Complex Chronic Pain: Cases from the Field Soraya Azari, MD - - PDF document

10/18/2019 1

Complex Chronic Pain: Cases from the Field

Soraya Azari, MD Associate Professor of Medicine

Objectives

To understand the current best approach to tapers for patients on opioids To improve recognition and diagnosis of an opioid use disorder in patients with chronic pain on

• pioids

To review the “four quadrants” of chronic pain treatment To develop empathic and sensitive ways of communicating with patients suffering from chronic pain

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Case 1

SE is a 64yo F with a h of sciatica, depression, HTN, COPD, tobacco use disorder, and hx of trauma presenting for follow-up. 10 years ago she was started on hydrocodone-APAP for arthritis (low dose), and then 8 years ago (2010) she was admitted for spinal surgery. She had difficult to control pain and was discharged on:

Oxycodone CR 80mg 1 tab PO 4x/day Oxycodone IR 30mg 1 tab PO 4x/day Morphine equivalent dose: 660mg/day

From 2010-2015 she is maintained on this dose.

Case Continued

Her primary care provider is worried about the high dose of opioids that she is on. The patient is/has:

Not requesting early refills No reported history of excess sedation or overdose Urine drug screens that are intermittently positive for

• pioids (“from my husband’s hydrocodone when pain

is bad”), but also her prescribed meds Attending most of her appointments, though misses somewhat frequently due to taking care of grandchildren & living far away She is retired, cares for grandkids

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Cases Continued

Which of the following represents the best course

• f action?

A) Start tapering due to extremely high dose B) Discuss the risks and benefits of high dose opioids C) Transition to buprenorphine-naloxone given concerns for opioid use disorder

Cases Continued

Which of the following represents the best course

• f action?

A) Start tapering due to extremely high dose B) Discuss the risks and benefits of high dose

• pioids

C) Transition to buprenorphine-naloxone given concerns for opioid use disorder

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Risks of High Dose

Excess mortality (LA opioids, 60% increased risk all-cause mort) Unintentional overdose (~0.7%/year 20-100MED) and re- exposure (91% w/rx at 10mos. post OD) Opioid use disorder (~20%) Depression Secondary Hypogonadism (~50% of men) Dec bone mineral density & inc. fracture risk Sleep-disordered breathing (60-70% of patients) Pneumonia (case-control) Others Opioid-induced hyperalgesia? Cardiac toxicity with methadone

Miller M, et al. JAMA Intern Med. 2015;175(4):608-15. Rose AR, et al. J Clin Sleep Med. 2014;10(8):847-

• 52. Guilleminault C, et al. Lung 2010;188(6):459-68. Rubinstein AL, et al. Clin J Pain. 2013;29(10):840-
• 5. Dublin Setal. JAGS, 2011;59(10): 1899.

Smith HS, Elliott JA. Pain Physician. 2012;15(3 Suppl): ES145-56. Teng Z et al. Plos One. 2015;10(6)

High dose opioids (>90MME) Concerning Behaviors?

Yes

Evaluate for opioid use disorder Present? Treat Not Present? Give warning. If behavior continues, re- eval OUD

No

• 1. Function Eval, 2. Bone Density Scan, 3.

EKG if on methadone, 4. Sleep Study, 5. total AM testosterone Risks Outweigh Benefits?

No

Continue meds & monitoring. Discuss taper

Yes Imminent Safety risk? Yes Taper quickly No

Strongly Encourage Taper

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High dose opioids (>90MME) Concerning Behaviors?

Yes

Evaluate for opioid use disorder Present? Treat Not Present? Give warning. If behavior continues, re- eval OUD

No

• 1. Function Eval, 2. Bone Density Scan, 3.

EKG if on methadone, 4. Sleep Study, 5. total AM testosterone Risks Outweigh Benefits?

No

Continue meds & monitoring. Discuss taper

Yes Imminent Safety risk? Yes Taper quickly No

Strongly Encourage Taper

How Do I Know if Someone Has an OUD on Prescription Opioids?

It’s hard. Clinical diagnosis. Pattern of behavior over time. Easier to detect with scarcity. And more monitoring.

Opioid use disorder

4 Rs

• Risk of bodily harm
• Relationship trouble
• Role failure
• Repeated attempts to

cut back

4 Cs

• Loss of Control
• Continued use despite

harm

• Compulsion (time &

activities)

• Craving

Withdrawal and tolerance

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How I might assess a person?

Education Know who is at risk

Mental health disorder Substance use disorder (including nicotine) Age ACEs High dose

Formal screeners

COMM-R

Have you ever gotten

• verly sleepy from your

meds? Most of my patients feel like it’s hard for family to understand what’s going

• n with them. Have you

had any family issues? Have you been able to go to your family events? Have you ever wished you weren’s on pain pills? Or tried to cut back

How I might assess a person?

A good history Increased monitoring

Weekly refills Pill count Urine toxicology testing

Some of my patients feel like their whole day revolves around their pills. When they take them…will they run out…can they get to the end of the

• month. Do you ever feel like

that’s happened: like the pills are controlling you? I think your pneumonias are related to the opioids. How does this make you feel about the pills? Do you feel a strong sense

• f your body needing the

pills?

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But shouldn’t I just decrease someone’s dose with these new Guidelines and all this evidence?

NO

Evidence for Tapers

Evidence-base

Systematic review (Aug 2017)

67 studies (3 good, 13 fair, 51 poor)

• dose reduction is possible
• Patient outcomes (low qual evidence): less pain, more

function, better QOL

CAVEATS

• These were VOLUNTARY tapers
• These were SLOW tapers
• Interventions were somewhat labor-intensive:

– multi-disciplinary (integrative pain programs w/behavioral therapies like CBT & meditation) – frequent follow-up

Do patients want this? Survey of patients on >50MME/day: 49% wanted to cut back or stop

Frank et al. Annals Int Med 2017;167:181-91. Tielke et al. Clin J Pain. 2014;30(2)

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Harms of Tapering

INVOLUNTARY tapers

NOT guideline recommended Expert opinion expressing concern over “mis-interpretation”

• f the guidelines

Data

Increased risk of leaving primary care (Starrels 2019) Discontinuations from COT were associated with increased mortality (Merrill 2019)

Black box warning for involuntary tapers: suicide

For example, the guideline states that “Clinicians should…avoid increasing dosage to ≥90 MME [morphine milligram equivalents]/day or carefully justify a decision to titrate dosage to ≥90 MME/day.”1 This statement does not address or suggest discontinuation of

• pioids already prescribed at higher dosages, yet it has been used to

justify abruptly stopping opioid prescriptions or coverage.

Suicide and OD death: 41K (2000) → 110K (2017)

*doubling of age-adjusted rate of death from suicide and unintentional OD Opioids: implicated in 2/3 of OD deaths; 1/3 of OD- related suicides

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Tapering Cont’d

How to do it

Education & Support

Less milligrams are better Counsel the patient in advance about the possibility of an OUD and the need to transition to a different treatment Team-based care Alternative agents for pain management

Schedule

10% per week cited by many guidelines (**no strong evidence base, too fast for chronic patients) CDC Taper Guide: https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_ta pering-a.pdf On-line schedule generator: http://www.hca.wa.gov/medicaid/pharmacy/ documents/taperschedule.xls

Berna et al. Mayo Clinic Proceedings 2015;90(6):828-842 VA Opioid Taper Decision Tool. See references for URL.

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I will kill you if I continue these meds. I will die if I don’t have these meds The closest I've ever come to describing it to a friend is: You know when you're underwater, and you need to come up for a breath? And it's taking too long to get to the surface? That feeling, of having no oxygen left, your whole body feeling like fire, salty and aching with the desperate need to breathe? That's it, only not exactly, because it's

• worse. –Sarah Beach xoJane Oct 2013

Tapering

So what should I do?

Be kind & empathetic (remember quote) Use your motivational interviewing skills!

Ask permission

• Would it be ok if we talked more about your opioid pain pills?

Open-ended questions

• How are things going? What do you like about your pills?

What do you not like?

Affirmation

• You’re attending appointments and taking care of your

grandchild despite your pain.

Reflections

• You are scared to not have the pills, but you’re tired of running
• ut each month

Summary

• It sounds like you think the meds are necessary for your pain
• n the one hand, and then on the other hand you’re worried

about the risks I’ve described. Can I tell you about how we could decrease the dose safely & maybe improve your pain?

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Remember the Law!

State of California (SB 482)

Check CURES before writing any controlled prescription (schedule 2-4, which includes Adderrall, Midrin, buprenorphine, benzos, SOMA, Ritalin, and testosterone) For patients on chronic opioid therapy, consult CURES every 4 months Exempt:

Non-refillable 5-day prescription for a schedule 2-4 controlled substance for a surgical procedure

AB 2760 Offer naloxone for patients: >90mg MME, opioid + benzo, increased risk for OD (hx of OD, hx of substance use disorder, patient returning to high dose opioid) Does NOT exempt hospice patients

http://www.mbc.ca.gov/Licensees/Prescribing/CURES/CURES_FAQ.pdf?utm_source=link&utm_medium=email&utm_ campaign=CURES&utm_content=faq https://www.mbc.ca.gov/Licensees/Prescribing/OverdosePrevention/AB2760FAQs.pdf

Safety, Safety, Safety

COVERED

$500 $0

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Case Continued

The provider and the patient discussed the risks associated with high dose opioid therapy. The patient had never been told about the risks of the medications and she was concerned. With some reluctance, she agreed to try and taper her medications for her overall health.

Case Continued

The patient started a slow opioid taper (~10% reduction/month). There was no integrative pain program to assist with her taper and she came q 4 weeks for refills. She complained of worsening pain and running out

• f her pills early each month. Her urine drug

screens were positive for hydrocodone on a consistent basis. Alternative pain management interventions were attempted with aqua therapy, spine clinic referral, and behavioral health, but the patient did not attend any of the appointments. She perseverated

• n opioids being only acceptable treatment.

She requests that her dose be escalated.

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Which of the following represents the best course

• f action?

A) Slow down the taper and refer to behavioral health B) Convert the patient to treatment for an opioid use disorder C) Increase the dose of her opioids

Which of the following represents the best course

• f action?

A) Slow down the taper and refer to behavioral health B) Convert the patient to treatment for an

• pioid use disorder

C) Increase the dose of her opioids

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Pain v. Addiction

Distinguishing between pain and an opioid use disorder?

Opioid use disorder

4 Rs

• Risk of bodily harm
• Relationship trouble
• Role failure
• Repeated attempts to cut back

4 Cs

• Loss of Control
• Continued use despite harm
• Compulsion (time & activities)
• Craving

Withdrawal and tolerance

Taking un-prescribed opioids

Borrowing from partner

I need more opioids (not other pain tx) Not attending any of her appointments Going into withdrawal each mo.

Pain v. Addiction

OUD/Misuse

2018 estimates (NSDUH)

10 million(4.5%) misuse 1.9 million (0.8% OUD) ~800K heroin use June 2015 goo.gl/NNpwgx

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Treatment of OUD & Chronic Pain

Methadone

Higher level of care

Other SUD, especially etoh & BZDs Active psychiatric illness Need for monitoring

Daily, observed dosing liquid med (lifestyle)

Buprenorphine- naloxone

Office-based treatment from primary care Dissolvable tab or film used sublingually Provider must have waiver to prescribe Safe storage

Treatment Program Locator

Buprenorphine-certified providers (SAMHSA):

http://www.samhsa.gov/medication-assisted- treatment/physician-program-data/treatment- physician-locator To get trained: PCSS (https://pcssnow.org/medication-assisted- treatment/)

Opioid treatment program directory (SAMHSA):

http://dpt2.samhsa.gov/treatment/directory.aspx

Substance use treatment warm line: 1-855-300-

• 3595. 10a-6pm EST

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VA Experience: Co-

• ccurring disorders clinic

VA retrospective cohort

• f 143 pts with chronic

pain and addiciton induced on bupe-nal

93/145 (65%) continued on the meds

Taken off if: uncontrolled pain >28mg, tox + 3+, miss 3+ visits, 3+ early refills

Pain scores modestly, but significantly improved

Observational cohort: dec pain 2.3 points

• n bupe

Pade PA et al. JSAT 2012;43(4):446-50. Daitch et al Pain Physcian 2012; 15:Es59.

With support, the primary care provider converted the patient to buprenorphine-naloxone via a home induction.

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Wait, what?

Go home You will be sick I will give you meds

Clonidine 0.2mg tid prn Ondansetron prn Prochlorperazine prn

Start the medicine You will feel better 16mg on 1st day Comes as 2, 8, and 12mg The patient went on bupe-nal and ended up taking 24mg/day. She then said she wanted to go back on her prior

• pioid prescription because she didn’t think she had

a problem. Provider gave her a trial on old regimen, and then requested switch back to bupe-nal. Patient continues maintenance bupe-nal and thinks “this medication is actually ok”

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Take Home Points

Risks of long-term chronic opioid therapy include unintentional overdose, hypogonadism, and sleep disordered breathing, among others. Tapers of opioids work best when they are

• voluntary. Use your MI skills to elicit reasons &

build motivation for change. Diagnosis of an opioid use disorder in a patient with chronic pain is an essential function of the primary care provider. There are highly effective treatments for OUD.

Case 2

UJ is a 73yo F with a hx of incontinence, DM, HTN, Paget’s disease, obesity, L buttock and leg pain, and social isolation coming for primary care. Main complaint is overwhelming pain. It starts in the buttock and radiates down the R leg. It is sharp, “electric,” “sometimes numb”. She has to massage her thigh to make it feel better or lay

• down. It is preventing her from leaving the house

to go on her daily errands. It also disrupts her sleep at night.

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Case Continued

Exam notable for: normal MSK exam, normal neuro exam, neg SLR bilaterally, paraspinal ttp MRI shows advanced DJD and moderate canal

• stenosis. SPECT scan shows no evidence of Paget’s

Disease.

Evaluation

Empower

What are you doing to control your pain? Acknowledge suffering while focusing on strength and recovery

Educate

Back pain is common (mean point prevalence 18%; lifetime prevalence 39%) At 1 mo. ~1/3 with mod. pain (20% activity); 1 year, ~1/3 with mod. pain Opioid efficacy

Evaluate

Function (work, apt), substance use, and psychiatric

Von Korff M, Saunders K. Spine (Phila Pa 1976). 1996 Dec 15;21(24):2833.

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Treatment: The Broader Context of Pain

Sensory radiculopathy Lonely, but reluctant to engage In social activities Relies on caretakers for social

• Interaction. Fam in NY and Eng.

Independent, “successful” one

Pharmacologic Physical Complementary and Alternative Medicine Cognitive and Behavioral

What Are My Alternatives?

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Pharmacologic

• NSAIDs
• Neuroleptics
• Antidepressants
• Muscle relaxants
• Topicals
• Opioid medications/Tramadol
• Pumps (baclofen, lidocaine)
• Buprenorphine

Physical

• Physical Therapy
• Joint injections
• Directed Exercise Program
• Pacing daily activity
• Heat or ice
• Trigger point injections

Complementary and Alternative Medicine

• Acupuncture (community and schools)
• Mindfulness Based Stress Reduction and

meditation

• Yoga
• Massage
• Supplements (glucosamine chondroitin,

SAM-e)

• Guided imagery
• Breathing exercises

Cognitive and Behavioral

• Pain Groups
• Cognitive and behavioral therapy
• Visualization, deep breathing, meditation
• Sleep hygiene
• Gardening, being outdoors, going to

church, spending time with friends and family, etc.

• Pain ToolKit

Check out: https://healthinsight.org/Internal/assets/SMART/Pain%20Guidelines%20alternative%20to%20opioids-final.pdf

https:// goo.gl/G gsemj

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Can it work?

Biopsychosocial Treatment

Patients with chronic neck or back pain >3mos (taken sick leave)(~50% depressed) 3 week inpatient multidisciplinary treatment (5d/w; 8h/d)

Physical exercises Ergonomic training Psychotherapy Patient education Behavioral therapy Workplace-based interventions

At 6 months: 67% returned to work; SF-36 score improved

Buchner et al. Scandinavian Journal of Rheumatology. 2006: 363

SPACE Trial

240 VA patients 2013-15 with moderate to severe chronic back or hip or knee OA pain despite analgesic use Excluded: patients on LT opioids or SUD Included: severe depression (~20%), PTSD (~20%) 13% F, 88% white, 65% LBP, 35% hip/knee OA, 25% current smokers, 3% Etoh, 10% illicit drugs Randomized to either: Opioids: IR → LA → fentanyl (to max 100ME) Non-opioids: APAP/NSAIDs → TCA, gaba, top lido → pregabilin, dulox, tramadol (11%) Monthly visit w/pharm., BPI (1˚), pain intensity (2˚) Outcome (1 yr): BPI: no difference, pain intensity (better in non-opioid), more side effects (opioid)

JAMA 2018. 319(6):872-82

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Now let’s say she had lumbosacral strain…

Paraspinous lidocaine injection for chronic nonspecific low back pain: A randomized controlled clinical trial (Imamura et al)

Design, Setting, and Intervention

Study Type RCT Time frame 1/2007 – 1/2013 Study Setting São Paulo Medical School, Brazil Intervention LID-INJ: Paraspinous lidocaine (1inj/wk x 3wks) + standard treatment SH-INJ: Sham lidocaine injection (1 sham inj/wk x 3wks) + standard treatment STD-TTR: Standard treatment (tid home exercises + acetaminophen 2g/d)

46

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Results: Paraspinous lidocaine injections resulted in more patients with reduced pain

NNT: 5.6 (comparing LID-INJ to STD-TTR)

47

Case continued

Patient tried the following treatments over 6 months:

Cognitive and Behavioral: behavioral health visits Physical Treatments: Aqua therapy, ESI, trochanteric bursa injection, fibular bursa injection Topicals: muscle analgesic rub, lidocaine gel, lidocaine patches Pharm: tylenol, NSAIDs, gabapentin, nortriptylline, pregabilin

For every monthly visit, the patient returned with the same complaints of horrible pain.

10/18/2019 25

Question

Which of the following is the best course of action? A) Continue with plan explaining it takes time to see improvement B) Add diazepam for muscle pain C) Check a urine drug screen D) Something else

Question

Which of the following is the best course of action? A) Continue with plan explaining it takes time to see improvement B) Add diazepam for muscle pain C) Check a urine drug screen D) Something else

10/18/2019 26

Case continued

Given ongoing, functional impairment from her leg pain, she had the following done:

Urine drug screen (neg) Substance use screen (neg), PHQ-9 (6) DIRE questionnaire (low risk) CURES report w/no prescriptions

Patient was given a trial of acetaminophen-codeine after a conversation about the risks and benefits.

Remember the Guidelines

CDC Opioid Guidelines*

Opioids not 1st line Non-pharm. and non-opioid tx are preferred Chronic opioids often start with acute rxs. Use lowest dose, <3d Limit MME to <50mg daily Monitor closely: urine drug screen, PDMP, risk/benefit

https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf

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Case Continued

Patient returned to her next visit still having pain. She said that the new medication had not helped either. In the meantime, the patient had been accepted into our chronic pain group class. She has attended every class, and also up-titrated her pregabilin to 100mg bid. Her opioid was stopped due to lack of efficacy. Pain group scale: 9, 9, 9, 6, 5 → one month holiday break → 8

Take-Home Points

Zero pain should not be the patient’s goal (OR YOUR GOAL) Multi-modal pain management is now the standard of care Opioids may still be indicated for patients that do not respond to multi- modal interventions

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Case 3

GC is a 58yo F with depression, HTN (poorly controlled), COPD and tobacco use disorder, HCV (cured), and low back pain presenting for f/u. She is on the following:

Hydrocodone-APAP 10-325 1 tab po q4hr PRN pain (#180/month)

She attends most appointments – has gone to physical therapy once (but missed follow-up), and went for f/u on her HTN. She has intermittently engaged with behavioral health. She is on disability and lives with her daughter. A urine drug screen returns positive for hydrocodone and marijuana.

Question

Which of the following represents the best course

• f action?

A) Stop medication immediately B) Assess the patient, renew the contents of the agreement, and increase monitoring C) Increase dose of opioids

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Question

Which of the following represents the best course

• f action?

A) Stop medication immediately B) Assess the patient, renew the contents of the agreement, and increase monitoring C) Increase dose of opioids

Marijuana Positivity in LTOT

Common

Cannabis 6-39%; urine ETG 12%

Why do we care?

Marijuana positivity: more likely to have aberrant behaviors in future

DO: Establish if patient has an active substance use disorder, typically through increased monitoring (dec refill interval, mandatory urine drug screen)

YES → taper/stop opioids NO → continue close monitoring, risks/benefits

Reisfield et al. Pain Med. 2009: 1434-41. Crews et al. J of Opioid Management 2011:415-21. Visconti et al. J Urban Health, 2015: 758-72.

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Take-Home Points

Use of other substances is common with chronic

• pioid therapy. Weigh the risks and benefits of

continuing opioids in light of substance use.

Summary

Use of chronic opioid therapy – especially at high dose – is associated with several possible harms, including unintentional overdose, infection, addiciton, and sleep-disordered breathing. There is no clear evidence base recommending the speed or design of opioid tapers. Low-quality evidence suggests that pain and function are improved in patients undergoing voluntary tapers. Use motivational interviewing to engage the patient in a possible taper.

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Summary cont’d

Apply the biopsychosocial model to chronic pain to inform management. Treatment for pain should be multi-modal and include pharmacologic, physical, complementary and alternative, and cognitive and behavioral techniques. In patients with an active substance use or mental health disorder, these should be treated/stabilized prior to prescribing chronic opioid therapy. Keep in mind your patients are suffering every day. Empower then to do the best they can via their

• wn strengths and resources.

Questions?

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Resources

Patients:

Pain Toolkit:

http://www.change-pain.com/cmsdata/change-pain- portal/en_EN/pdf/pain_toolkit_cp_en.pdf

Chronic Pain Facebook Groups You tube videos to educate patients about pain:

Chronic pain in 5 minutes: https://www.youtube.com/watch?v=C_3phB93rvI Treatment options: https://vimeo.com/74825810

Providers:

Washington Agency Medical Directors Guidelines: http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpio idGuideline.pdf SFHP patient/provider resources: http://www.sfhp.org/providers/pain-management/resource- tools/ CDC: https://www.cdc.gov/drugoverdose/pdf/guidelines_at- a-glance-a.pdf

With permission from Peter Moore.

Resources Continued

Tapers Info:

https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/ SACB/CDPH%20Document%20Library/OpioidPrescrib ersResources.pdf VA Tool: https://www.pbm.va.gov/AcademicDetailingService/ Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96 820.pdf

Chronic pain group manuals

https://www.va.gov/painmanagement/docs/cbt- cp_therapist_manual.pdf