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
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
At-Risk Use: a pattern of substance use that increases the risk of unhealthy consequences to the individual
Unhealthy use thresholds for alcohol: >14 drinks per week for men, > 7 drinks per week for women
Addiction: Loss of control of substance use despite harm to oneself or others
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.
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
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, clickhere.
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)
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).
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…
Diagnose an opioid use disorder
Apply an evidence-based approach to screening for substance use disorders.
Develop an approach to pain management in a patient with opioid use disorder
Develop substance use harm reduction strategies to utilize in your clinical practice.
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.
all so timely and interesting. you may want to interview Dr. Peter Coleman. He's a family practice/addiction doc in Richmond, VA who has specialized in naltrexone therapy and implants for about 20 years. he's in recovery, himself. www.thecolemaninstitute.com
love, love, love your show. keeps me laughing while walking.
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Comments
all so timely and interesting. you may want to interview Dr. Peter Coleman. He's a family practice/addiction doc in Richmond, VA who has specialized in naltrexone therapy and implants for about 20 years. he's in recovery, himself. www.thecolemaninstitute.com love, love, love your show. keeps me laughing while walking.