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

Pain and Addiction: where we’ve been and where we’re going! UCSF Continuing Medical Education Era Kryzhanovskaya, MD June 16, 2020

Learning Objectives  Describe morphologies of pain and multi-modal treatment options  Develop an approach to screening for concomitant opioid use disorder (OUD) in patients on controlled substances  Identify treatment options for patients with OUD and consider COVID-19 impacts on current practices 2

Roadmap  Background  Pain ‐ Definition ‐ Multi-modal management  Addiction ‐ Opioid use disorder (OUD) ‐ Treatment options  COVID impact  Reflections and next steps  No conflicts or disclosures 3

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. 4

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 5

Background  In 20 years, we went from this…  to… 6

Opioid Epidemic New York Times, 2018 7

Three Waves of Opioid Overdose Deaths CDC 2017 8

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 9

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 10

Multimodal Pain Treatment 11

https://thecurbsiders.com/podcast/156-chronic-pain Garland 2020 12

Multimodal Pain Treatment: Non-opioid Rx Finnerup 2019 13

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? 14

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 15

Where meds work: https://www.slideshare.net/drdhriti/opioid-analgesic Volkow 2016 16

Opioids?! Source: http://masstapp.edc.org/opioid-misuse 17

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? 18

“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 or quality of life improves with long-term opioid therapy” Source: CDC 2016 https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf 19 Presentation Title

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 20 Presentation Title

Why do we care about doses? 21

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 22

Roadmap  Background  Pain ‐ Definition ‐ Multi-modal management  Addiction ‐ Opioid use disorder (OUD) ‐ Treatment options  COVID impact  Reflections and next steps 23

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. 24

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 25

Dependence vs Addiction  Physical dependence ‐ Biological adaptation ‐ Withdrawal, Tolerance  Addiction ‐ Behavioral maladaptation (loss of control, craving, continued use despite harm) 26

27

28

Opioids OUD Chronic Pain Overlap Soran 2018 29

30

Opioid Use Disorder (OUD) The 4R’s -Role failure  How to diagnose -Relationship trouble -Risk of bodily harm ‐ DSM-5 -Repeated attempts to cut back ‐ 4R’s, 4C’s The 4C’s ‐ Use + consequences of use -Control (loss of it) -Craving -Compulsion to use  What you may see in clinic or hospital -Consequences of use  Withdrawal  Uncontrolled pain (10% of patient with chronic pain have OUD)  Skin and Soft Tissue Infections, Endocarditis, Osteomyelitis  Trauma  Overdose 31

Why treat OUD?  Decrease mortality  Chronic disease requiring chronic medication  Reduce cravings  Detox doesn’t last Chutuape 2001 Sordo 2017 32

Medications for OUD 33

 Evidence based tx options: methadone, buprenorphine, IM naltrexone , OTP Medications for OUD 34

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 35

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 36

Medications for OUD: How to choose?  Co-morbidities?  Ability to take daily medication?  Start on inpatient?  Whatever the patient is willing to take! 37

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. 38

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 other 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 39

Pain and medication for OUD 40

Harm Reduction  Prescribe Naloxone for all!  Safe injection practices (and facilities), needle exchanges  Vaccinations  Treat infectious dz  PrEP 41

Roadmap  Background  Pain ‐ Definition ‐ Multi-modal management  Addiction ‐ Opioid use disorder (OUD) ‐ Treatment options  COVID impact  Reflections and next steps 42

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 43 Presentation Title

Reflection Take 1 minute… • One change you plan on implementing in your own 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. 44

Thank You! Questions? Collaboration? irina.kryzhanovskaya@ucsf.edu 45