� 3/12/2016 I have no disclosures to report. � Complex Chronic Pain: Cases from the Field Soraya Azari, MD Assistant Clinical Professor of Medicine Objectives Case 1 To develop empathic and sensitive ways of 46yo M with a history of HTN, depression, � � communicating with patients suffering from chronic generalized anxiety disorder, asthma/COPD, pain chronic low back pain on opioid therapy, HCV, hx “polysubstance abuse”, and homelessness is To review the “four quadrants” of chronic pain � admitted to the hospital with a COPD flare and treatment acute kidney injury (Cr 1.6, from 0.8). To improve recognition and diagnosis of an opioid � He was taking: gabapentin, venlafaxine ER, use disorder in patients with chronic pain on � amlodipine, inhalers, docusate, senna, and the opioids following opioids: To be able to explain the risks associated with � � Morphine sulfate CR 30mg po tid long-term opioid therapy to patients � Oxycodone IR 15mg po qid � MED = 180mg daily � http://agencymeddirectors.wa.gov/mobile.html � 1
� 3/12/2016 Case 1 continued Case continued He received treatment for his asthma/COPD The patient was transitioned from morphine sulfate � � exacerbation and intravenous fluids with ER to methadone 20mg po TID + hydromorphine improvement in his creatinine to 1.3. 8mg po q4hrs PRN in discussion with the PCP, pain consult, and hospitalist. He reported doing well – taking his pain pills and � abstaining from cocaine. He was buying diazepam The patient missed his initial follow-up appointment � off the street (10/d). He is homeless & estranged but then got repeat labs showing an increase of his from family. Has few trustworthy friends. creatinine back to 1.6. He could not be contacted by phone despite several attempts. His main complaint is severe, uncontrolled pain in � his back (sharp and tight, paraspinal), and closely 5 days after discharge he was found dead. � watched the clock for his next PRN. Cause of death: acute mixed drug intoxication � He was seen by Pain Consult and described poor � � Serum methadone = 1600ng/mL pain control. He’d been buying methadone off the street and that was helping much more than the morphine. He had been out of his gabapentin. Which of the following represents the best Case continued management plan with regard to his pain? Which of the following represents the best Stop morphine sulfate � A. management plan with regard to his pain? ER and switch to � A) Stop morphine sulfate ER and switch to methadone + short methadone + short acting PRN acting PRN � B) Continue morphine sulfate ER and oxycodone and Continue morphine B. add non-opioid pain relievers sulfate ER and � C) Stop all opioids and refer to methadone oxycodone and add maintenance treatment non-opioid pain relievers � D) Increase dose of morphine sulfate ER + short Stop all opioids and 0% 0% 0% 0% C. acting PRN agent refer to methadone Stop morphine sulfate E... Continue morphine sulfa.. Stop all opioids and refer .. Increase dose of morphin... maintenance treatment Increase dose of D. morphine sulfate ER + short acting PRN agent � 2
� 3/12/2016 Lessons: the New Is this New? Epidemic Drug overdose � � Leading cause of injury death in 2014 (>47,000 deaths), surpassing motor veh. accidents in 25-64 year olds � 51% of deaths related to prescription drugs � ~19,000 deaths from prescription opioid pain relievers � 10,000 deaths from heroin � Rx-opioid overdose: quadrupled (2000-2014) � Increased risk: high dose, hx of substance use or mental health disorder CDC Rx Opioids. 259 million KFF Health Tracking Poll Nov 2015 Lessons Lessons Distinguishing between pain and an opioid use Methadone � � disorder? � serum half life: 15-60 hours; variable bioavailability; metabolized by CYP3A4 � Opioid use disorder � 1999-2008: methadone poisoning increased 600% � 4 Rs Benzos + opioids • Risk of bodily harm � American Pain Society recs: 2.5mg q 8, inc q week • Relationship trouble • Role failure Homeless, disconnected from family • Repeated attempts to cut back � 4 Cs • Loss of Control • Continued use despite harm • Compulsion (time & activities) Time/hustle to buy street pills • Craving I need more; pain pills are not holding me � Withdrawal and tolerance www.compassionandsupport.org; Chou R, et al. J Pain. 2014;15(4):338�65 � 3
� 3/12/2016 If you can…prevention Example: � � Morphine sulfate 60mg po bid � total 15mg methadone daily � Morphine sulfate 200mg po tid � total 40mg daily $15 � 30 � 45 $500 $75/2 for $0 Medicaid But this pain…do you want Treatment Program me to start shooting dope?? Locator No, I don’t want you to start injecting heroin. I Buprenorphine-certified providers: � � don’t think you want that either. You should feel � http://www.samhsa.gov/medication-assisted- proud that you don’t use needles anymore. treatment/physician-program-data/treatment- physician-locator My job is to take care of you and make sure you’re � � To get trained: www.buppractice.com safe. Opioid treatment program directory: I don’t think you can safely continue on opioid pain � � � http://dpt2.samhsa.gov/treatment/directory.aspx pills. I want to give you a better, safer treatment because I think you have severe, uncontrolled pain, Substance use treatment warm line: 1-855-300- � and an opioid use disorder. 3595. 10a-6pm EST I’m not going to leave you. I know you are � suffering right now. The treatments I can offer you are methadone � maintenance programs, or buprenorphine- naloxone. Do you want to hear more about those? � 4
� 3/12/2016 Take�home points Case 2 Be the most sensitive and empathetic you can be A 34yo F with a history of depression, obesity, � � when communicating discontinuation of opioids. PCOS, and low back pain presenting for primary care follow-up. She describes sharp pain in L back, Run towards the patient, not away. � 8/10, with occasional radiation down her leg x2 Avoid opioids in individuals with active substance � weeks. She denies weakness and numbness and use disorders given safety risks. Show caution with has a normal neurologic exam. methadone, benzodiazepine, and alcohol use. She says the pain is excruciating and she’s had � difficulty at work. She’s been using her husband’s pain pills (hydrocodone-acetaminophen) and is wondering if you can prescribe some. You try NSAIDs, ice/heat, massage and basic wall � exercises and ask her to return in 2 weeks. Case 2 continued Evaluation Empower � She returns in 2 weeks and says the pain is still � What are you doing to control your pain? � very severe (8/10), “tight and throbbing”, almost � Acknowledge suffering while focusing on strength and constant. She tried the ibuprofen which had some recovery effect, as does ice/heat, but it’s only temporary. Educate � She is still using her husband’s hydrocodone- � Back pain is common (mean point prevalence 18%; acetaminophen and says that’s her preferred lifetime prevalence 39%) agent. She’s having difficulty sleeping, which is � At 1 mo. ~1/3 with mod. pain (20% activity); 1 year, making her more tired throughout the day. ~1/3 with mod. pain She denies depressed mood or lack of interest in � Opioid efficacy � daily activities. She continues to feel stress and Evaluate � anxiety about life at home. She does not smoke or � Function (work, apt), substance use, and psychiatric use drugs or alcohol. Von Korff M, Saunders K. Spine (Phila Pa 1976). 1996 Dec 15;21(24):2833. � 5
� 3/12/2016 What Are My Alternatives? Treatment: The Broader Context of Pain Husband disabled. Sole wage Pharmacologic Physical earner. IHSS hours decreased. Tired. Stressed. Depressed. Worried something is wrong with her body. Lumbosacral strain Complementary and Cognitive and Alternative Medicine Behavioral Pharmacologic Physical • NSAIDs • Physical Therapy Can it work? • Neuroleptics • Joint injections • Antidepressants • Directed Exercise Program • Muscle relaxants • Pacing daily activity • Topicals • Heat or ice • Opioid medications/Tramadol Biopsychosocial Treatment � • Trigger point injections • Pumps (baclofen, lidocaine) � Patients with chronic neck or back pain >3mos (taken • Buprenorphine sick leave)(~50% depressed) � 3 week inpatient multidisciplinary treatment (5d/w; Complementary and Cognitive and 8h/d) Alternative Medicine Behavioral � Physical exercises • Acupuncture (community and schools) • Pain Groups � Ergonomic training • Mindfulness Based Stress Reduction and • Cognitive and behavioral therapy � Psychotherapy • Visualization, deep breathing, meditation meditation • Yoga • Sleep hygiene � Patient education • Massage • Gardening, being outdoors, going to � Behavioral therapy • Supplements (glucosamine chondroitin, church, spending time with friends and � Workplace-based interventions SAM-e) family, etc. • Guided imagery • Pain ToolKit � At 6 months: 67% returned to work; SF-36 score • Breathing exercises improved Check out: https://healthinsight.org/Internal/assets/SMART/Pain%20Guidelines%20alternative%20to%20opioids�final.pdf Buchner et al. Scandinavian Journal of Rheumatology. 2006: 363 � 6
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