#73: Opioid Addiction, Chronic Pain, and Abstinence

December 19, 2017 | By Carolyn Chan

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 persons with a history of opioid use disorder (OUD), discuss treatment options for OUD, 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, MD and Carolyn Chan, MD

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Credits

• Producer: Elena Gibson and Carolyn Chan
• Writer: Carolyn Chan
• Infographic: Elena Gibson
• Cover Art: Elena Gibson
• Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com
• Guest:  Dr. Stefan Kertez and Dr. Ajay Manhapra

Time Stamps

• 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 use, unhealthy 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 use of opioids
• 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 SUD treatment
• 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

Opioid Use Disorder, Chronic Pain, and Recovery Pearls

1.  At-Risk Use:  a pattern of substance use that increases the risk of unhealthy consequences to the individual
2. Unhealthy use thresholds for alcohol: >14 drinks per week for men, > 7 drinks per week for women
3.  Addiction: Loss of control of substance use despite harm to oneself or others
4.  Opioid use disorder (OUD) is diagnosed by an individual meeting DSM-V criteria.  OUD is a pattern of opioid use leading to clinically significant impairment or distress (eg: interpersonal relationship, cravings, consequences etc.) within a 12-month period.
5.  Screening tool for OUD: The Two-Item Conjoint Screen (TICS) -see figure.
6.   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
7. Prescribe naloxone for patients with opioid use, as it can reverse opioid overdoses and can save lives. 

#73: Opioid Use Disorder, Chronic Pain, and Recovery

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 a patient with Opioid Use Disorder (OUD)

• Trial nonpharmacologic (e.g. exercise, rest, CBT) and non-opioid treatments (e.g. NSAIDs).
•   If conservative measures fail and opioid therapy is 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 return to use? 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.

Medications for OUD and Psychosocial Interventions

•   Medications for OUD (MOUD) for OUD: Methadone or suboxone (buprenorphine/naloxone) are evidence based therapy (see UptoDate article MOUD), and are often long term treatments.
• Psychosocial Interventions: 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 should a patient stay on buprenorphine/naloxone?

•  Long term to lifelong therapy: Recommend at least one year off treatment with medications such as buprenorphine/naloxone, then reassessment to see if the patient 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).

Links

1.  Paul’s picks – T.S. Eliot poems:
2. The Love Song of J.Alfred Prufrock
3. The Waste Land
4. Paul doesn’t recommend – Dark Tower Series Stephen King (books)
5. Stuart’s pick The Wheel of Time Series (books) by James Oliver Rigney Jr.
6. Matt’s pick Hospital and Internal Medicine Podcast- Urine Drug Testing
7. Multipliers: How the Best Leaders Make Everyone Smarter (book) by Liz Wiseman and Greg McKeown
8. Or just check out this Video about Multipliers
9.     Sapiens a Brief History of Humankind (book) Yuval Hirari
10. 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
11. 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.
12. 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
13.   POATS: Prescription opioid addiction treatment study:
    • Learn more at this link
    • Primary Study outcomes article: Weiss, R. D. (2011). Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence. Archives of General Psychiatry, 68(12), 1238. doi:10.1001/archgenpsychiatry.2011.121
14.   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
15. The Hill Op-Ed: As a physician, I urge caution as we cut back opioids

Goal

Listeners will learn how to approach acute pain management in patients for individuals who have a history of opioid use disorder, and discuss evidence-based treatments for opioid use disorders.

Learning objectives

After listening to this episode listeners will…  

1. Diagnose an opioid use disorder
2.  Apply an evidence-based approach to screening for substance use disorders.
3. Develop an approach to pain management in a patient with opioid use disorder
4. Develop substance use harm reduction strategies to utilize in your clinical practice.
5. Discuss the evidence behind the different  treatment strategies for opioid use disorder.

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.

Recommended Reading:

1. AAFP: A Primary Care approach to Substance Misuse
2.   Annals of IM: Beyond The Guidelines How Would You Manage Opioid Use in These Three Patients?
3. 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.
4. AAFP: Urine Drug Screening: A Valuable Office Procedure
5.   Mundkur, M, Kertesz, S, Gordon A. Will strict limits on opioid prescription duration prevent addiction? Advocating for evidence-based policymaking. Substance Abuse 2017.
6. The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2016.16070792