San Francisco Safety Net Chronic Pain Management Education Day
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San Francisco Safety Net Chronic Pain Management Education Day Finding Common Ground in the Gray Zone
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San Francisco Safety Net Chronic Pain Management Education Day. Finding Common Ground in the Gray Zone. Welcome!. Why are we here today?. Why are we here today?. Objectives. Identify and manage risk factors for opioid misuse Respond to patient behaviors that are concerning for opioid misuse - PowerPoint PPT Presentation
Transcript of San Francisco Safety Net Chronic Pain Management Education Day
San Francisco Safety Net Chronic Pain Management
Education Day
Finding Common Ground in the Gray Zone
WELCOME!
Why are we here today?
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Objectives
• Identify and manage risk factors for opioid misuse
• Respond to patient behaviors that are concerning for opioid misuse
• Support patients in managing substance use disorders
• Examine systems-level interventions that support safe pain management
• Develop policies or procedures in your own clinic to improve pain management practices
Shape of the Day
• Keynote
• Case-based panel
• Break
• Lecture
• Lunch• Facilitator breakout
• Small Groups
• CURES Table
Disclosures
None of the speakers have financial disclosures to report
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Managing the Risks of Opioid Prescribing
Mr. Anderson
• 46 year old man discharged from LHH 8 days ago
• Requesting refill of pain medications• Hospitalized 4 mo ago s/p MVA
• Right femur fracture• Pelvic fracture• Multiple rib fractures• s/p surgical fixation of fractures• BZD, EtOH, opiates in blood and urine
drug test
Mr. Anderson
• Discharged to Laguna Honda• Discharged from rehab 8 days ago• Currently with pain in right leg, right
chest• Leg pain constant ache, worst in cold
• Able to walk 2 blocks• Increased irritability due to pain• Poor sleep
Mr. Anderson
• Medications:• MS contin 100mg TID• Oxycodone 30mg q6 hrs PRN
• No change in this regimen over 10 weeks at LHH
Mr. Anderson• Drank 2-4 beers daily before accident,
none since• h/o heroin use, none for 3y before
accident• Occasionally buys prescription opioids
on the street, had taken Morphine the day before the accident
• Occasional benzodiazepine use “when they’re around”
• 1 ppd cigarettes• Unemployed, on GA, applying for
disability• Mother with cocaine and EtOH
dependence
Who is at high risk for harm from opioids?
Characterizing Risk of Opioid Misuse
What We Don’t Want
I prescribe opioids to
my patient
Opioid Use Disorder (abuse, dependency)
Diversion
HARM
Fishbain et al. Pain Medicine; 9(4): 444-59. 2008
How Common is the Bad Stuff296 HIV+, marginalized patients, lifetime (Hansen et al 2011)
Purposeful oversedation
--
Felt intoxicated from opioids
34% (used “to get high”)
Meds from other doctors
--
Using alcohol w/meds 31%
Hoarding pain meds 41% (saved for later)
Sold opioid analgesics 18%
Snorted, crushed, injected opioids
17%
Risk Assessment
• Purpose of Risk Assessment– Prior to initiation of
opioids– Ongoing monitoring
• How to do it– Formal instruments – Clinical evaluation
• Underlying principle: universal precautions
• Guidelines (APS, AAPM), 2009
Chou et al. 2009. Journal of Pain. 10(2): 113-30.
Risk Assessment Instruments
• Lots of them – Screener and Opioid Assessment for Patients with
Pain (SOAPP) – 24 items– Pain Medication Questionnaire (PMQ) – 26 items– Prescription Drug Use Questionnaire –Patient
Version (PDUQP) – 24 items– Opioid Risk Tool (ORT) – 5 items – Diagnosis, Intractability, Risk, Efficacy (DIRE) – 7
items– Alturi & Sudarshan – 6 items
Two Options: Opioid Risk Tool (ORT)
Webster LR, Webster RM. Pain Med. 2005;6(6):432-442
Scoring patients:•low risk (0-3)•medium (4-7)•high (≥ 8)
High risk: •91% sensitivity for ADRB•Positive LR 14
Second Option
• Atluri Tool– 6 clinical criteria
1. Focus on opioids2. Opioid overuse3. Other substance use4. Low functional status5. Unclear etiology of pain6. Exaggeration of pain
– Score >3 OR of 16 for opioid misuse
Atluri SL et al. Pain Physician 2004; 7:333-338.
Not willing to try non opioid modalitiesAlways asking about opioids (inc 1st visit)Upset when denied opioidsRequesting particular med
History of drug/EtOH abuseCurrently using marijuanaFeels need for benzos
On disability or applying
Pain “everywhere”Non-physiologic distribution
ER visit for pain; Use up own supply too fast
Risk Assessment Tools
• Clinical Evaluation– Pain clinic study comparing: SOAPP-R, ORT, PMQ
and a 45-min semi-structured interview with a psychologist
– Psychologist’s evaluation of risk was the most sensitive predictor for later discharge from pain clinic
• Note: psychologist had 27 years of clinical experience – 6 years in substance abuse
Jones et al. The Clinical Journal of Pain. 2012; 28(2): 93-100.
Substance Use Screening
• Single Item screeners • NIDA: “How many times in the past year have
you used an illegal drug or used a prescription medication for non-medical reasons?”
• NIAAA: “How many times in the past year have you had more than 4/3 drinks in a day?”
Substance Use Screening
Our Patient
ORT score:18 = HIGH RISK
Second Option
• Atluri Tool– 6 clinical criteria
1. Focus on opioids2. Opioid overuse3. Other substance use4. Low functional status5. Unclear etiology of pain6. Exaggeration of pain
– Score >3 OR of 16 for opioid misuse
Atluri SL et al. Pain Physician 2004; 7:333-338.
Not willing to try non opioid modalitiesAlways asking about opioids (inc 1st visit)Upset when denied opioidsRequesting particular med
History of drug/EtOH abuseCurrently using marijuanaFeels need for benzos
On disability or applying
Pain “everywhere”Non-physiologic distribution
ER visit for pain; Uses up own supply too fast
What to do with the risk evaluation?
Atluri et al. Pain Physician; 2012; 15: ES177
Our Patient
• High risk for “ADRBs”• Options
• Taper off opioids• Continue opioids with close monitoring
• Frequent Utox (q month)• Short refill interval (q 2 weeks)• Frequent CURES report (3-4 times per year)• Patient Agreement and Informed Consent with
explanation of reasons for discontinuation (i.e. no show, refusal of alternative treatments, abnormal Utox results)
How do we assess and understand the impact of psychosocial issues on
the pain experience?
Psychosocial Assessment
• Brief Intervention vs.
Detailed Psychosocial Assessment
• Brief Intervention in Primary Care Behavioral Health• Review presenting problem/referral question• Assess/strengthen supports• Identify/build coping skills
Detailed Psychosocial Assessment (may be gathered over time by various team members)
• Presenting problem/referral question• Culture/family history• Educational/work history• Relationship history/interpersonal issues• Trauma history• Substance use history• Psychiatric/medical history• Current:
• Symptoms• Supports• Coping skills
Mr. Anderson’s Psychosocial Assessment
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•Culture/family historyBorn in Ohio, family background Irish/German/DanishNo strong cultural/religious affiliationsMiddle of 3 kids, father left when pt. was 7 Mother and siblings moved around
•Educational/work historyCompleted 10th grade, fair gradesHas worked odd jobs, mostly house paintingCurrently on GA, in SRO
•Relationship history/interpersonal issuesMarried twice, now lives with female partnerHistory of anger management problems including IPV with partners No longer speaks to siblingsFeels angry/disappointed with medical
system for not curing his pain
•Trauma historyVague memories of IPV between parents, mother verbally and physically abusive, sexual assault by an older man age 11
•”I’ve tried everything”•Drank 2-4 beers daily before accident, none since• H/O heroin use, none for 3 years • Occasionally buys prescription opioids on the street (Morphine) • Occasional benzodiazepine use •1 ppd cigarettes
Substance use history
• Psychiatric history
• Long history of depressive sx, “I’ve been depressed all my life”
• No history of manic episodes, no psychiatric hospitalizations
• On various antidepressants with little effect • Intermittent suicidal ideation, one non-lethal
gesture as adolescent
Current Symptoms
• Depressed feelings, feeling “empty”, feeling like no one cares/no point in living, but no clear suicidal plan
• Reports daily “mood swings”, but not mania• Feels that pain is intolerable, nothing helps• Angry that “system” is not helping him, feels
abandoned by medical team for “withholding” medication
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Psychosocial Assessment: Strengths
• Support• Has female partner of 3 years• Has one “buddy” he sees quite regularly
• Coping skills• Intelligent, resourceful• Reasonably good eating/exercise habits• Has managed to reduce/abstain from substances
since the accident• Can respond to encouragement, support
Psychosocial Assessment: Findings
• Does NOT currently meet criteria for major depression, more likely dysthymia
• Not acute PTSD (“complex PTSD”)• Borderline personality features
• Mood instability• Interpersonal issues, extremes• Impulse control problems, suicidal
thoughts/gestures• Chronic feelings of emptiness• Expectation/fear of abandonment
Patient’s Experience of Pain
• May experience pain as unrelenting, not distinguishing between physical and emotional pain
• Feels that no one/nothing can help• May test limits to see if can influence you• May see things in extremes, you are “a
wonderful provider” when increasing meds, a “%#&^!?!” when setting limits
Discussing Risk Issues
Use understanding of pt. when discussing limits and risk issues
• Interpersonal
• The relationship is paramount• Stress partnership, trust, working together,
listen to pt’s concerns • Put in the context of caring for pt; communicate respect
Splitting, Thinking in Extremes
• Recognize the patient’s “all-or-nothing” thinking; help to find middle ground
“It’s not exactly black and white. Let’s weigh the risks and benefits of going up on your dose together. We have to find a way to find some balance between how it helps and what the downsides are.”
Testing (Will you abandon me?)
• Clear limits, consequences, structure helpful
“I want to be able to work with you to find our best options over time. The only way I can do that is if we have some agreement about how we’re going to do this.”
• Consciously give patient choices when possible
“Would you prefer to take your meds twice a day or three times a day?”
Countertransference
• Understand your personal reactions • Don’t let yourself be provoked by testing• Don’t take patient’s anger at/rejection of you as a
failure
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How do we minimize the risks if we do prescribe?
• Clear patient-provider agreement
• Frequent visits
• Monitor function, not just pain score
• Urine drug testing
• CURES reports
• Pill counts
How can we use Naloxone to reduce the risk of death by overdose?
Lay Naloxone for Overdose Prevention
• Readily reverses opioid overdoses
• Patient & provider support
• Training easy & effective
• Frequent reversals reported
• Community-level mortality reduced
Bazazi et al., J Health Care Poor Underserved 2010. Seal et al; Coffin et al., JUH 2003. Green et al., Addiction 2008. Enteen et al., JUH 2010. Walley et al., BMJ 2013; Albert et al., Pain Med 2011
Fatal Opioid Overdose Rates by Naloxone Implementation
Adjusted Models RR ARR* 95% CI
Cumulative enrollments per 100k
No enrollment Ref Ref Ref
1-100 0.93 0.73 0.57-0.91
> 100 0.82 0.54 0.39-0.76
* Adjusted Rate Ratios (ARR) adjusted for city/town population rates of age<18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, year
Walley et al. BMJ 2013; 346: f174.
DOPE Project Dispensing 1993-2012
0
100
200
300
400
500
600
700
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012*
New Enrollments
Refills
Reversals
Heroin Related Deaths: SF 1993-2010
Naloxone distribution begins
*Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org **no data available for FY 2000-2001
Potential Behavior Changes
• Risk of non-fatal opioid overdose• U.S. Army Fort Bragg• EMS/ED visits in SF• Syringe sharing in Seattle• Model
• Overdose may influence behavior
Why pain patients?
• Rx opioid deaths presaged an increase in heroin overdose and death (Unick et al., Plos One 2013)
• Prescribed opioids associated with a transition to heroin (e.g. Young & Havens, Addiction 2012)
• SF opioid analgesic overdose decedents engaged in primary care• 69% on chronic opioids
San Francisco Naloxone Access
• Community-based dispensing• Drug Overdose Prevention and Education
(DOPE)
• Access for other populations• Primary care patients at selected sites and
connected pharmacies• Mental health patients at CBHS clinics• Buprenorphine/methadone patients dosing
at CBHS
Intranasal Naloxone Kit
• Atomizer (2)• Brochure• Naloxone 2mg/2ml prefilled syringes (2)
Provider Education
• Training document on CBHS website• Naloxone Training for Providers
• Key components • Causes • Recognition• Actions (call 911, rescue breathing,
naloxone administration)
Primary Care
Clinic
Rx Opioid
Rx Naloxone
Atomizer
Brochure
Education
Pharmacy
Dispense Opioid
Dispense Naloxone
Education
Mental Health
Clinic
Opioid user
Rx Naloxone/disp Naloxone
Atomizer
Brochure
Education
Pharmacy
Dispense Naloxone refill
OBOT Methadone/Buprenorphine
Clinic
OBOT Methadone order
or
Rx buprenorphine
CBHS Pharmacy
Methadone or buprenorphine
Clinical Pharmacist Evaluation
Rx Naloxone/Disp Naloxone
Atomizer
Brochure
Education
SFDPH Naloxone Distribution Summary as of 4/11/2013
Setting Sites Unique individuals
Reported Reversals
DOPE 50 >3,700 916
Primary Care 2 67 --
Mental Health 1 13 --
Opioid Agonist Treatment
1 38 2
Mr. Anderson part 2
• You discussed your concerns about risk with the patient
• You signed a patient provider agreement• May not use other controlled substances• May not give medications to others• Must take meds as prescribed• Must inform you if he receives prescriptions
from other providers• Must follow up with diagnostic and treatment
strategies• Will have regular urine drug tests• Will only receive refills in the context of
scheduled appointments• Will not receive early refills
Mr. Anderson, part 2
• Start gabapentin for neuropathic component of pain
• Refer to behavioral health team for support with pain coping• Group or individual
Mr. Anderson, Part 2
• Over the next few months:• Increase gabapentin dose, helping a
little• Patient adheres to the patient-provider
agreement
Mr. Anderson, Part 2
• 4 months later • Drops in to clinic 1 week before
appointment requesting early refill• Fell from a ladder, has been taking extra
morphine and oxycodone for increased pain. Ran out early
• Gets an early refill from urgent care provider
• Misses his next appointment with you
Mr. Anderson, Part 2
• Drops in one week later requesting morphine and oxycodone from urgent care provider• States that insurance would not cover
the full monthly amount of his last rx, so he needs early refill
• Provider requests urine drug test• Patient becomes angry and leaves
without providing a urine sample
Mr. Anderson part 2
• You schedule an appointment with the patient • Refill his medications• Order a urine drug test
• Urine contains • Oxycodone• Morphine• Hydromorphone• Benzodiazepenes
What are your concerns at this point?
Labmed.ucsf.edu/sfghlab
Given these concerns, options include
• Discontinue prescribing of all controlled substances
• Require the patient to enter substance abuse treatment in order to continue prescribing
• Increase visit frequency, urine drug test frequency, check CURES
• Change to a medication that treats pain and substance abuse simultaneously
What is the role of buprenorphine/naloxone in the treatment of co-occurring pain and substance use disorder?
Scott Steiger, MDAssistant Professor of Clinical Medicine
Division of General Internal MedicineUniversity of California – San Francisco
Outline
1. buprenorphine (bup) pharmacology
2. Buprenorphine/Naloxone (Bup/Nx) treats opioid dependence
3. Bup/Nx treats pain
4. Bup/Nx for this patient?
Buprenorphine is a partial agonist of the µ-opioid receptor
*NABBT.org
Buprenorphine is a partial agonist of the µ-opioid receptor
*NAABT.org
RR <6
Buprenorphine Still Blocks Opioids as It Dissipates
Courtesy of NAABT, Inc. (naabt.org)
Imperfect Fit – Limited Euphoric Opioid Effect
BuprenorphineOpioid
Empty Receptor
Withdrawal Pain
Receptor Sends Pain
Signal to the Brain
Perfect Fit - Maximum Opioid Effect
Empty Receptor
Euphoric Opioid Effect
No Withdrawal Pain
Buprenorphine formulations
• Temgesic (UK, sl)
• Buprenex (IM)
• Subutex and generic (sl)
• Suboxone, Orexa, generics: coformulated with naloxone (sl)
• Norspan and Butrans (td)
• ?Nabuphine (subq implants)
Buprenorphine formulations
Bup/Nx comes in a couple of forms
Bup/Nx is available for treatment of opioid dependence• DATA 2000
• Lower barrier to addiction tx
• Requires extra training, DEA waiver
• FDA approval in 2002• “Office based” opioid
replacement
• Medicaid covers in CA
Addiction or chronic pain?
•Tolerance?
•Withdrawal?
•Loss of control over use?
•Use despite negative consequences?
Off label Bup/Nx is effective for pain
•Acute pain in patients already on Bup/Nx
•Chronic pain failing other opioids*
•Chronic pain in “extremely high risk” patient?
*Malinoff et al Am J Ther 2005
Co-occurring disorders clinic
VA retrospective cohort of 1
•Referrals from PCP, pain mgmt, hospital, substance abuse treatment
•Screened, induced, then maintained
•Bup/nx stopped if…• Uncontrolled pain on >28 mg bup/nx• Tox + 3+, miss 3+ visits, 3+ early refills
Pade et al. JSAT 2012
Change in pain scores and retention
Pade et al. JSAT 2012
Patients APS change # (% retain)Preferred opioid Heroin 16 -0.7 10 (63%) Methadone 23 -0.3 17 (74%) Oxycodone 63 -1 40 (63%) Hydrocodone 18 -0.1 13 (72%) Fentanyl 9 -1.1 3 (33%) Morphine 12 -1.2 9 (75%) Codeine 1 -7.8 1 (100%) Hydromorphone 1 0.6 0 (0%)Age group21-40 y 25 -1.1 15 (60%)41-60 y 81 -0.7 51 (62%)61-80 y 37 -0.9 27 (72%)
Bup/nx maintenance better than taper for high risk patients
“we found that it was quite difficult to wean opioids among those with chronic non-cancer pain and co- existent opioid addiction.”
Blondell et al J Addict Med 2010
Special considerations using bup/nx for chronic pain• Induction
• More “off time” required, esp with methadone
• Low COWS? • ?safer just to taper
•Dosing considerations• POTENT• Consider increased frequency for pain
•Payor considerations
Initial dose must be appropriate
VA Co-occurring sorders clinic dropped everyone to MS 90 mg eq—and short-acting
Prospective cohort study NYC (n=12)•3 highest doses (>300 MS eq) and 3 lowest doses (<20 MS eq) quit at induction•4 who completed reported better pain control
Rosenblum J Opioid Manag 2012
46 yo M with high risk chronic pain
Treat with bup/nx!!• Meets criteria for opioid
use disorder• Risk < benefit of opiates• Poor candidate for
abstinence only or naltrexone
Maybe we should hold off…• MAY meet criteria for
SUD for benzos• Dose may be too high
for easy transition• MAY have greater
benefit from MMTP
Summary
• Bup/nx’s pharmacology offers unique advantages compared to other opioids
• Consider bup/nx in• Opioid dependence
• High risk chronic pain
• Pain refractory to other opioids
• Bup/nx requires a DEA waiver to Rx
How do I get the waiver?
Buprenorphine.samhsa.gov
May 15 Training
What else can we offer for pain?
Pain Treatment ≠ Opioids
How do opiates compare?
What about function?
Drug Class Average Pain ReductionOpioids 30-40%Tricyclics/AEDs 30-60% for neuropathic
painAcupuncture 10% CBT/Mindfulness 30-60%Exercise/ PT 30-60%Massage 30-40% for LBP
Pharmacologic Physical
Complementary and Alternative Medicine
Cognitive and Behavioral
Pharmacologic•Neuroleptics•Antidepressants•Anesthetics (lidocaine patch)•Muscle relaxants•Topicals (capsacin)•Opioid medications/Tramadol•Baclofen pumps, lidocaine pumps•Buprenorphine/naloxone
Physical
Complementary and Alternative Medicine
Cognitive and Behavioral
Pharmacologic•Neuroleptics•Antidepressants•Anesthetics (lidocaine patch)•Muscle relaxants•Topicals (capsacin)•Opioid medications/Tramadol•baclofen pumps, lidocaine pumps•Buprenorphine/naloxone
Physical•Physical Therapy/Physiatry consults•Joint injections•Spine injections•Surgery•Stretching/strengthening exercises•Heat or ice•Trigger point injections
Complementary and Alternative Medicine
Cognitive and Behavioral
Pharmacologic•Neuroleptics•Antidepressants•Anesthetics (lidocaine patch)•Muscle relaxants•Topicals (capsacin)•Opioid medications/Tramadol•baclofen pumps, lidocaine pumps•Buprenorphine/naloxone
Physical•Physical Therapy/Physiatry consults•Joint injections•Spine injections•Surgery•Stretching/strengthening exercises•Recommendations for pacing daily activity•Heat or ice•Trigger point injections
Complementary and Alternative Medicine
•Acupuncture (community and schools)•Mindfulness Based Stress Reduction and meditation•Community yoga classes•Tai-chi classes•Massage schools•Anti-inflammatory diets and herbs•Supplements •Guided imagery•Breathing exercises
Cognitive and Behavioral
Pharmacologic•Neuroleptics•Antidepressants•Anesthetics (lidocaine patch)•Muscle relaxants•Topicals (capsacin)•Opioid medications/Tramadol•baclofen pumps, lidocaine pumps•Buprenorphine/naloxone
Physical•Physical Therapy/Physiatry consults•Joint injections•Spine injections•Surgery•Stretching/strengthening exercises•Recommendations for pacing daily activity•Heat or ice•Trigger point injections
Complementary and Alternative Medicine
•Acupuncture (community and schools)•Mindfulness Based Stress Reduction and meditation•Community yoga classes•SFGH Tai-chi classes•Massage schools•Anti-inflammatory diets and herbs•Supplements •Guided imagery•Breathing exercises
Cognitive and Behavioral
•Pain Groups•Individual therapy•Brief cognitive and behavioral interventions in clinic•Visualization, deep breathing, meditation•Sleep hygiene•Gardening, being outdoors, going to church, spending time with friends and family, etc.
Questions
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How To Think About Concerning Behaviors
Concerning Behaviors
• Poor functionality• Requests for a specific
medication• Tox (-) for drug prescribed• Tox (+) for other drugs• Early refill requests• Multiple prescribers• Hoarding• Lost or stolen medications• Comes for appointments
only when opi needs refill• Neglects other aspects of
care plan
• Reports that pharmacy “shorted” the prescription
• Alcohol/drug use• Forgery• over sedation (purposeful or not)• MVAs or other accidents• Self-initiated dose changes• Escalating/very high doses• Refusal to sign ROI• Drug cravings• Reports “allergies” • Refusal to take DOT
Prescribers Dilemmas
• Unproven standards• Stigma associated
with treating patients• Conflicting guidelines
and recommendations
• Pressure to prescribe opiates and liberally treat pain
• Wondering if pain is real
• Epidemic of Rx overdoses and misuse
• Addiction long associated with abstinence treatment models
• Provider disciplinary action/malpractice
• Mistrust of self/skills and patients
Goals in addressing concerning behaviors
• Improve pain and functioning
• Reduce risks
• Reduce suffering
• Improve feeling of provider effectiveness
Framework: How to structure thinking
Framework:The Nursing Process
• Assess• Diagnose• Outcome
Identification• Plan• Implement and
Evaluate
Research and Risks
• Aberrant medication behavior rate: 5 % to 24% 1
• For all patients on opioids for CNCP 2
• Abuse/addiction rate = 3.27%• Aberrant behavior rate = 11.5%
• For all patients excluding past or current SUD diagnosis: 2
• Abuse/addiction rate = 0.19%• Aberrant behavior rate = 0.59%
1. Martel et al, 2007. 2. Fishbain et al, 2008.
Research and Risks
• Younger Age 1, 2, 3, 4, 5, 6
• Male gender 2, 4
• Caucasian/White 1
• Mental Health Disorders 1, 3, 4, 5, 6, 7
• Large dose or supply 3, 4, 8
• Drug Cravings 7
relation to pain severity 2
1. Dowling et al, 2006. 2. Ives et al, 2006. 3. Edlund et al, 2010. 4. White et al, 2009. 5. Fleming et al, 2007. 6. Reid et al, 2002. 7. Wassan et al, 2007. 8. Dunn et al, 2010.
Research and Risks
FHx SUD 1
Personal Hx SUD 1, 2,
3
Specific Drugs•Cannabis 4, 5, 6
•Cocaine 4, 6, 7, 8
•Alcohol 8, 9
•Heroin 4
1. Webster & Webster, 2005. 2. Edlund et al, 2010. 3. Turk et al, 2008. 4. Dowling et al, 2006. 5. Reisfield et al, 2009. 6. Fleming et al, 2007. 7. Meghani et al, 2009. 8. Ives et al, 2006. 9. Dunbar & Katz, 1996.
Research and Risks
Pain, SUDs, and Functionality
• SUD reported greater disability due to pain
• Pts w/ SUD more likely to be prescribed an opioid analgesic
• Pts w/ SUD less likely improvement in pain related function
Morasco et al, 2011.
Assessment
• H & P: SUD history, FHx, and psychosocial assessment.
• Testing: UDT, other toxicology
• Risk Assessment & stratification.
Differential Diagnosis
• Psychiatric disorders• Cognitive disorders• Diversion• Pseudo-addiction• Opioid tolerance• Allodynia or opioid-
induced hyperalgesia• Addiction/abuse
Substance Dependence
• Tolerance• Withdrawal• Larger amounts or longer time than
intended• Persistent desire or unsuccessful efforts to
cut down• A lot of time spent to obtain or recover from
use• Important activities given up• Substance use continues despite having a
related persistent or recurrent health problem
Planning
• Risks dictate structure• Structure helps
• Reduce or resolve aberrant behaviors
• Result in self-discharge• ID who needs higher level of
care
Elements of Structure
• Visit Frequency• Refill frequency• Medication call backs• UDT
• Presence/absence of rx’d drug• Presence/absence drugs of abuse
• PDMP
Planning
When plan is insufficient to reduce risk: change it.
•Explain why
•Offer options
•Refer: addiction care, ORT plus pain care, pain clinic
Opiate analgesics may not be appropriate if…
• Pain unimproved on upward titration
• Unmanageable side effects
• Recurrent non-adherence to treatment plan or agreement
• Non-resolution of risky drug behaviors with tight controls
Assess the “Four A’s”
• Analgesia
• ADLs
• Adverse events
• Aberrant Behaviors
AAAA
Passik & Weinreb, 2000.
Universal Pain Precautions
1) Make diagnosis2) Psychological
Assessment3) Informed consent4) Treatment
agreement5) Pre-Intervention
assessment of pain level and functioning
6) Pharmacotherapy trial
7) Post-intervention assessment of pain level and functioning
8) Assess the “Four A’s”
9) Review diagnosis and co-morbidities
10)Documentation
Gourlay, Heit & Almahrezi, 2005.
Opioid prescription management includes
• Both pharmacologic and psychosocial interventions
• Regular monitoring• Routine evaluation of treatment goals• Patient education• Encourage patient to engage in the
treatment process• Inclusion of other supports for overall
health
Summary
• Concerning behaviors: not always addiction• Assess and identify risks, balance with benefits• Formulate differential and diagnosis• Create plan including risk stratification• More risks indicate more elements of plan• Use a consistent, standardized approach to opioid
prescribing with all patients, e.g. “universal precautions”
• Join a team: multidimensional psychosocial, pharmacologic, non-pharmacologic, referrals and resources
• Team decision making based on risks and successes• Apply essential elements of chronic disease
management
Sources• Chou, R, Fanciullo, GJ, Fine, PG et al. (2009). Clinical guidelines for the
use of chronic opioid therapy in chronic noncancer pain. The journal of pain, 10(2), 113-130.
• Dowling, K, Storr, C L, & Chilcoat, H D. (2006). Potential influences on initiation and persistence of extramedical prescription pain reliever use in the US population. The Clinical journal of pain, 22(9), 776-783.
• Dunbar, S A, & Katz, N P. (1996). Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. Journal of pain and symptom management, 11(3), 163-171.
• Edlund, M J, Martin, B C, Fan, M, et al. (2010). Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study. Drug and alcohol dependence, 112(1-2), 90-98.
• Fishbain, D A, Cole, B, Lewis, J, et al. (2008). What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain medicine, 9(4), 444-459.
• Fleming MF, Balousek, SL, Klessig, CL, et al. (2007). Substance use disorders in a primary care sample receiving daily opioid therapy. The journal of pain, 8(7), 573-582.
• Gourlay, D L, Heit, H A, & Almahrezi, A. (2005). Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain medicine, 6(2), 107-112.
• Ives, T J, Chelminski, P R, Hammett Stabler, C A, et al. (2006). Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC health services research, 6, 46-46.
• Jamison, R N, Ross, E L, Michna, E, et al. (2010). Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain, 150(3), 390-400.
• Martell, B A, O'Connor, P G, Kerns, R D, et al. (2007). Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146(2), 116-127.
• Meghani, S H, Wiedemer, N L, Becker, W C, et al. (2009). Predictors of resolution of aberrant drug behavior in chronic pain patients treated in a structured opioid risk management program. Pain medicine, 10(5), 858-865.
• Morasco, B J, Corson, K, Turk, D C, et al. (2011). Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain. The journal of pain, 12(3), 352-359.
• Passik, S D. (2009). Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clinic proceedings, 84(7), 593-601.
• Passik, S D, & Weinreb, H J. (2000). Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Advances in therapy, 17(2), 70-83.
• Paulozzi, L J, Budnitz, D S, & Xi, Y. (2006). Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology and drug safety, 15(9), 618-627.
• Reid, M C, Engles Horton, L, Weber, M B, et al. (2002). Use of opioid medications for chronic noncancer pain syndromes in primary care. Journal of general internal medicine, 17(3), 173-179.
• Reisfield, G M, Wasan, A D, & Jamison, R N. (2009). The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: a review of the extant literature. Pain medicine, 10(8), 1434-1441.
• Savage, S R. (2002). Assessment for addiction in pain-treatment settings. The Clinical journal of pain, 18(4 Suppl), S28-S38.
• Savage, S R. (2009). Management of opioid medications in patients with chronic pain and risk of substance misuse. Current psychiatry reports, 11(5), 377-384.
• Sehgal, N, Manchikanti, L, & Smith, H S. (2012). Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain physician, 15(3 Suppl), ES67-ES92.
• Turk, D C, Swanson, K S, & Gatchel, R J. (2008). Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. The Clinical journal of pain, 24(6), 497-508.
• Warner, M, Chen, L H, Makuc, D M, et al. (2011). Drug poisoning deaths in the United States, 1980-2008. NCHS data brief, (81), 1-8.
• Wasan, A D, Ross, E L, Michna, E, et al. (2012). Craving of prescription opioids in patients with chronic pain: a longitudinal outcomes trial. The journal of pain, 13(2), 146-154.
• Webster, L R, & Webster, R M. (2005). Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain medicine, 6(6), 432-442.
• White, A G, Birnbaum, H G, Schiller, M, et al. (2009). Analytic models to identify patients at risk for prescription opioid abuse. The American journal of managed care, 15(12), 897-906
When and How to Taper Opioids
When to discontinue opioids
• Treatment goals not met/opioid trial failed• Insufficient improvement of
pain/function/quality of life• Significant non adherence to treatment plan
• Risks/harms outweigh benefits• Intolerable/dangerous side effects• Concerning/dangerous behaviors
suggesting:• Active substance abuse (opioid, other)• Diversion• Psychiatric instability
When/Where to taper opioids
• When• Patient taking medication• Physiologic dependence• Safe to do so
• If clearly unsafe or illegal behaviors, stop and assess for withdrawal
• Where• “Although there is insufficient evidence to
guide specific recommendations on optimal strategies, a taper … can often be achieved in the outpatient setting in patients without severe medical or psychiatric comorbidities.”
Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009, 113-130.
Where/How to taper opioids
• Assess patient’s opioid use, medical problems, and psychosocial issues
• Involve other team members
• Provide written instructions
Where/How to taper opioids
• Consider referral to methadone treatment program if opioid abuse
• Consider referral to addiction medicine/ substance abuse or psychiatric treatment if (risk of) unsafe behaviors (e.g., suicidality, lack of impulse control)
How to taper opioids
• “Evidence to guide specific recommendations on the rate of reductions is lacking, though a slower rate may help reduce the unpleasant symptoms of opioid withdrawal.”
• Factors that may influence rate:• reason for discontinuing• medical/psychiatric comorbidities• withdrawal symptoms during process
Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009, 113-130.
How to taper opioids – rules of thumb
• One taper regimen (Univ of Mich Health System):• Decrease 10% of original dose every week until
20% remains, then 5% of original dose until off• Other considerations:
• Amount of opioid necessary to prevent withdrawal is 20% of previous day’s dose
• Convert multiple medications to 1 medication, then taper
• Reduce dose 20-50% because of incomplete cross tolerance
• Taper faster at higher doses (>200mg morphine), slower when reach 60-80mg morphine/d
• Some suggest the longer the treatment, the slower the taper
Opioid taper - example
• MSSR 60mg 3x daily plus MSIR 30mg 1 q4hr (DNE 3/d)
• Total daily dose: 60X3=180, 30X3=90→270mg
• Initial taper• 100% to 20% initial dose → 270mg to 54mg
• 10%/wk →27mg/wk (round to 30mg/wk)
• Final taper• 5%/wk →14mg/wk (round to 15mg/wk)
• MSSR pill strengths: 15, 30, 60, 100, 200mg
Opioid taper - exampleWeek Total dose morphine/ day (mg) Script
1 240 (begin 10%/wk taper) MSSR 60mg 3xd #21MSIR 30mg 2xd prn #14
2 210 MSSR 60mg 3xd #21MSIR 30mg 2xd prn #7
3 180 MSSR 60mg 3xd #21
4 150 MSSR 15mg 3 pills 2xd + 4 pills qhs #70
5 120 MSSR 15mg 3 pills 2xd + 2 pills qhs #56
6 90 MSSR 15mg 2 pills 3xd #42
7 60 MSSR 15mg 1 pill 2xd + 2 pills qhs #28
8 45 (begin 5%/wktaper) MSSR 15mg 3xd #21
9 30 MSSR 15mg 2xd #14
10 15 MSSR 15mg 1xd #7
11 0
Managing Withdrawal Symptoms
• Rarely life threatening
• May persist up to 6 mos
• Treat symptomatically• Provide “kick pack”
or have pt return if symptoms
• Avoid opioids or benzodiazepines
Managing Withdrawal Symptoms
Symptom MedicationAnxiety, restlessness hydroxyzine 25mg q6h prn,
diphenhydramine 25mg q6h prn Insomnia hydroxyzine 25-50mg qhs,
diphenhydramine 25-50mg qhs Nausea metoclopramide 10mg q6h prn
Dyspepsia CaCarbonate 500mg 1-2 q8h prnmylanta 1-2 tsp prn
Diarrhea loperamide 1-2 prn diarrheaPain, fever APAP 325mg 1-2 q6h prn,
ibuprofen 200mg 1-3 q6h prnAutonomic symptoms (rhinorrhea, sweating, hypertension, tachycardia)
clonidine 0.1mg q6h prn or patch 0.1mg/24hr qwk
Other treatments/support
• Make efforts to preserve therapeutic relationship• Pt may not feel pain taken seriously• Pt’s clinical situation may deteriorate• Pt may feel poor quality of care and
threaten action
Other treatments/support
• Concerning behaviors may emerge during taper• May be mitigated by initial plan• Use clear, consistent message with focus
on safety and harms/benefits• Offer counseling/support if significant
behavioral issues• Make psychiatric, substance abuse
referrals if indicated
Other treatments/support
• Consider others’ support (team, provider, pharmacist)
• If threats/intimidation occur, take appropriate steps, including preventive actions (other staff/ security present)
References
• Agency Medical Directors Group. Interagency Guidelines on Opioid Dosing for Chronic Non-cancer Pain. http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf
• Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009, 113-130.
• Group Health Cooperative. Chronic Opioid Therapy Safety Guideline For Patients With Chronic Non-Cancer Pain. http://www.ghc.org/all-sites/guidelines/chronicOpioid.pdf
• University of Michigan Health System. Managing Chronic Non-Terminal Pain in Adults. http://www.michigan.gov/documents/mdch/UM_Pain_guidelines_290232_7.pdf
• VA/DoD. Clinical Practice Guidelines for Management of Opioid Therapy for Chronic Pain. http://www.va.gov/PAINMANAGEMENT/docs/CPG_opioidtherapy_fulltext.pdf
Treating Substance Use Disorders
Stimulants, Opioids, and Alcohol
138
Stimulant Use: cocaine and methamphetamine
Judith Martin, MDMedical Director of Substance Abuse
Services, SFDPH
Question for you:
• A patient who is on your clinic’s chronic pain registry tests positive for cocaine when she comes in for her opiate prescription. You ask her what she has noticed about effects of cocaine on her body. She says it makes her heart “jump” in her chest.
• How would you explain this symptom, and how does your clinic protocol address a positive cocaine test?
Effects of stimulants: short term
wakefulness, increased physical activity, decreased appetite, increased respiration, rapid heart rate, irregular heartbeat, increased blood pressure, and hyperthermia.
Effects of stimulants, long term
• Can be damaging to brain, emotions, and body.
• Cardiovascular: high pulse, BP may lead to heart attack or stroke, leads to atherosclerosis, myopathy
• Psychiatric: anxiety, paranoia, depression , egocentric delusions
• Neurostimulation: formication, excoriations, seizures, tremor
Stimulant use, treatment
• Many medications have been tried, none clearly useful.
• CBT, incentives and MI have all been successful.
• In the case of methamphetamine, brain recovery takes time.
Volkow et al., 2001
DATs Recover with Abstinence
Summary: stimulant use
• Evaluate patient’s stage of change
• Information about effects of drug
• Information about types of treatment
• Note: overlap with psychiatric and trauma histories, overlap with other risk behaviors, special urgency in cardiovascular disease.
Medically Assisted treatment for Opiate dependence
MAT for Opiate Dependence
• Reduces overdose
• Decrease illicit opiate use
• Reduced HIV and HCV transmission
• Reduces criminality
• Improves medical, psychiatric, and social functioning
NIH Consensus Statement on Opiate Dependence: 1997
• Opioid addiction is a medical disorder that can be treated effectively
• All should have access to opiate agonist treatment
• Reduce unnecessary treatment regulations
• Coverage should be a required benefit in public insurance programs
Approved Medications• Methadone
• Full opiate agonist• Provided only at licensed specialized
clinics
• Buprenorphine• Partial opiate agonist• Office based settings
• Naltrexone• Opiate antagonist• Office-based settings
Methadone• Synthetic opioid
• Full μ agonist
• Repeated administration leads to physical dependence
• Hepatic storage and subsequent slow release
• Linear dose-response curve
• Half life: 15 to 60 hours
Methadone
• Special Alert (2009): Recommendations for QTc interval screening before and during methadone treatment
• CNS depression
• Respiratory depression
• Hypotension
• Consider synergistic effects with sedative or alcohol abuseCNS, central nervous systemKrantz MJ et al. Ann Intern Med. 2009;150:387-395.
Methadone Prescribing• For pain with a DEA license• For opiate replacement
• At licensed NTPs• Through OBOT methadone program:
Tom Waddell and Potrero Hill Clinics only
• Federal and State Regulations: Title 9 in California• Setting, dose limits, dosing frequency,
drug testing, counseling (addiction)• Liquid formulation
Methadone and Benzodiazepines• 51% to 70% of MMTP patients use
benzodiazepines (similar to buprenorphine patients and heroin users not in treatment)1-3
• 18% to 50% with problematic use1,3,4
• In studies, benzodiazepine-related deaths for MMTP patients range from 10% to 80%5-8
1Gelkopf M et al. Drug Alcohol Depend. 1999;55:63-68; 2Stitzer ML et al. Drug Alcohol Depend. 1981;8:189–199; 3San L et al. Addiction. 1993;88:1341-1349; 4Ross J, Darke S. Addiction. 2000;95:1785-1793; 5Maxwell JC et al. Drug Alcohol Depend. 2005;78:73-81; 6Lintzeris N, Nielsen S. Am J Addictions. 2010;19:59-72; 7Williamson PA et al. Med J Australia. 1997;166:302-305; 8Zador D, Sunjic S. Addiction. 2000;95:77-84.
Methadone: Contraindications
• MAOIs: MTD within 14 days of MAOI increase the risk of serotonin syndrome1,2
• Phenothiazines: additive effects include ileus, cardiac arrhythmias (QT prolongation), CNS depression, psychomotor impairment1,3
• Venlafaxine: cardiac arrythmias (QT prolongation), serotonin syndrome, NMS4
• Ziprasidone: additive effects5
1Roxane Laboratories, 2009; 2Gillman PK. Br J Anaesth. 2005;95:434-441; 3Baxter Healthcare Corporation. Phenergan (prescribing information. 2009; 4Wyeth Pharmaceuticals Inc. (venlafaxine) prescribing information. 2009; 5Pfizer Inc. (ziprasidone) prescribing information. 2009.
Methadone: Drug Interactions
• CYP450 system: metabolized at 3A4, 2B6, 2C19, and (lesser) at 2C9, 2D61,2
1Roxane Laboratories. Methadone hydrochloride prescribing information. 2009; 2Mallinckrodt Inc. Methadose Oral Concentrate (methadone hydrochloride oral concentrate) prescribing information. 2009.
Methadone: Drug Interactions• CYP inhibitors
• Fluoxetine and norfluoxetine: CYP3A4, 2D6, 2C9. No clinically significant interaction in vivo1,2
• Fluvoxamine: CYP3A4 and 2C9. Watch for methadone toxicity due to increase methadone levels. When stopping fluvoxamine watch for methadone withdrawal2,3
• Quetiapine: increased methadone levels (CYP2D6)4
• Grapefruit juice: moderate inhibitor at CYP3A42
1Bertschy G et al. Ther Drug Monit. 1996;18:570-572; 2McCance-Katz EF et al. Am J Addict. 2009;19:4-16; 3Perucca E et al. Clin Pharmacokinet. 1994;27:175-190; 4Uehlinger C et al. J Clin Psychopharmacol. 2007;27:273-278.
Methadone Drug Interactions
Methadone may inhibit metabolization at CYP2D6
•Desipramine: levels may double or more1,2
•Risperidone: 2D6 substrate, may have potential for adverse drug interaction, but no clinically significant reports of such and no human pharmacokinetic studies3
•Phenothiazines: 2D6 substrate, consider potential for adverse drug interaction4
1Kosten et al. Am J Drug and Alcohol Abuse. 1990;16:329-336; 2Maany et al. Am J Psychiatry. 1989; 146:1611-1613; 3McCance-Katz et al Am J Addict. 2009;19:4-16; 4Ereshefsky et al. Clin. Pharmacokinet. 1995; 29(Suppl 1):10-18.
Methadone Drug Interactions
CYP inducers
•St. John’s Wort: CYP3A4 and 2C91-3
•Carbamazepine, phenytoin, and barbiturates: CYP3A4. Lower methadone levels and lead to opiate withdrawal4,5
1Izzo AA. Int J Clin Pharmacol Ther. 2004;42:139-148; 2Puzantian T. Drug Interactions of Methadone and Psychiatric Medications; information brochure presented to staff and faculty of UCSF at San Francisco General Hospital. 1997; 3McCance-Katz EF et al. Am J Addictions. 2009;19:4-16; 4Bell J et al. Clin Pharmacol Ther. 1988;43:623-629; 5Perucca E. Br J Clin Pharmacol. 2006;61:246-255.
Reduced Methadone Levels
Consider:
•Risk for relapse to illicit opioids
•Non-adherence to prescribed medications
McCance-Katz EF, Mandell TW. Am J Addict. 2010;19:2-3.
SF Methadone Clinics• Ward 93*• BAART Market Street*• BAART Turk Street*• Westside*• Bayview-Hunter’s Point*• Fort Help• VA Ft Miley
*Referrals through COPE
COPE• Eligibility: Title 9, CHN, not Medi-
Cal• Referral to COPE: phone 552-6242• COPE assessment: toxicology &
pregnancy testing, counseling and medical visits per Title 9; DADP exception
• Goal: methadone intake ASAP• Funding limits
Buprenorphine
• Semi-synthetic derivative of thebaine (an opium alkaloid)
• Partial μ agonist, antagonizes κ receptor
• High binding affinity and slow dissociation for μ receptor
• Sigmoidal dose-response curve: ceiling effect
• Half life: 37 hours• Side effects: sedation, CNS
depression, hypotension
Buprenorphine Prescribing • FDA approved in 2002 for opiate
replacement, schedule III• Buprenex (FDA 1985),
Suboxone*, Subutex
• Requires 8 hours special training and DEA “waiver”
• MDs only..no mid-levels
• Office-based setting
• OBIC Clinic
Buprenorphine: Safety• Hepatic impairment1
• Monitor CYP3A42
• Monitor with other CNS depressants • BZD-BUP drug related deaths reported as
high as 80%.
• Deaths associated with IDU BUP and concomitant BZDs and neuroleptics3-5
• Phenothiazines: enhance the hypotensive effect?6
• Alcohol: enhanced CNS depression1Zuin M et al. Dig Liver Dis. 2009;41:38-e10; 2Reckitt Benckiser Pharmaceuticals Inc. Suboxone prescribing information. 2010; 3Kintz P. Clin Biochem. 2002;35:513-516; 4Lintzeris N, Nielsen S. Am J Addict. 2010;19:59-72; 5Lai SH, Yao YJ, Lo DS. Forensic Sci Int. 2006;162(1-3):80-86; 6Thioridazine. Harrison’s Practice. http://www.harrisonspractice.com/practice/ub/view/DrugMonographs/156600/5/thioridazine. *Reckitt Benckiser Pharmaceuticals Inc. Suboxone film prescribing information. 2010.
OBIC• Referral to OBIC: phone 552-
6242
• Intake: • orientation appointment
• Induction appointment
• Stabilization. All OBIC notes in LCR.
• Transfer back out to the community: integrated care
OBIC Services• Induction and stabilization
• Counseling and education: individual and group
• Provider Education and Support
• “Safety net” re-stabilization PRN
• PRN health and mental health assessments and referrals.
• Ancillary services PRN: pharmacy, UDT, counseling
IBIS: Integration Flow“any door the right door”
Naltrexone• 1984: FDA approval for opiate
dependence• Opiate antagonist• No significant drug interactions
(opioids)• Black box warning: dose-related
hepatocellular injury is possible: avoid in acute hepatitis or liver failure
• Patients should be opioid-free for a minimum of 7 to 10 days
Naltrexone• Most appropriate for those highly
motivated and frequently monitored• Poorly accepted by patients• Long duration of action (24-72
hours) permitting less than daily dosing (TIW)
• Oral form 50mg tablet (25mg on day 1)
• I.M. 380mg Q 4 weeksFram et al J Sub Abuse Treatment 1989; 6:119-122.
Alcohol and OpioidsOh My!
James J. Gasper, Pharm.D., BCPP
San Francisco Department of Public Health
Community Behavioral Health Services
170
Alcohol: Scope of the Problem
• Alcohol abuse is common in chronic pain patients• About 40% (5 % current, 35 % past) • Preceded pain by average of 15 yrs
• Alcohol use is dangerous in combination with opioids• Present in about 50% of heroin deaths and
30% of methadone deaths• Deaths occur at lower opioid and alcohol
blood concentrations
Katon W, et al. Am J Psychiatry 1985;142:1156-1160. Hickman M, et al. Addiction 2008;103:1060-1062
Approach
Problematic Alcohol Use
Address Opioid Address Alcohol
psychosocial interventions
pharmacotherapy
Hold/taper
Restrict supply
Refer to methadone maintenance
Pharmacotherapy
Detoxification:
• Medically assisted detoxification may be needed
Maintenance:
• Naltrexone contraindicated with concurrent opioids
• Available options: disulfiram, acamprosate, topiramate
Evidence• A few small studies of disulfiram
use in methadone maintenance
• “Reinforced Disulfiram”
• Methadone dose contingent on taking disulfiram
• (N=25) 2% of days spent drinking vs. 21%
Liebson IA, et al. An Int Med 1978;89:342-344
Alcohol Treatment:Opioid Dependence Pathway
Disulfiram
CBHS Alcohol Dependence Guidelines 8/6/2009
Acamprosate
or
Disulfiram + Acamprosate
Topiramate
Principles of Motivational Interviewing
Matt Tierney, NP
Motivational Interviewing is:
• A collaborative and goal-oriented style of communication with particular attention to the language of change
Rollnick S & Miller WR (2013). Motivational interviewing: helping people change. (3nd Ed.) Guilford Press: New York
Spirit of MI• Partnership• Acceptance
• Absolute worth• Accurate
empathy• Autonomy
support• Affirmation
• Compassion • Evocation
MI: Four key processesDevelop commitment to change AND formulate a concrete plan of action
MI is Not• Based on the Transtheoretical Model
of change• A way of tricking people into doing
what you want them to do• A solution for all clinical dilemmas• Decisional balance, equally exploring
pros and cons of change• A form of CBT• Easy to learn Miller & Rollnick, 2008 & 2013
MI is about Exploring
… the discrepancy between current behavior and a core value. A powerful motivator for change when explored in a safe and supportive atmosphere.
Common MI Traps1) “Expert” trap
2) “Question-answer” trap
3) “I rectify gaps in knowledge.”
4) “Fear is a motivator” trap.
5) “I just need to tell them clearly what to do.”
Ethics and MI
Three conditions that present ethical complexities in MI:1. When client’s aspirations are dissonant
with the interviewer’s or institution’s goals of what is in the client’s best interest
2. When the interviewer has an increasing personal investment in the direction the person takes
3. When the nature of the relationship includes coercive power of the interviewer to influence the direction the client takes
Miller & Rollnick, 2008 & 2013
The Case• 51 yo woman here to renew opioid
prescription• Pain began 3 years ago after a car
accident• 7/10, constant aching in the low
back. No red flags.• PMH: COPD, Depression• SH: lives alone, on disability, smokes
tobacco, recently cut down to 1/2ppd • No h/o illicit drug use
The Case• FH: Father died of cirrhosis, h/o
breast cancer on mother’s side
• Meds: • morphine SR 30 mg TID
• oxycodone IR 15 mg q6 PRN BTP
• bupropion 300 mg daily
• inhalers for COPD
The Case• After attending a conference on
pain management, you realize that you have not asked about alcohol use.
• 4 or more drinks in a day in last year? No.
• Drinks 1 beer a night, 7 days/week.• Drinking not more than intended; no
risk of bodily harm.
Motivational Interviewing Skills
How do you increase motivation?
Sharing information without generating resistanceAsk-Tell-Ask•Open ended question, listen to patient
•Respond with additional advice or information
•Ask how that advice or information lands for the patient
“ASKING”
“TELLING”
“ASKING”
Change talk
Any speech in favor of changing a target behavior.
The more a patient engages in change talk, the more likely he or she is to change.
Change Talk• Desire: I want to… • Ability: I can… • Reasons: I should change
because…• Need: I really need to… I have to• Commitment Talk: I’m going to…
I intend to… I will… I plan to… • Taking Steps: I started…
Find the change talk
I want to stay clean and sober. But I can’t get a job because of this court thing, and so I have to live with my brother who drinks all the time.
Find the change talk
I want to stay clean and sober. But I can’t get a job because of this court thing, and so I have to live with my brother who drinks all the time.”
Find the change talk
I don’t want to die of lung cancer, but everyone has to die sometime.
Find the change talk
I don’t want to die of lung cancer, but everyone has to die sometime.
Listen for the meaning in what someone is saying and repeat it back to them
Reflections
Types of reflection
• Repeating • Paraphrasing• Reflect feeling• Reflect values• Double sided• Amplified
Case
Part 1 continued
Two major predictors of a patient’s likelihood to change are
• The amount of change talk that occurs in the visit
• The patient’s sense of self-efficacy
Affirmations
Reflective Listening Exercise
• Repeating
• Paraphrasing
• Reflect feeling
• Reflect values
• Double sided
• Amplified
One thing I like about myself is…
Small Group Practice: Motivational Interviewing
Case
Part II
Your Tasks1. Affirm patient’s decision to engage in
more intensive monitoring2. Share your concerns about the
potential harms of mixing alcohol and opioid analgesics in the setting of COPD
3. Learn the patient’s perspective4. Provide information on reducing
alcohol through self-management strategies
Your Tools• Use reflective listening to find out what
the patient thinks about her drinking
• Use Ask-Tell-Ask to give information on• her risk of opioid analgesic overdose in the
setting of alcohol and COPD• strategies to reduce her alcohol
consumption.
• When you find something to affirm in the patient’s behavior, express your affirmation of the patient’s strengths and ability to care for herself.
Small Group Practice: Difficult Conversations
Case Part 3Difficult ConversationsAt this point, the case will
become more complicated and the provider decides to discontinue opioids.
Your Tasks1. Explain why observed behavior raises your
concern for alcohol use disorder
2. Inform the patient that you cannot safely prescribe opioid analgesics; benefits no longer outweigh risks
3. Develop an opioid analgesic taper plan
4. Listen for signs that patient wants to change her behavior
5. Offer information and referral for alcohol treatment and/or depressed mood
6. Maintain your primary care relationship
Your Tools• Maintain a non-confrontational stance:
avoid arguments; resist the righting reflex
• Stay 100% in “Benefit/Risk” mindset
• Share decision making: include patient in treatment planning
• Respect her autonomy
• Use reflections and affirmations to reinforce patient’s strengths and any change talk
• Use Ask-tell-ask to provide information about alcohol treatment
Navigating the intersection between pain and addiction: SFHP’s role in supporting a system of safe, effective, patient-centered pain management
Kelly Pfeifer, MD
Chief Medical Officer
Beth’s story
• 38 years old, erratically employed
• Anxious and depressed – “counseling doesn’t help”
• Chronic LBP s/p MVA
• 8 Vicodin/day --> 180 mg daily of Morphine over 5 years
• Ativan for anxiety
• Some concerning behaviors:• 1 urine positive for cocaine• 1 drug test refused• Didn’t follow through with
PT or behavioral referral
215
Outcome
Found dead of accidental overdose:
• Methadone • Ativan • Morphine• Cocaine
What did the PCP do wrong?
• According to Chou and Portland clinics:
• Combined benzos and opiates• Continued opiates after positive cocaine UDS• Untreated depression and anxiety• Methadone clinic client (not known)• Poor indication (opiates not effective in chronic LBP)• Over 120 mg a day
217
“We are not accountable for
everything that leads up to drug deaths – poverty, addiction, childhood trauma, despair.
But we are responsible. With our pens, we are writing the drugs into the hands of 8th graders”
Amit Shah, previous Medical Director, Multnomah County Public Health Clinics
218
Based on MMWR: 1:9:35:161:461
CDC/MMWR report Numbers of people in San Francisco
Opiate deaths in SF in 2 years 261
Admitted for substance abuse treatment 2,349
Emergency Department Visits 9,135
Self-reported drug abuse or dependence 42,021
Self-reported nonmedical use of opiates 120,321
Myth # 1
• More opiates means better pain relief
220
No change in pain score with large opiate increases
J. Pain 2013. Vol 14 (4): 384
Myth # 2
• We know when our patients are misusing meds
222
PCPs can’t accurately assess misuse
• 72% misuse in SFGH chronic pain cohort
• No concordance between PCPs’ opinions and participants’ self-reports of past-year misuse:• Missed 38% of those who WERE misusing
• Misjudged 46% of those who WEREN’T misusing (often based on race)
223
Vijayaraghavan M, Penko J, Guzman D, Miaskowski C, Kushel MB. Primary Care Providers' Judgments of Opioid Analgesic Misuse in a Community-Based Cohort of HIV-Infected Indigent Adults. J Gen Intern Med. 2011;26(4):412–8.
Myth # 3
• We know when our patients are diverting meds
224
The incentive to divert is overwhelming
• Typical yearly income for patient on SSI: $13,000
• Typical street value:• $1 per mg• $370 mg a day or
$135,000 per year• Selling 10% of meds
doubles income
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This is the Oxy corner.
Vicodin is next block.
Can I get some
Vicodin?
Partnership Health Plan
• Formulary implemented in Marin in 2009
• Local cop:“Within months the level of Oxycontin on
the street had dropped dramatically”
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Mike’s story
• Occasional marijuana use as a junior, heavy use as a senior
• Tried Vicodin at State College… liked it• 2nd most common drug of abuse for
8th graders
• Got too expensive; switched to heroin• Now homeless
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There is a lot of drug on the streets
• 585 mg of morphine equivalents prescribed per SF resident in 2010
• Enough opiates for each San Franciscan to take the equivalent of 1 Vicodin every 6 hours for a month
CURES data, courtesy of James Gaspar
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Should we consider a dose ceiling in San Francisco?
• There is evidence that high doses of opiates:• Do not improve pain; may make it
worse J Pain, 2011. Vol 12(2): 288.
• Increase death rates (JAMA 2011:30(13): 1315-1321; Annals of Internal Medicine, 2010:152: 85-92; Arch Intern Med. 2011:171(7): 686-691)
• Increase depression, and increase pain perception (hyperalgesia) (General Hospital Psychiatry 34 2012, 581-587)
• There is evidence that lowering doses reduces mortality and pain scores
Am J Ind Med. 2012 Apr;55(4):325-31.
J Opioid Manag 2:277-282, 2006
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“We are not at fault…. But we are responsible”
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Medicaid patients have six times the death rate of the general population when given opiates
Current approach
• Practice Improvement Program measure• For 2013: applies to only 6 clinics with 30 or
more high-dose patients• Requires all providers to agree to consistent
best practices• Requires population management:
• Updated pain management agreement in last 12 months
• Urine Drug Screen in last 12 months
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Potential steps for SFHP
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• 2014: expand Practice Improvement Program measure• All clinics• Providers agree to consistent protocols• Panel management of pain patients• Opiate Oversight Committees
• Spread opportunity for technical assistance for clinics• Registries• Opiate Oversight Committees
Possible future directions for SFHP
• Should we implement lock-in programs?• One pharmacy• One prescriber
• Should we implement dose limits?• PA requirements for high-dose patients?• Waive PAs for clinics with good pain
management infrastructure?
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Are dose limits manageable?
• 487 SFHP members in DPH or SFCCC clinics on >120 mg morphine equivalents daily• Only 6 clinics with over 30 on the list
• 21 prescribers have >6 patients on the list • For these 21 prescribers:
• range 7 – 26 patients• average 13 patients
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Why would providers ask SFHP to take this role?
• SFHP could provide structure to liberate providers from policing and judging role
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“Budget cuts – I’m good cop and bad cop.”
Mission of SF Safety Net Pain Management Workgroup:
We aim to create a consistent system of patient-centered, effective and safe pain management across the safety net.
I welcome your feedback.
Thank you!
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