Treatment of Chronic Pain in People at Risk for or With Substance Use Disorders - PowerPoint Presentation

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Treatment of Chronic Pain in People at Risk for or With Substance Use Disorders

Dean Drosnes, MD, FASAM

Associate Medical Director

Director, Chronic Pain Treatment Program

Caron Treatment Centers

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Disclosures

Name

Commercial Interests

Relevant Financial Relationships: What Was Received

Relevant Financial Relationships: For What RoleNo Relevant Financial Relationships with Any Commercial InterestsX

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Educational Objectives:

Participants will be able to:

Describe the confluence of events which led up to the current American opioid addiction crisis and recognize prescribers’ part in contributing to this crisis.

Recognize risk factors for substance use disorders that are inherent in those with chronic pain.Explain the need for individualized pain treatment plans, considering patient characteristics, pain context, and expected severity and duration of pain.

Compare a program of integrated multi-modality pain treatment by a specialty team to treatment as usual for chronic pain.

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How did we get here?

Confluence of factors, beginning in the 1990s

JCAHO standard for pain assessment (2001)

VA categorization of pain as the 5th vital sign (1990’s)

Launch of Oxycontin in 1996Hospital Consumer Survey of Health Care Providers and Systems (HCAHPS) in 2006 had 3 pain questionsHCAHPS Optional in 2006….Mandatory in 2010 (ACA)CMS tied responses to reimbursement

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Case #1

49

y.o

. woman with a history of “multiple sports and MVA injuries” who reports chronic back pain. She was prescribed Vicodin, 10mg tabs, 180 tabs/month beginning two years ago. Because of inadequate pain relief, her hydrocodone dose was recently increased from 20 to 30 mg TID.

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Case #1 (cont.)

She’s had no surgery, no interventional treatments and no imaging related to her back pain.

She’s been using 4mg alprazolam nightly for sleep and also during the day prn anxiety x 7 years.

She is a recreational intranasal cocaine user.

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Case #1 (cont.)

Thirteen years ago she had been in residential treatment for opioid addiction, and was “clean for a long time” until the recent prescribing.

Patient called, asking for help because of concern for her college age daughter.

Any concerns here?

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Characteristics of patients referred to Pain Management

distress

psychopathology

functional impairment work / M.V.A. related injuries frequent use of health care system constant pain prior surgery (ies) for pain using narcotic medication

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Characteristics of patients referred to Addiction Medicine

distress

psychopathology

functional impairment work / M.V.A. related injuries frequent use of health care system constant pain prior surgery (ies) for pain using narcotic medication

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Chronic Pain is Common

Pain is cited as the most common reason Americans access the health care system.

Up to 100,000,000 U.S. citizens have chronic pain. One third of them are likely to have a substance use disorder.

Pain is a leading cause of long-term disability and it is a major contributor to health care costs.

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Chronic Pain- Treatment As Usual

Evaluation of chronic pain is often limited to a search for structural and mechanical causes.

None of the currently available treatments eliminates pain for the majority of patients.

We use opioids for treating non-cancer pain based on their efficacy in treating cancer pain

Significant benefit shown in RCTs up to 12 weeksNo trials longer than 16 weeksOpioid use in acute pain settings is “traditional.”Poor data for chronic non-cancer pain (CNCP); use is based on studies finding clinically meaningful (>30%) pain reduction.

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Chronic Pain- Treatment As Usual259,000,000 opioid prescriptions were written in 2012.

U.S. = 4.6 percent of the world's population

consumes 80% of its opioids

and 99% of its hydrocodone.

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Opioid use in the U.S. is aberrant

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CDC Guideline

MMWR

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Recommendations and Reports / March 18, 2016 / 65(1);1–49

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CDC Guidelines for Opioid Prescribing for Chronic Pain 03/2016

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Summary of evidence used in determining the recent CDC Opioid prescribing guidelines

No evidence shows a long-term benefit of opioids

in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later (with most placebo-controlled randomized trials ≤6 weeks in duration).

Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury).

Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacologic treatments compared with long-term opioid therapy, with less harm

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Opioid Prescribing Trends

Prescribers habits are changing

But…

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Opioid overdose deaths continue to increase

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Newest Opioid OD trends

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Chronic Pain: Treatment As Usual

Focus is on the pain, not the person

Over-reliance on medication

ExpeditiousLow cost

Inadequate relief of discomfortMultiple components of discomfortInadequate restoration of functionInadequate long-term follow up

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Pain – What are we treating?…an “unpleasant sensory and emotional experience associated with actual or potential tissue damage”

Unpleasant

…

experience…Broken legBroken promise

Broken heart

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Acute and chronic pain are represented in different regions of the brain

2 mos.

anterior to mid-insula, thalamus, striatum, orbitofrontal and inferior cortex, anterior cingulate cortex.

10+ yrs.

anterior cingulate cortex, medial prefrontal cortex, amygdala.Chronic physical pain becomes emotional pain!Hashmi, J.A. et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain 136, 2751–2768 (2013).

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ASAM definition of addiction

Addiction is a

primary, chronic

disease of brain reward, motivation, memory and related circuitry.Dysfunction in these circuits leads to characteristic

biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors…

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Pain relief is Priority #1!The brain doesn’t care if the pain is emotional or physical; all it wants is immediate relief.

Chronic Pain and Addiction share common brain circuits.

Opioid analgesics are not the correct medicines for people who have chronic pain who also have or are at risk for addiction!

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Q: How can we treat pain appropriately?

A: Address the

unpleasant experience

.

Biological componentNociceptiveNeuropathicOther – “central pain syndromes, migraine, cancer pain, fibromyalgia”

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Pain – the unpleasant experience

The Psychological Component

Distraction

Focused attention

Inability to concentrateSleep disturbance

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Pain – the unpleasant experience

The Emotional Component

Anger

Depression

FrustrationAnxiety

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Pain – the unpleasant experience

The Sociologic Component

Homebound

Loneliness

Diminished sense of usefulnessDependence on others

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Pain – the unpleasant experience

The Spiritual Component

Suffering

IsolationResistanceFeeling threatenedGiving up

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In the News…

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In the News…

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In the News…

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Case #2 24

y.o

. female basketball player who has been permanently “sidelined” due to severe osteoarthritis of bilateral knees. She’s had a total of 5 arthroscopic procedures involving both knees. She is now hoping to find a career in coaching/sports management. She needs bilateral knee replacement for chronic pain and deteriorating function. She has a history of heavy alcohol use leading to residential addiction treatment.

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Problem listOsteoarthritis of knees

Alcohol use disorder

Chronic pain/chronic illness “disorder”:

The Emotional Dimension of PainAnxietyAngerDepressionFrustration

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What does this patient need? Are opioids appropriate?

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Case 2 (cont.): What are the likely consequences of prolonged opioid use?

Opioid-induced hyperalgesia

Delayed rehabilitationOpioid use disorder

Avoidance of appropriate grief reaction to loss of athletic prowessProcrastination of exploration of career optionsIsolation from supportive friends, family, and professionals

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Case 2 (con’t)

Patient discharged temporarily from treatment to undergo surgery. She returned 2 days post-op. She’d received full agonist opioid analgesics intra-operatively and for the first post-operative day. She brought with her a prescription for oxycodone tabs.

Oral analgesic was converted to buprenorphine 0.5mg QID prn pain. Patient required this for 2 days, after which pain was well controlled with NSAIDs.

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Case 2 (con’t)

Patient initiated physical therapy at an outside facility for a brief period then continued prescribed P.T. regimen while completing residential treatment for substance use disorder and chronic pain.

2 weeks post-operatively, patient reported pain level of 2-3/10. She was planning her return to school for sports management.

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Integrated Treatment Team Approach

Medical specialist

Psychologist/psychotherapistPhysical therapist/trainer

AcupuncturistMassage therapistYoga instructorFamilyFriends/coworkers /employers12 Step Recovery community (Chronic Pain Anonymous fellowship)

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Adjuvant medications

Antidepressants

SNRIsDuloxetine (Cymbalta)

Venlafaxine (Effexor)Desvenlafaxine (Pristiq)TicyclicsAmitriptyline (

Elavil)Nortriptyline (Pamelor)Desipramine (Norpramin)

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Adjuvant medications

Anticonvulsants

Gabapentin (Neurontin)Pregabalin (Lyrica)

Carbamazepine (Tegretol)Topiramiate (Topamax)Levetiracetam (Keppra)Lamotrigine (Lamictal)

AntiarrhythmicsMexiletineTocainide

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Adjuvant medications

Topical agents

Anesthetics

LidocaineLidocaine and prilocaine (EMLA)

Tetracaine NSAIDsDiclofenac (Voltaren, Flector)KetoprofenIbuprofenOthersCapsaisinNitroglycerin

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Case #351 y.o

. male with cervical spine degenerative disk disease, s/p C3-5 discectomy with prosthetic disk replacement 5 years PTA. Symptoms of chronic neck pain were treated with oral Oxycontin and IR oxycodone plus morphine prior to surgery. Surgery was successful but patient continued to have post-operative pain which prohibited weaning of analgesics. His current analgesic regimen is:

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Case #3 (cont.)Opana

ER, 40mg, 8 tabs/day x 1 yr

Opana IR, 10mg 8 tabs/day x 1 yr

Fentanyl TD, 300mcg q 2 days x 3.5 yrsFentanyl spray (Subsys), 2 sprays/night x 3.5 yrsLevorphanol 2mg, 12 tabs/day x 1 yrValium, 10mg, 5 tabs/day x 2 years

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Case #3 (cont.)16 years ago, patient entered his 1

st

of six addiction treatment episodes with drugs of choice of heroin and cocaine. He has been recently employed in the SA treatment industry. He enters treatment now with the CC:

“I am here to bring my medication down to an acceptable level so that I do not seem impaired."

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What are you going to do?

Meet the patient where they are:

Problem listOpioid use disorder-severe

Sedative/hypnotic use disorder-severeChronic neck painInadequate psychosocial supportFear of worsening painFear of stopping drugs! Fear !!!

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Treatment Plan: Facilitation of opioid and benzodiazepine withdrawal

Buprenorphine 16 mg/day

Weaned off over 22 day period

Phenobarbital 64 mg QIDWeaned off over 12 day period

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Treatment Plan: New medications

Ketorolac

(Toradol), 30mg IM QID prn painAmitriptyline 50 mg HS

“Comfort medications”ClonidineDicyclomineTrazodonePromethazineLoperamide

Ibuprofen

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Treatment Plan: Alternative modalities

Acupuncture

1-2x/weekMedical massage

1-2x/weekPhysical therapy1-2x/weekIndividualized fitness planAd libYogaWeekly and ad lib

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Treatment Plan: Support

Family involvement

Individual and group substance use psychotherapy

Individual and group chronic pain psychotherapySpiritual interventionsSpiritual care consultation and follow upMeditationPrayer12 step recovery

Alcoholics Anonymous, Narcotics Anonymous, Alanon, Chronic Pain Anonymous

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Case #3 (cont.)Progress

Day #2, wife, father, PCP involved in case.

Patient remained in treatment

Day #9, patient reported having “an amazing experience” following acupuncture.Confidence in non-medication modalitiesDay #23, “I’m not feeling anxious and not thinking that I need a medicine or drug to feel better.”

Recovery from addiction is beginning

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Case #3 (cont.)More progress

Day #23, patient called previous pain management doctor’s office to inform them he will no longer be needing their services.

Day #35, patient taking no medications other than occasional prn ibuprofen.

Days #35 –--Patient’s speech and behavior express commitment to recovery from chronic pain and addiction

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The Chronic Pain and SUD Program at Caron

Data obtained on 283 patients between September 2012 and June 2016

Age range: 19 – 82, mean 44.2

Sex Male 152Female 131

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Measuring progressBrief Pain Inventory (modified)

Valid and reliable for assessing effectiveness of pain treatment

Useful in the context of pain as a multifaceted experience

Well-suited to studying pain in SUD patients

Snapshot assessment of the personal burden of pain

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Brief Pain Inventory

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The Chronic Pain and SUD Program at Caron

For patients with complete data sets,

there were statistically significant improvements in all eleven items on the BPI between admission and discharge.

The greatest difference was seen for the item: In the past 24 hours, how much has your pain interfered with your enjoyment of life?None of the patients were using opioids at the time of the second BPI.

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Evidence-based treatment

Opioids compared to placebo or other treatments for chronic lower back pain.

Chaparro

LE, Furlan AD, Deshpande A, Mailis

-Gagnon A, Atlas S, Turk DC. Cochrane Database Syst Rev. 2013 Aug 27;8:CD004959. doi: 10.1002/14651858.CD004959.pub4. There is some evidence (very low to moderate quality) for short-term efficacy (for both pain and function) of opioids to treat chronic low-back pain (CLBP) compared to placebo. The very few trials that compared opioids to non-steroidal anti-inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. The initiation of a trial of opioids for long-term management should be done with extreme caution, especially after a comprehensive assessment of potential risks. There are no placebo-RCTs supporting the effectiveness and safety of long-term opioid therapy for treatment of CLBP.

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Evidence-based treatment

Management of persistent pain in the older patient: a clinical review.

Makris

UE, Abrams RC, Gurland B, Reid MC. JAMA. 2014 Aug 27;312(8):825-36. doi: 10.1001/jama.2014.9405. Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined

nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis… A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician.

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Evidence-based treatment

Opioid Abuse in Chronic Pain - Misconceptions and Mitigation Strategies

Nora D. Volkow, M. D. , and A. Thomas McLellan, Ph. D.

N

Engl J Med 2016; 374:1253-1263March 31, 2016DOI: 10. 1056/NEJMra1507771 CDC GuidelinesCDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI: http://dx. doi. org/10. 15585/mmwr. rr6501e1

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Evidence-based treatment

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

Erin E. Krebs, MD, MPH

1,2

; Amy Gravely, MA1; Sean Nugent, BA1; et al Agnes C. Jensen, MPH1; Beth DeRonne, PharmD1; Elizabeth S. Goldsmith, MD, MS1,3; Kurt Kroenke, MD4,5,6; Matthew J. Bair4,5,6; Siamak Noorbaloochi, PhD1,2 JAMA. 2018;319(9):872-882. doi:10.1001/jama.2018.0899 Conclusions and Relevance: Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

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Thank You!