10/18/2019 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 opioids To review the “four quadrants” of chronic pain treatment To develop empathic and sensitive ways of communicating with patients suffering from chronic pain 1
10/18/2019 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 opioids (“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 2
10/18/2019 Cases Continued Which of the following represents the best course of 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 of 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 3
10/18/2019 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 No Evaluate for opioid use disorder 1. Function Eval, 2. Bone Density Scan, 3. EKG if on methadone, 4. Sleep Study, 5. total AM testosterone Present? Not Present? Risks Outweigh Benefits? Treat Give warning. If Yes No behavior continues, re- eval OUD Continue Imminent Safety risk? meds & monitoring. Discuss Yes No taper Taper quickly Strongly Encourage Taper 4
10/18/2019 High dose opioids (>90MME) Concerning Behaviors? Yes No Evaluate for opioid use disorder 1. Function Eval, 2. Bone Density Scan, 3. EKG if on methadone, 4. Sleep Study, 5. total AM testosterone Present? Not Present? Risks Outweigh Benefits? Treat Give warning. If Yes behavior No continues, re- eval OUD Continue Imminent Safety risk? meds & monitoring. Discuss Yes No taper Taper quickly Strongly Encourage Taper How Do I Know if Someone Has an OUD on Prescription Opioids? It’s hard. Opioid use disorder Clinical diagnosis. 4 Rs • Risk of bodily harm Pattern of • Relationship trouble behavior over • Role failure • Repeated attempts to time . cut back Easier to detect 4 Cs with scarcity. And • Loss of Control • Continued use despite more monitoring. harm • Compulsion (time & activities) • Craving Withdrawal and tolerance 5
10/18/2019 How I might assess a person? Have you ever gotten Education overly sleepy from your meds? Know who is at risk Mental health disorder Substance use disorder Most of my patients feel (including nicotine) like it’s hard for family to Age understand what’s going on with them. Have you ACEs had any family issues? High dose Formal screeners Have you been able to go COMM-R 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? Some of my patients feel like A good history their whole day revolves around their pills. When they take Increased monitoring them…will they run out…can Weekly refills they get to the end of the month. Do you ever feel like Pill count that’s happened: like the pills are controlling you? Urine toxicology testing I think your pneumonias are related to the opioids. How does this make you feel about the pills? Do you feel a strong sense of your body needing the pills? 6
10/18/2019 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) 7
10/18/2019 Harms of Tapering INVOLUNTARY tapers NOT guideline recommended Expert opinion expressing concern over “ mis- interpretation” of 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 opioids 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 8
10/18/2019 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. 9
10/18/2019 I will die I will kill if I don’t you if I have continue these these meds. 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 out each month Summary • It sounds like you think the meds are necessary for your pain on 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? 10
10/18/2019 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 $500 COVERED $0 11
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