Pain and Addiction: where weve been and where were going! UCSF - - PowerPoint PPT Presentation

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Pain and Addiction: where weve been and where were going! UCSF - - PowerPoint PPT Presentation

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Pain and Addiction: where weve been and where were going! UCSF Continuing Medical Education Era Kryzhanovskaya, MD June 16, 2020 Learning Objectives Describe morphologies of pain and multi-modal treatment options Develop an

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June 16, 2020

Era Kryzhanovskaya, MD

Pain and Addiction: where we’ve been and where we’re going!

UCSF Continuing Medical Education

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Learning Objectives

  • Describe morphologies of pain and multi-modal

treatment options

  • Develop an approach to screening for concomitant
  • pioid use disorder (OUD) in patients on controlled

substances

  • Identify treatment options for patients with OUD and

consider COVID-19 impacts on current practices

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Roadmap

  • Background
  • Pain

‐Definition ‐Multi-modal management

  • Addiction

‐Opioid use disorder (OUD) ‐Treatment options

  • COVID impact
  • Reflections and next steps
  • No conflicts or disclosures
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Case

  • TM is a 47M h/o depression and moderate lumbar spinal

stenosis s/p remote L4-5 laminectomy who comes in for follow up of his back pain. His regimen for the last year has been duloxetine 30mg daily and hydrocodone-APAP 10-325mg q6hr prn pain of which he uses 3-4 pills a day. He reports no other substance use. Able to manage his job as glass blower and painter, but recently noted increased back pain at night.

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Case: Polling question

  • What would you suggest next for TM?
  • A) Refer for Orthopedics for surgical evaluation
  • B) Start morphine ER 60mg BID
  • C) Start gabapentin 100mg qHS
  • D) Order total spine MRI; you don’t know until you know!
  • E) Up-titrate his duloxetine
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Background

  • In 20 years, we went from this…
  • to…
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Opioid Epidemic

New York Times, 2018

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Three Waves of Opioid Overdose Deaths

CDC 2017

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Opioid Use, Chronic pain

  • 100 million people with chronic pain (1/3 of US population)
  • 191 million opioid prescriptions written in 2017
  • Overlap of chronic pain and addiction
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Pain: Definitions!

  • Nociceptive pain: due to tissue injury or

harmful stimulus

  • Neuropathic pain: due to injury of the

nervous system itself

  • Central sensitization pain: occurs in the

absence of injury, caused by overactivation of the nervous system that leads to hyperalgesia

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Multimodal Pain Treatment

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https://thecurbsiders.com/podcast/156-chronic-pain Garland 2020

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Multimodal Pain Treatment: Non-opioid Rx

Finnerup 2019

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Case

  • TM is currently prescribed duloxetine 30mg daily and

hydrocodone-APAP 10-325mg q6hr prn pain of which he uses 3-4 pills a day. For his neuropathic pain, which medication class is missing from his regimen and may be most helpful to him?

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Case: Polling question

  • What medication class would you suggest next for TM?
  • A) Vitamins (specifically Vit D)
  • B) Partial opioid agonists
  • C) TCAs
  • D) Gabapentinoids
  • E) SSRIs
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Where meds work:

https://www.slideshare.net/drdhriti/opioid-analgesic Volkow 2016

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Opioids?!

Source: http://masstapp.edc.org/opioid-misuse

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Do opioids work for chronic non-cancer pain?

  • Few randomized controlled trials
  • Generally short-term trials
  • Exclusion: patients w/ mood disorders, multiple pain

conditions, SUD, use of sedatives/hypnotics

  • Cochrane: low quality evidence suggests about 10-15%

improvement on a 10-point scale *clinically significant?

  • SPACE trial: is there space for more than opioids in OA

management?

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Presentation Title 19

https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf Source: CDC 2016

“Although opioids can reduce pain during short-term use, the clinical evidence review found INSUFFICIENT EVIDENCE to determine whether pain relief is sustained and whether function

  • r quality of life improves with

long-term opioid therapy”

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Presentation Title 20

Guidelines for opioid therapy

  • Establish and measure goals for pain and function
  • Discuss a trial and an exit plan if/when the risks outweigh the benefits

CDC 2016 https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf Wood 2019 https://jamanetwork.com/journals/jama/fullarticle/2753128 mytopcare.org

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Why do we care about doses?

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Why do we care about doses?

  • One factor in

connection to addiction

  • Risk of addiction from

chronic opioids is hard to define: 3-26%

Volkow 2016 Soran 2018

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Roadmap

  • Background
  • Pain

‐Definition ‐Multi-modal management

  • Addiction

‐Opioid use disorder (OUD) ‐Treatment options

  • COVID impact
  • Reflections and next steps
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Case Continued: Polling question

  • TM misses a few appointments. He’s on your schedule for

tomorrow, and during pre-rounding, you notice his utox from that last visit shows hydrocodone, hydromorphone, and oxycodone. Additionally, he recently requested an early refill, reported missing an art exhibition that was supposed to feature his work last month, and told another provider he stopped taking his duloxetine.

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Case: Polling question

  • What would you do next for TM?
  • A) Refer to CBT: no time like the present to start!
  • B) Stop hydrocodone-APAP, start Morphine ER 60mg BID
  • C) Start Gabapentin 300mg qHS with uptitration to TID
  • D) Recommend he restart duloxetine; that NNT is so good!
  • E) Identify aberrant medication taking behaviors and

screen for substance use disorders

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Dependence vs Addiction

  • Physical dependence

‐ Biological adaptation ‐ Withdrawal, Tolerance

  • Addiction

‐ Behavioral maladaptation (loss of control, craving, continued use despite harm)

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Overlap

Soran 2018

Chronic Pain Opioids OUD

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Opioid Use Disorder (OUD)

  • How to diagnose

‐ DSM-5 ‐ 4R’s, 4C’s ‐ Use + consequences of use

  • What you may see in clinic or hospital
  • Withdrawal
  • Uncontrolled pain (10% of patient with chronic pain have OUD)
  • Skin and Soft Tissue Infections, Endocarditis, Osteomyelitis
  • Trauma
  • Overdose

The 4R’s

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

The 4C’s

  • Control (loss of it)
  • Craving
  • Compulsion to use
  • Consequences of use
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Why treat OUD?

  • Decrease mortality
  • Chronic disease requiring chronic medication
  • Reduce cravings
  • Detox doesn’t last

Chutuape 2001 Sordo 2017

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Medications for OUD

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Medications for OUD

, OTP

  • Evidence based tx options: methadone, buprenorphine, IM naltrexone
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Medications for OUD: Methadone

  • Agonist therapy
  • At licensed OTP w/ counseling, frequent UDS
  • Observed ingestion of Methadone (until ready for take homes)
  • Peak level in 4 hours, wide variability in half-life
  • Metabolized in liver
  • Doses individualized
  • EKG for QTc
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Medications for OUD: Buprenorphine

  • Partial mu and delta opioid agonist
  • Ceiling effect on respiratory

depression

  • Poor oral bioavailability
  • Half life >24h, high affinity
  • Mono or combo product
  • DATA 2000 Waiver needed
  • Start at home or in-office
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Medications for OUD: How to choose?

  • Co-morbidities?
  • Ability to take daily medication?
  • Start on inpatient?
  • Whatever the patient is willing to take!
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Case Continued: Polling question

  • TM returns to clinic interested in buprenorphine treatment

after thinking about your last visit together. You had discussed your concern for the development of opioid use disorder (OUD). He is worried about his pain being addressed if he’s on treatment for OUD.

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Case: Polling question

  • What would you tell TM next?
  • A) He will not need extra pain medication on top of

buprenorphine

  • B) Buprenorphine is an effective analgesic, and if he has

new pain, full opioid agonists can be added

  • C) TCA can be up-titrated if needed for his pain, but no
  • ther opioids will be added
  • D) Regional nerve blocks and interventional approaches

will be considered as mainstay of treatment for his pain

  • E) Oxycodone 5mg daily prn can be added to

buprenorphine to help his pain

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Pain and medication for OUD

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Harm Reduction

  • Prescribe Naloxone for all!
  • Safe injection practices

(and facilities), needle exchanges

  • Vaccinations
  • Treat infectious dz
  • PrEP
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Roadmap

  • Background
  • Pain

‐Definition ‐Multi-modal management

  • Addiction

‐Opioid use disorder (OUD) ‐Treatment options

  • COVID impact
  • Reflections and next steps
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Presentation Title 43

COVID-19 effects

  • Patient:

‐ Increased susceptibility? ‐ Increased overdose events ‐ Functional assessments

  • Environment:

‐ Safe places to self-isolate ‐ OTP, prescribing changes ‐ Telehealth: exacerbating disparities in care?

  • Opportunities

Slat 2020

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Reflection

  • One change you plan on implementing in your
  • wn practice.
  • One take-home point that will help you empower

your home institution to understand, diagnose, and promote treatment of pain and addiction for patients locally.

Take 1 minute…

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Thank You!

irina.kryzhanovskaya@ucsf.edu

Questions? Collaboration?

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Additional resources

  • Real time support/questions: UCSF Substance use warmline: (855) 300‐

3595, 6am‐5pm PST

  • Bup and methadone guide: SAMHSA, TIP 63: Medications for OUD
  • Bup protocols, ordersets, guides: www.bridgetotreatment.org
  • Bup telemedicine/guide for rural areas: www.oregonechonetwork.org
  • Bup and pain: www.ncbi.nlm.nih.gov/pubmed/31433765 ‐

PMID: 31433765

  • Bup DATA2000 X Waiver PCSS: www.pcssnow.org/medication‐assisted‐

treatment OR

  • Bup DATA2000 X Waiver ASAM: elearning.asam.org/buprenorphine‐

waiver‐course

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Opioid Use

  • >50% obtained from friend, relative