pain (Hagen, 2012, Ambrose, 2015). But they won’t necessarily know how to exercise and remain active with their movement limitations secondary to pain.  Ask patients if they are engaging in physical therapy. Have them walk you through their exercise routine, and then brainstorm about activity options. Encourage paced activity, in which an individual starts small, and increases their activity day by day at a regular rate (evidence-based, Wallman, 2004).  And of course, ice and heat are almost zero-risk interventions that patients may find useful.

Ask about habits that could be worsening pain, and patient life outside of the pain

There are lots of “life” things that could be exacerbating a patient’s pain. Ask patients what type of pillow they’re using, how they’re carrying groceries and other heavy loads, how much sleep they’re getting, whether they’re feeling stressed, and how their relationships are with their loved ones. Address these, one by one.

Cognitive Behavioral Therapy? Yes, if you can get access.

Cognitive Behavioral Therapy to improve coping strategies for chronic pain is evidence-based and well-established, and if you have access to it, you should recommend it to your patients (Maikovich-Fong, 2019). But access to psychologists–both in terms of waits and insurance coverage–is a huge issue.  There is recent research on remote CBT showing it to be non-inferior to in-person CBT (Heapy, 2017), but payment remains a problem. Apps do exist that patients can use on their phones: Affirmations (for a daily pick me up) is totally free, and Calm and Headspace both have free versions.

Now, let’s talk about Medications.

Consider Therapy Options

First, ask what source of pain is bothering the patient the most. For certain types of MSK pain, we can actually do very effective injections in the office that help, immediately, with pain and function. We treat neuropathic pain with tricyclic antidepressants and anti-epileptic drugs, which make patients feel very different from opioid-type medications.

Do opioids work for musculoskeletal pain?

Not great. The 2018 SPACE trial suggests that starting opioids for moderate to severe chronic back, hip, or knee osteoarthritis pain will not result in better pain-related function or well-being at one year (Krebs, 2018).  

Sometimes, if the patient is complaining of acute or subacute MSK pain (where there will likely be some healing and the opioids would be a temporary measure) or if there are other contraindications, then you might trial a course of opioids. Make it very clear that this short opioid course will be a trial–that it is time-limited with re-evaluation. That said, opioids should not be first line in these cases.

Initiating Opioids

When patients request to start opioids

Ask them: “What do you know about opioids and their risk?”. Then do some educating, and talk to patients about the 20% risk of developing addiction, the higher risk of death on opioids, especially with higher dose and long-acting medications (Garg, 2017), and the increased risks of pneumonia in the elderly, hypogonadism, and osteoporosis. Don’t just cite guidelines or worries about licensure when you decline to prescribe opioids. –Expert advice on how to counsel about opioid initiation

How to risk-stratify regarding opioid use  

Older age, bone thinning, falls, and cognitive changes are risks for experiencing greater side effects or sequelae of opioids.  

A quick two question screener: You also always need to screen for substance use disorder and history of mental health disorder, because they are the strongest risks for experiencing serious harm from opioid use.

For more detail, there are opioid risk tools that are patient- or provider-completed to help categorize risk level. Consider the Opioid Risk Tool prior to initiating, the DIRE score for providers to predict compliance, and the COMM tool for monitoring during treatment. They are not deterministic but objective measures to potentially combat implicit bias., They also contain sensitive questions that you need to be prepared to address if they screen positive.

Managing long-term opioid use

In the patient taking opioids long-term, still with chronic pain…

First, check whether your diagnosis is right. Next, screen for opioid use disorder or physical dependence, since it is possible that this patient will have developed opioid use disorder in the period of time he or she has been taking the medication (higher morphine milligram equivalents confers increased risk of developing opiate use disorder). Lastly, if the patient is on high doses and experiencing more pain, he/she may be experiencing opioid-induced hyperalgesia (largely a diagnosis of exclusion).

When patients are on high-dose opioids, have a low barrier for suspecting opioid use disorder. Be proactive in thinking about opioid replacement therapy, or lowering the opioid dosage. A slow taper can sometimes result in improved pain control, or can also unmask opioid use disorder.

How to look for opioid use disorder:

Look for an all-consuming pill narrative (patients biding time to their next pill, needing to know exactly where the pills are and feeling out of control in between pills, with wean off periods between doses). These patients will feel as though the opioids are controlling them and their schedules, and will sometimes even go through withdrawal when they run out of pills each month, only to start again the following month (use despite harm).

Red flags to look for: the patient who is unable to dole out their medication as intended between appointments, the patient giving their medications to someone else to store to avoid being able to take extra of them in between doses, and the patient who says the pill doesn’t really help with pain but that they feel yucky if they don’t take it.

Tapering: The good, the bad, and the ugly

There are many different ways to taper patients. Taper consistently, and do not make a patient go cold turkey. The majority of tapers can be voluntary tapers, where you agree with patients about the rate and duration of the taper. Do it very slowly, and offer to go down on frequency of dose or dose level. Dr. Azari’s recommendation: go down 2-10% of total MME (morphine milligram equivalents) per month. Monitor the patient during the taper with urine screens, and re-evaluate at every follow-up how well the recent month has worked for the patient. This process takes a long time, and needs regular tweaking.

Buprenorphine

Most patients transitioned to opioid replacement therapy will be maintained on buprenorphine, Naltrexone or methadone, unless they express a desire to taper down.  There’s a low risk of misuse, and these medications may very well help with underlying pain. This can treat chronic pain (Aiyer, 2018) as well.

The types of Buprenorphine available:

Transdermal patch (microgram range) is FDA-approved for moderate to severe continuous pain. The sublingual tablets (milligram range) are higher dose and are used for opioid replacement therapy (and probably also have some pain mitigating effects). There’s no wear-off effect from buprenorphine, it has a long half life, and it has a good safety profile. Its analgesic properties are better when it is taken more frequently (3-4 times per day) than the daily dosing often given to prevent withdrawal. Monthly injectable formulations are available, though are inconsistently covered by insurance and are available in relatively lower effective daily doses.

What about gabapentin as an adjunct to opioids?

While this opioid-sparing approach of adding gabapentin to opioid regimens had a lot of uptake in the past, it turns out that it puts patients at increased risk of harm. Recent evidence suggests patient taking both gabapentin and opioids, compared to those taking opioids alone, have an increased rate of unintentional overdose with an odds ratio of 1.99, and it also shows dose-response effect (Gomes, 2017). Furthermore, evidence shows significant risk of harm and no benefit of gabapentin for lower back pain, one of the most common causes of chronic pain (Shanthanna, 2017).

Final Plugs

1. If you’re prescribing opioids (and even if you’re not): Get your waiver to prescribe buprenorphine! And advocate for elimination of the waiver to decrease barriers to access! Check out https://pcssnow.org/ for more.
2. To make real change in the medical community, we need to advocate to broaden education and training to include these important topics, for example as board exam questions. Advocate for these curricular changes at your institution and within your societies.

Goal

Listeners will develop an approach to managing chronic pain including: recognizing and treating opioid use disorder in the clinic; clinical updates in chronic pain; and how to taper opioids.

Learning objectives

After listening to this episode listeners will…

1. Classify chronic pain as nociceptive, neuropathic, or central sensitization pain.
2. Identify different modalities for the treatment of pain
3. List resources for management of chronic pain and the supporting evidence
4. Describe key findings of recent articles in pain medicine, and their relevance to clinical practice
5. Appreciate the implications of advocacy and health equity as applied to patients with pain

Links

1. Becoming by Michelle Obama
2. There There by Tommy Orange
3. We Need to Talk by Celeste Headlee
4. Where’d You Go, Bernadette by Maria Semple
5. Killing Eve television series
6. PEG Scale for monitoring pain
7. Recommended apps for patients: Affirmations (for a daily pick me up; *maybe this one? We’re not sure), Calm and Headspace
8. Calculators: Opioid Risk Tool prior to initiating, the DIRE score for providers to predict compliance, and the COMM tool for monitoring during treatment.
9. Get your buprenorphine waiver: https://pcssnow.org/

References

1. Krebs EE et al. Development and initial validation of the PEG. J Gen Intern Med. 2009. [https://www.ncbi.nlm.nih.gov/pubmed/?term=19418100]
2. Hagen KB et al. Exercise therapy for bone and muscle health. BMC Med. 2012. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568719/]
3. Abmrose KR et al. Physical exercise as non-pharmacological treatment of chronic pain. Best Pract Res Clin Rheumatol. 2015. [ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4534717/]
4. Wallman KE et al. Randomised controlled trial of graded exercise in chronic fatigue syndrome.Med J Aust. 2004. [https://www.ncbi.nlm.nih.gov/pubmed/15115421]
5. Maikovich-Fong AK. Handbook of psychosocial interventions for chronic pain: an evidence-based guide. Print. 2019
6. Heapy AA et al. Interactive Voice Response-Based Self-management for Chronic Back Pain: The COPES Noninferiority Randomized Trial. JAMA Intern Med. 2017. [https://www.ncbi.nlm.nih.gov/pubmed/28384682]
7. Garg RK et al. Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid Patients. Med Care. 2017. [https://www.ncbi.nlm.nih.gov/pubmed/?term=28614178]
8. Aiyer R et al. Treatment of Chronic Pain With Various Buprenorphine Formulations. Anesthesia & Analgesia. Abstract, 2018. [https://journals.lww.com/anesthesia-analgesia/Abstract/2018/08000/Treatment_of_Chronic_Pain_With_Various.36.aspx]
9. Krebs EE et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018. https://www.ncbi.nlm.nih.gov/pubmed/29509867]
10. Gomes T et al.Gabapentin, opioids, and the risk of opioid-related death. PLoS Med. 2017.  [https://www.ncbi.nlm.nih.gov/pubmed/28972983]
11. Shanthanna H et al. Benefits and safety of gabapentinoids in chronic low back pain. PLoS. 2017. [ https://www.ncbi.nlm.nih.gov/pubmed/?term=28809936]

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