Managing the patient who is failing opioid pain treatment

Jane C Ballantyne, University of Washington, Seattle

A case of high dose and difficulty tapering

Video here of male patient who is having difficulty tapering despite wishing to taper

“Complex persistent dependence”

• taper or maintain?

• strong evidence that patients who taper from high doses improve in terms of general function and well-being

• unfortunately many relapse

• tapering is hard to achieve for all but the most motivated

• rehab setting is more successful than outpatient setting

Rationale for opioid maintenance treatment for addiction

•steady state opioid administration allows for physiological (cellular and molecular) normalization

•prevents withdrawal and craving

•blocks the euphoric effects of superimposed short-acting opioids

• Continue slow and painstaking taper vs. force off or to a lower, safer dose

• If forcing dose lowering, how?

Principles

• Patient must agree to the plan

• Forcing off may require a degree of ruthlessness

• Continue multimodal treatment, must include behavioral component

• Tapering regime does not need to be complicated

• For this patient who is on very high dose, could reduce by 10 mg per month

• On the basis that he is opioid dependent, it would probably be too ambitious to attempt to go lower than 80 mg/day DEBATABLE

A case of a patient on high dose, motivated to come off altogether

Video here of male patient who succeeded in coming off with the help of suboxone. Before and after videos.

Principles

• Patient must agree to the plan

• Use of a suboxone induction speed up the process of coming off opioids

• Continue multimodal treatment, must include behavioral component

What is buprenorphine?

• Partial opioid agonist, with high affinity for opioid receptors and slow dissociation

• Originally launched as pain treatment (especially in Europe)

• Later used for office based treatment of opioid dependence

• Less likely to cause respiratory depression than full agonists, therefore safer

• Less potential for abuse because of less dependence

• Ceiling effect, therefore less good as an analgesic for severe acute or terminal cancer pain

Uses of buprenorphine in pain management

• Analgesic

• Rapid detox (office or home ‘induction’)

• Maintenance treatment for opioid dependence

• Theoretically, can only be used on its own, not in combination with other opioids

Buprenorphine induction

• Instruct patient to abstain from any opioid use so they are in mild withdrawal at the time of first buprenorphine dose

short acting opioids, 12-24 hrslong acting opioids, 24-48 hrs

• Objective signs of mild-moderate withdrawal (use COWS)

• If not in withdrawal, consider having patient return another day or wait in the office until evidence of withdrawal seen

• For ‘experienced’ patients, can do induction at home

Using buprenorphine for pain• Manufacturers recommend 5μg/hr patch for 30 mg/day

morphine and 10μg/hr patch for 80 mg/day morphine

• 8 mg suboxone is equivalent to 10 mg morphine (single dose), but this is conservative, and the equivalence will be very different according to level of tolerance (available as 2mg, 4 mg and 8 mg)

• Dosing principle for suboxone treatment of pain is start low, titrate upwards as needed, remembering that there is a ceiling effect, so 24 mg (8 mg 3 times daily) is probably the highest dose

• Subutex has only one indication - pregnancy

A case of a patient who has behavioral issues but is not on a high dose

Video here of female patient with behavioral issues, but not on a hight dose

Principles

• Patient must agree to the plan

• She could stay on opioid treatment since the dose is not high, but would she better off if she hadn’t continued for so long?

• Continue multimodal treatment, must include behavioral component

Treating Chronic Pain Chronic pain is never simple

Use measurement tools as a means of understanding the scope of the problem PHQ-9 (depression) GAD (anxiety) ORT (opioid risk)

Primary treatments for chronic paini. Motivation/activation/self-helpii. Counseling

Secondary treatments for chronic paini. Low risk analgesics (eg gabapentin)ii. Psych meds for depression/anxiety/PTSD/psychosis

What is serious pain?

Pain with a clear pathoanatomic or disease basis

Underlying cause is disabling cannot be improved by primary disease treatment or lifestyle changes

Goal of pain treatment is comfort

All other treatments (best efforts) have failed

NOTE: 90% pain complaints do not meet these criteria1.Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. Feb 2009;10(2):113-130.2.Sullivan MD, Ballantyne JC. What are we treating with chronic opioid therapy? Arch Int Med. 2012;172(5):433-434.

The 90% of chronic pain for which opioids have not proven helpful

Axial low back pain without a pathoanatomic diagnosis

Fibromyalgia

Headache

A case of a patient motivated to come off and does

Video here of female patient whose life is greatly improved after tapering off. She succeeded by means of a slow taper.

Principles

• Patient must agree to the plan

• Slow taper to off

• Continue multimodal treatment, must include behavioral component