2/26/2019 Updates in Complex Chronic Pain Soraya Azari, MD Associate Professor of Medicine Disclosures None 1
2/26/2019 Objectives To be familiar with all the new, exciting medical evidence related to chronic pain management and the use of opioids. To be able to describe the level of evidence for opioid tapers & best practices To review the management of patients with opioid use disorder and chronic pain. To give you resources for patient education and support for chronic pain. Case MW is a 35yo F with a prior motor vehicle accident (~ 10 years ago) s/ p surgery with resultant chronic pain syndrome, GAD, PTSD, depression, and she is taking chronic opioid therapy. She has been on these medications for ~ 10 years. Her meds include: Oxycodone ER 20mg 1-2 tabs QID Oxycodone IR 20mg 1 tab tid MME= 290mg Duloxetine 60mg BID Tizanidine 4mg tid prn spasm pain Diclofenac 1% gel TID prn pain Lidocaine 5% cream applied tid prn pain APAP 500mg q6hr prn pain 2
2/26/2019 Case Continued The patients is seen by primary care, pain management clinic, orthopedics (recommending no surgical intervention) The pain management clinic does not prescribe opioids (only provides recs on non-opioid analgesics). There is a cognitive behavioral therapist that sees the patients when she goes to clinic (which is every 1-2 mos). The patient is very fixated on her opioid analgesics. She is splitting the oxycodone IR tabs so she can take some every 3 hours exactly (she watches the clock). She feels like the oxycodone is the only thing she can use for her pain. She feels minimal benefit from her duloxetine, tizanidine, and topical agents. She is seen in the clinic with her daughter She is diaphoretic, anxious-appearing and with pressured speech talking about the ways she takes her pills. Her daughter is very active in the exam room, and the patient seems to have poor recognition of the child’s need for attention. Case Continued Her pain Pain scores shown Her function She is not working Dose increases She has a spouse and 80mg 180mg 290mg a 2 year old child She attends ~ 65% of her appointments 9 Concerning behaviors 8 7 Utox pos oxy, THC 6 Denies any substance Pain Level 5 use 4 Admits that she uses 3 her opioids to help 2 1 manage her anxiety 0 Mar-14 Mar-15 Mar-16 Mar-17 Mar-18 3
2/26/2019 Her Perspective I don’t have a problem with my medications. I need these to get through my day and function. These are allowing me to function. I keep feeling pressured by everyone to change my dose of the medication or to do something different. Question Which of the following summarizes the best treatment for this patient? 1) Taper medication due to 2016 CDC guideline recommendations 2) Opioid rotation based on prospective RCTs demonstrating benefit of this technique 3) Continue same medications and amplify psychological interventions 4) Transition to buprenorphine-naloxone or methadone maintenance 5) Taper medication due to abnormal urine tox screen 4
2/26/2019 Question Which of the following summarizes the best treatment for this patient? 1) Taper medication due to 2016 CDC guideline recommendations 2) Opioid rotation based on prospective RCTs demonstrating benefit of this technique 3) Continue same medications and amplify psychological interventions 4) Transition to buprenorphine-naloxone or methadone maintenance 5) Taper medication due to abnormal urine tox screen Let’s Go Through These: 1. Tapers Tapers of chronic opioid therapy Evidence-base New, systematic review looking at opioid tapers in patients on chronic opioid thearpy • KEY: We have 20 studies looking at this. NONE are prospective, RCTs of opioid tapers • 81% of trials shows statistically significant reduction in pain • 65% of trials done in multi-disciplinary pain clinics • 55% of trials did partial reductions (not to off) • WHAT THI S MEANS: – Voluntary tapers with support likely do not cause worsening of pain, and may be associated with improvement Fishbain and Pulikal. Pain Medicine 2018 5
2/26/2019 Tapers Cont’d Unilateral tapers of chronic opioid therapy (based on dose) NOT a recommendation in the 2016 CDC Guidelines Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf Tapers Cont’d Health Systems Interventions VA (Clin Practice Guidelines 2017) • Opioids + BZD tapering one or both • > 90mg MME evaluation for taper Kaiser Strongly encourage taper if any are present: • Concurrent use of sleeping pills, alcohol, muscle relaxers, THC, illicit drugs, sedating antihistamines • Uncontrolled psych issues • 65 or older • COPD, CHF, cognitive concerns, CKD • Osteoporosis • Severe obesity • OSA • Pregnancy 6
2/26/2019 Outcomes? Kaiser 40% reduction in high dose patients No change in patient satisfaction scores VA From 2012 to 2016 (Opioid Safety Initiative): decrease in opioid prescriptions 25% across VA clinics (baseline 25% COT) 47% dec opioid+ BZD Dec rate OD in pts on COT from 0.16 to 0.08% CMS, Medicare Part D Sponsor may put in “hard safety edits” > 200MME Sharp et al. Am Journal Of Managed Care 2018. Gellad W JAMA IM. 2017;177:611. Legislation Available at: www.ncsl.org 7
2/26/2019 Public Health Benefits? Dose Cap State https://agportal-s3bucket.s3.amazonaws.com/uploadedfiles/Another/News/Press_Releases/ OpioidSummitReport.pdf 8
2/26/2019 Will There Be Harm From Tapers? 50 deaths Drop in life expectancy CDC report: Available at: https://www.cdc.gov/nchs/data/hus/hus17.pdf Tapering Cont’d How to do it: Voluntary Taper Education & Support Counsel the patient in advance about the possibility of an OUD and the need to transition to a different treatment Team -based care : IPMP?, Behavioral health?, RNs?, PharmD? Alternative agents for pain management Schedule 10% per week cited by many guidelines (* * no strong evidence base) 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 9
2/26/2019 VA Opioid Taper Decision Tool. See references for URL. Advice to Clinicians on Tapers 1. Identify the Social, Emotional, and Health Factors that will impact the Taper 2. Address Fears about Tapering, INCLUDING Fear of Abandonment Separate fear of pain from anticipation of pain Talk about withdrawal 3. Only Propose Tapering When You Believe It is in the Patient’s Best Interest Don’t just cite guidelines. Risks and benefits. 4. Tell them What To Expect and Make a Plan. Be OK with Adjustments Pause, temporarily reverse taper during flares Henry et al 2018 J of Pain 10
2/26/2019 Henry et al 2018 J of Pain Henry et al 2018 J of Pain 11
2/26/2019 Education for Patients Tapering handouts: Vancouver DPH: https: / / vch.eduhealth.ca/ PDFs/ EA/ EA.835.O86.pdf Pain and Ways To Manage I t: https: / / vch.eduhealth.ca/ PDFs/ FM/ FM.850.M311.PHC.pdf McMaster Univ: http: / / nationalpaincentre.mcmaster.ca/ documents/ Opioid% 20Tape ring% 20Patient% 20Information% 20(english).pdf Tapering Videos UC Davis: patient testimonials (13min): https: / / www.youtube.com/ watch?v= bdAdkcpxXdw Laura’s Story: Stanford: https: / / www.youtube.com/ watch?v= 75PEivn1I Ok&index= 3&list= P LT73E4yXLvEWr5VZ9q6UM_Ctmx_fh5SXz&t= 0s TED Talk by patient (14min): https: / / www.youtube.com/ watch?v= WhpAYw9kCt8 Take-Home Points on Tapers Low quality medical evidence suggests the feasibility of opioid tapering and possible reductions in pain. National guidelines for chronic opioid therapy DO NOT recommend involuntary tapers. Most patients have thought about or are interested in tapering their dose. Major, large health-care institutions have successfully decreased opioid prescribing, but have utilized ancillary supports for behavioral health and pain management. For opioid tapers: go slow, provide choice, cheerlead, and pause, if needed. If a patient has an OUD, do NOT taper. Treat OUD. 12
2/26/2019 Question Which of the following summarizes the best treatment for this patient? 1) Taper medication due to 2016 CDC guideline recommendations 2) Opioid rotation based on prospective RCTs demonstrating benefit of this technique 3) Continue same medications and amplify psychological interventions 4) Transition to buprenorphine-naloxone or methadone maintenance 5) Taper medication due to abnormal urine tox screen 2. Opioid Rotation Bottom Line, Evidence-base: No proven benefit in prospective, RCTs. Low quality evidence (case reports, retrospective, uncontrolled studies) Quigley C. Cochrane Database Syst Rev 2004;CD004847 13
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