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San Francisco Safety Net
Chronic Pain Management
Education Day
Finding Common Ground
in the Gray Zone
WELCOME!
Why are we here today?
3
Why are we here today?
4
Objectives
• Identify and manage risk factors for
opioid misuse
• Respond to patient behaviors that are
concerning for opioid misuse
• Support patients in managing
substance use disorders
• Examine systems-level interventions
that support safe pain management
• Develop policies or procedures in your
own clinic to improve pain
management practices
Shape of the Day
•
•
•
•
•
Keynote
Case-based panel
Break
Lecture
Lunch
• Facilitator breakout
• Small Groups
• CURES Table
Disclosures
None of the speakers have financial
disclosures to report
7
Managing the Risks of
Opioid Prescribing
Mr. Anderson
• 46 year old man discharged from
LHH 8 days ago
• Requesting refill of pain medications
• Hospitalized 4 mo ago s/p MVA
•
•
•
•
•
Right femur fracture
Pelvic fracture
Multiple rib fractures
s/p surgical fixation of fractures
BZD, EtOH, opiates in blood and urine
drug test
Mr. Anderson
• Discharged to Laguna Honda
• Discharged from rehab 8 days ago
• Currently with pain in right leg, right
chest
• Leg pain constant ache, worst in
cold
• Able to walk 2 blocks
• Increased irritability due to pain
• Poor sleep
Mr. Anderson
• Medications:
• MS contin 100mg TID
• Oxycodone 30mg q6 hrs PRN
• No change in this regimen over 10
weeks at LHH
Mr. Anderson
• Drank 2-4 beers daily before accident,
none since
• h/o heroin use, none for 3y before
accident
• Occasionally buys prescription opioids
on the street, had taken Morphine the
day before the accident
• Occasional benzodiazepine use “when
they’re around”
• 1 ppd cigarettes
• Unemployed, on GA, applying for
disability
• Mother with cocaine and EtOH
dependence
Who is at high risk for harm from
opioids?
Characterizing Risk of Opioid
Misuse
What We Don’t Want
I prescribe
opioids to
my
patient
Opioid Use
Disorder (abuse,
dependency)
Diversion
HARM
How Common is the Bad Stuff
296 HIV+,
marginalized patients,
lifetime (Hansen et al
2011)
Addiction
3.2%
ADRBs
11%
Purposeful
oversedation
--
Felt intoxicated from
opioids
34% (used “to get
high”)
Meds from other
doctors
--
Using alcohol w/meds
31%
Hoarding pain meds
41% (saved for later)
Sold opioid analgesics
18%
Snorted, crushed,
injected opioids
17%
None
Fishbain et al. Pain Medicine; 9(4): 444-59.
2008
Risk Assessment
• Purpose of Risk
Assessment
• Guidelines (APS,
AAPM), 2009
– Prior to initiation of
opioids
– Ongoing monitoring
• How to do it
– Formal instruments
– Clinical evaluation
• Underlying principle:
universal precautions
Chou et al. 2009. Journal of Pain. 10(2):
113-30.
Risk Assessment Instruments
• Lots of them
– Screener and Opioid Assessment for Patients with
Pain (SOAPP) – 24 items
– Pain Medication Questionnaire (PMQ) – 26 items
– Prescription Drug Use Questionnaire –Patient
Version (PDUQP) – 24 items
– Opioid Risk Tool (ORT) – 5 items
– Diagnosis, Intractability, Risk, Efficacy (DIRE) – 7
items
– Alturi & Sudarshan – 6 items
Two Options: Opioid Risk Tool (ORT)
Scoring patients:
• low risk (0-3)
• medium (4-7)
• high (≥ 8)
High risk:
• 91% sensitivity
for ADRB
• Positive LR 14
Webster LR, Webster RM. Pain Med. 2005;6(6):432-442
Second Option
• Atluri Tool
– 6 clinical criteria
1.
2.
3.
4.
5.
6.
Not willing to try non opioid modalities
Always asking about opioids (inc 1st
visit)
Upset when denied opioids
Requesting particular med
Focus on opioids
ER visit for pain; Use up own supply too fast
Opioid overuse
History of drug/EtOH abuse
Other substance use
Currently using marijuana
Feels need for benzos
Low functional status
Unclear etiology of pain
On disability or applying
Exaggeration of pain
– Score >3  OR of 16 for opioid misuse
Atluri SL et al. Pain Physician 2004; 7:333338.
Pain “everywhere”
Non-physiologic
distribution
Risk Assessment Tools
• Clinical Evaluation
– Pain clinic study comparing: SOAPP-R, ORT, PMQ
and a 45-min semi-structured interview with a
psychologist
– Psychologist’s evaluation of risk was the most
sensitive predictor for later discharge from pain
clinic
• Note: psychologist had 27 years of clinical experience
– 6 years in substance abuse
Jones et al. The Clinical Journal of Pain. 2012; 28(2): 93-100.
Substance Use Screening
• Single Item screeners
• NIDA: “How many times in the past year have
you used an illegal drug or used a prescription
medication for non-medical reasons?”
• NIAAA: “How many times in the past year have
you had more than 4/3 drinks in a day?”
Substance Use Screening
Our Patient
ORT score:
18 = HIGH
RISK
Second Option
• Atluri Tool
– 6 clinical criteria
1.
2.
3.
4.
5.
6.
Not willing to try non opioid modalities
Always asking about opioids (inc 1st visit)
Upset when denied opioids
Requesting particular med
Focus on opioids
ER visit for pain; Uses up own supply too fast
Opioid overuse
History of drug/EtOH abuse
Other substance use
Currently using marijuana
Feels need for benzos
Low functional status
Unclear etiology of pain
On disability or applying
Exaggeration of pain
– Score >3  OR of 16 for opioid misuse
Atluri SL et al. Pain Physician 2004; 7:333338.
Pain “everywhere”
Non-physiologic
distribution
What to do with the risk evaluation?
Atluri et al. Pain
Physician; 2012;
15: ES177
Our Patient
• High risk for “ADRBs”
• Options
• Taper off opioids
• Continue opioids with close monitoring
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•
•
•
Frequent Utox (q month)
Short refill interval (q 2 weeks)
Frequent CURES report (3-4 times per year)
Patient Agreement and Informed Consent with
explanation of reasons for discontinuation (i.e. no
show, refusal of alternative treatments, abnormal
Utox results)
How do we assess and understand
the impact of psychosocial issues on
the pain experience?
Psychosocial Assessment
• Brief Intervention vs.
Detailed Psychosocial Assessment
• Brief Intervention in
Primary Care Behavioral Health
• Review presenting problem/referral question
• Assess/strengthen supports
• Identify/build coping skills
Detailed Psychosocial Assessment
(may be gathered over time by various team members)
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Presenting problem/referral question
Culture/family history
Educational/work history
Relationship history/interpersonal issues
Trauma history
Substance use history
Psychiatric/medical history
• Current:
• Symptoms
• Supports
• Coping skills
Mr. Anderson’s
Psychosocial Assessment
•Culture/family history
Born in Ohio, family background Irish/German/Danish
No strong cultural/religious affiliations
Middle of 3 kids, father left when pt. was 7
Mother and siblings moved around
•Educational/work history
Completed 10th grade, fair grades
Has worked odd jobs,
mostly house painting
Currently on GA, in SRO
32
•Relationship history/interpersonal issues
Married twice, now lives with female partner
History of anger management problems including
IPV with partners
No longer speaks to siblings
Feels angry/disappointed with medical
system for not curing his pain
•Trauma history
Vague memories of IPV between parents, mother
verbally and physically abusive, sexual assault by
an older man age 11
Substance use
history
• ”I’ve tried everything”
• Drank 2-4 beers daily before
accident, none since
• H/O heroin use, none for 3 years
• Occasionally buys prescription
opioids on the street (Morphine)
• Occasional benzodiazepine use
• 1 ppd cigarettes
• Psychiatric history
• Long history of depressive sx, “I’ve been
depressed all my life”
• No history of manic episodes, no psychiatric
hospitalizations
• On various antidepressants with little effect
• Intermittent suicidal ideation, one non-lethal
gesture as adolescent
Current Symptoms
• Depressed feelings, feeling “empty”, feeling like
no one cares/no point in living, but no clear
suicidal plan
• Reports daily “mood swings”, but not mania
• Feels that pain is intolerable, nothing helps
• Angry that “system” is not helping him, feels
abandoned by medical team for “withholding”
medication
36
Psychosocial Assessment: Strengths
• Support
• Has female partner of 3 years
• Has one “buddy” he sees quite regularly
• Coping skills
• Intelligent, resourceful
• Reasonably good eating/exercise habits
• Has managed to reduce/abstain from substances
since the accident
• Can respond to encouragement, support
Psychosocial Assessment: Findings
• Does NOT currently meet criteria for major
depression, more likely dysthymia
• Not acute PTSD (“complex PTSD”)
• Borderline personality features
• Mood instability
• Interpersonal issues, extremes
• Impulse control problems, suicidal
thoughts/gestures
• Chronic feelings of emptiness
• Expectation/fear of abandonment
Patient’s Experience of Pain
• May experience pain as unrelenting, not
distinguishing between physical and emotional
pain
• Feels that no one/nothing can help
• May test limits to see if can influence you
• May see things in extremes, you are “a
wonderful provider” when increasing meds, a
“%#&^!?!” when setting limits
Discussing Risk Issues
Use understanding of pt. when discussing
limits and risk issues
• Interpersonal
• The relationship is paramount
• Stress partnership, trust, working together,
listen to pt’s concerns
• Put in the context of caring for pt;
communicate respect
Splitting, Thinking in Extremes
• Recognize the patient’s “all-or-nothing” thinking;
help to find middle ground
“It’s not exactly black and white. Let’s weigh the
risks and benefits of going up on your dose together.
We have to find a way to find some balance between
how it helps and what the downsides are.”
Testing (Will you abandon me?)
• Clear limits, consequences, structure helpful
“I want to be able to work with you to find our
best options over time. The only way I can do
that is if we have some agreement about how
we’re going to do this.”
• Consciously give patient choices when possible
“Would you prefer to take your meds twice a day
or three times a day?”
Countertransference
• Understand your personal reactions
• Don’t let yourself be provoked by testing
• Don’t take patient’s anger at/rejection of you as a
failure
43
How do we minimize the risks if we
do prescribe?
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Clear patient-provider agreement
Frequent visits
Monitor function, not just pain score
Urine drug testing
CURES reports
Pill counts
How can we use Naloxone to reduce
the risk of death by overdose?
Lay Naloxone for Overdose
Prevention
• Readily reverses opioid overdoses
• Patient & provider support
• Training easy & effective
• Frequent reversals reported
• Community-level mortality reduced
Bazazi et al., J Health Care Poor Underserved 2010. Seal et al; Coffin et al., JUH 2003. Green et al.,
Addiction 2008. Enteen et al., JUH 2010. Walley et al., BMJ 2013; Albert et al., Pain Med 2011
Fatal Opioid Overdose Rates by
Naloxone Implementation
Adjusted Models
RR
ARR*
95% CI
No enrollment
Ref
Ref
Ref
1-100
0.93
0.73
0.57-0.91
> 100
0.82
0.54
0.39-0.76
Cumulative enrollments per 100k
* Adjusted Rate Ratios (ARR) adjusted for city/town population rates of age<18,
male, race/ ethnicity (hispanic, white, black, other), below poverty level,
medically supervised inpatient withdrawal treatment, methadone treatment,
BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, year
Walley et al. BMJ 2013; 346: f174.
DOPE Project Dispensing 1993-2012
700
600
500
400
New Enrollments
Refills
300
Reversals
200
100
0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012*
Heroin Related Deaths: SF 1993-2010
Naloxone distribution begins
*Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org **no data available for FY 2000-2001
Potential Behavior Changes
• Risk of non-fatal opioid overdose
•
•
•
•
U.S. Army Fort Bragg
EMS/ED visits in SF
Syringe sharing in Seattle
Model
• Overdose may influence behavior
Why pain patients?
• Rx opioid deaths presaged
an increase in heroin
overdose and death (Unick et al.,
Plos One 2013)
• Prescribed opioids
associated with a transition
to heroin (e.g. Young & Havens,
Addiction 2012)
• SF opioid analgesic
overdose decedents
engaged in primary care
• 69% on chronic opioids
San Francisco Naloxone Access
• Community-based dispensing
• Drug Overdose Prevention and
Education (DOPE)
• Access for other populations
• Primary care patients at selected sites
and connected pharmacies
• Mental health patients at CBHS clinics
• Buprenorphine/methadone patients
dosing at CBHS
Intranasal Naloxone Kit
• Atomizer (2)
• Brochure
• Naloxone 2mg/2ml prefilled syringes (2)
Provider Education
• Training document on CBHS
website
• Naloxone Training for Providers
• Key components
• Causes
• Recognition
• Actions (call 911, rescue breathing,
naloxone administration)
Primary Care
Clinic
Rx Opioid
Rx Naloxone
Atomizer
Brochure
Education
Pharmacy
Dispense Opioid
Dispense Naloxone
Education
Mental Health
Clinic
Opioid user
Rx Naloxone/disp
Naloxone
Atomizer
Brochure
Education
Pharmacy
Dispense Naloxone
refill
OBOT Methadone/Buprenorphine
Clinic
OBOT Methadone
order
or
Rx buprenorphine
CBHS Pharmacy
Methadone or
buprenorphine
Clinical Pharmacist
Evaluation
Rx Naloxone/Disp
Naloxone
Atomizer
Brochure
Education
SFDPH Naloxone Distribution
Summary as of 4/11/2013
Setting
Sites
Unique
individuals
Reported
Reversals
DOPE
50
>3,700
916
Primary Care
2
67
--
Mental Health
1
13
--
Opioid Agonist
Treatment
1
38
2
Mr. Anderson part 2
• You discussed your concerns about risk
with the patient
• You signed a patient provider agreement
•
•
•
•
•
•
•
•
May not use other controlled substances
May not give medications to others
Must take meds as prescribed
Must inform you if he receives prescriptions
from other providers
Must follow up with diagnostic and treatment
strategies
Will have regular urine drug tests
Will only receive refills in the context of
scheduled appointments
Will not receive early refills
Mr. Anderson, part 2
• Start gabapentin for neuropathic
component of pain
• Refer to behavioral health team for
support with pain coping
• Group or individual
Mr. Anderson, Part 2
• Over the next few months:
• Increase gabapentin dose, helping a
little
• Patient adheres to the patient-provider
agreement
Mr. Anderson, Part 2
• 4 months later
• Drops in to clinic 1 week before
appointment requesting early refill
• Fell from a ladder, has been taking extra
morphine and oxycodone for increased
pain. Ran out early
• Gets an early refill from urgent care
provider
• Misses his next appointment with you
Mr. Anderson, Part 2
• Drops in one week later requesting
morphine and oxycodone from
urgent care provider
• States that insurance would not cover
the full monthly amount of his last rx,
so he needs early refill
• Provider requests urine drug test
• Patient becomes angry and leaves
without providing a urine sample
Mr. Anderson part 2
• You schedule an appointment with
the patient
• Refill his medications
• Order a urine drug test
• Urine contains
•
•
•
•
Oxycodone
Morphine
Hydromorphone
Benzodiazepenes
What are your concerns at this point?
Given these concerns, options
include
• Discontinue prescribing of all
controlled substances
• Require the patient to enter
substance abuse treatment in order
to continue prescribing
• Increase visit frequency, urine drug
test frequency, check CURES
• Change to a medication that treats
pain and substance abuse
simultaneously
What is the role of
buprenorphine/naloxone in the
treatment of co-occurring pain
and substance use disorder?
Scott Steiger, MD
Assistant Professor of Clinical Medicine
Division of General Internal Medicine
University of California – San Francisco
[email protected]
Outline
1. buprenorphine (bup)
pharmacology
2. Buprenorphine/Naloxone
(Bup/Nx) treats opioid
dependence
3. Bup/Nx treats pain
4. Bup/Nx for this patient?
Buprenorphine is a partial agonist
of the µ-opioid receptor
*NABBT.org
Buprenorphine is a partial agonist
of the µ-opioid receptor
RR <6
*NAABT.org
Opioid
Buprenorphine
Perfect Fit Maximum Opioid
Effect
Empty
Receptor
Receptor
Sends Pain
Signal to the
Brain
Empty
Receptor
No Withdrawal Pain
Withdrawal
Pain
Imperfect Fit –
Limited
Euphoric
Opioid Effect
Courtesy of NAABT, Inc. (naabt.org)
Euphoric
Opioid Effect
Buprenorphine
Still Blocks
Opioids as It
Dissipates
Buprenorphine formulations
•
•
•
•
Temgesic (UK, sl)
Buprenex (IM)
Subutex and generic (sl)
Suboxone, Orexa, generics:
coformulated with naloxone (sl)
• Norspan and Butrans (td)
• ?Nabuphine (subq implants)
Buprenorphine formulations
•
•
•
•
Temgesic (UK, sl)
Buprenex (IM)
Subutex (sl)
Suboxone, Orexa, generics:
coformulated with naloxone (sl)
• Norspan and Butrans (td)
• ?Nabuphine (subq implants)
Bup/Nx comes in a couple of
forms
Bup/Nx is available for treatment
of opioid dependence
• DATA 2000
• Lower barrier to addiction tx
• Requires extra training, DEA
waiver
• FDA approval in 2002
• “Office based” opioid replacement
• Medicaid covers in CA
Addiction or chronic pain?
•Tolerance?
•Withdrawal?
•Loss of control over use?
•Use despite negative
consequences?
Off label Bup/Nx is effective
for pain
• Acute pain in patients already
on Bup/Nx
• Chronic pain failing other
opioids*
• Chronic pain in “extremely
high risk” patient?
*Malinoff et al Am J Ther 2005
Co-occurring disorders clinic
VA retrospective cohort of 1
• Referrals from PCP, pain mgmt,
hospital, substance abuse treatment
• Screened, induced, then maintained
• Bup/nx stopped if…
• Uncontrolled pain on >28 mg bup/nx
• Tox + 3+, miss 3+ visits, 3+ early refills
Pade et al. JSAT 2012
Change in pain scores and retention
Patients
Preferred opioid
Heroin
Methadone
Oxycodone
Hydrocodone
Fentanyl
Morphine
Codeine
Hydromorphone
Age group
21-40 y
41-60 y
61-80 y
APS change # (% retain)
16
23
63
18
9
12
1
1
-0.7
-0.3
-1
-0.1
-1.1
-1.2
-7.8
0.6
10 (63%)
17 (74%)
40 (63%)
13 (72%)
3 (33%)
9 (75%)
1 (100%)
0 (0%)
25
81
37
-1.1 15 (60%)
-0.7 51 (62%)
-0.9 27 (72%)
Pade et al. JSAT 2012
Bup/nx maintenance better than
taper for high risk patients
“we found that it was quite
difficult to wean opioids among
those with chronic non-cancer
pain and co- existent opioid
addiction.”
Blondell et al J Addict Med 2010
Special considerations using
bup/nx for chronic pain
• Induction
• More “off time” required, esp with
methadone
• Low COWS?
• ?safer just to taper
• Dosing considerations
• POTENT
• Consider increased frequency for pain
• Payor considerations
Initial dose must be appropriate
VA Co-occurring sorders clinic dropped
everyone to MS 90 mg eq—and short-acting
Prospective cohort study NYC (n=12)
• 3 highest doses (>300 MS eq) and 3 lowest
doses (<20 MS eq) quit at induction
• 4 who completed reported better pain control
Rosenblum J Opioid Manag 2012
46 yo M with high risk chronic pain
Treat with bup/nx!!
Maybe we should hold off…
• Meets criteria for opioid
use disorder
• Risk < benefit of opiates
• Poor candidate for
abstinence only or
naltrexone
• MAY meet criteria for
SUD for benzos
• Dose may be too high
for easy transition
• MAY have greater
benefit from MMTP
Summary
• Bup/nx’s pharmacology offers
unique advantages compared to
other opioids
• Consider bup/nx in
• Opioid dependence
• High risk chronic pain
• Pain refractory to other opioids
• Bup/nx requires a DEA waiver to
Rx
How do I get the waiver?
Buprenorphine.samhsa.gov
May 15 Training
What else can we offer for pain?
Pain Treatment ≠ Opioids
Addiction
Emotional
Trauma
Physical
Pain
Financial
Insecurity
Suffering
Depression,
Anxiety
How do opiates compare?
Drug Class
Average Pain Reduction
Opioids
Tricyclics/AEDs
30-40%
30-60% for neuropathic
pain
10%
30-60%
30-60%
30-40% for LBP
Acupuncture
CBT/Mindfulness
Exercise/ PT
Massage
What about function?
Pharmacologic
Physical
Complementary and
Alternative Medicine
Cognitive and
Behavioral
Pharmacologic
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsacin)
•Opioid medications/Tramadol
•Baclofen pumps, lidocaine pumps
•Buprenorphine/naloxone
Complementary and
Alternative Medicine
Physical
Cognitive and
Behavioral
Pharmacologic
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsacin)
•Opioid medications/Tramadol
•baclofen pumps, lidocaine pumps
•Buprenorphine/naloxone
Complementary and
Alternative Medicine
Physical
•Physical Therapy/Physiatry consults
•Joint injections
•Spine injections
•Surgery
•Stretching/strengthening exercises
•Heat or ice
•Trigger point injections
Cognitive and
Behavioral
Pharmacologic
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsacin)
•Opioid medications/Tramadol
•baclofen pumps, lidocaine pumps
•Buprenorphine/naloxone
Physical
•Physical Therapy/Physiatry consults
•Joint injections
•Spine injections
•Surgery
•Stretching/strengthening exercises
•Recommendations for pacing daily activity
•Heat or ice
•Trigger point injections
Complementary and
Alternative Medicine
•Acupuncture (community and schools)
•Mindfulness Based Stress Reduction and
meditation
•Community yoga classes
•Tai-chi classes
•Massage schools
•Anti-inflammatory diets and herbs
•Supplements
•Guided imagery
•Breathing exercises
Cognitive and
Behavioral
Pharmacologic
•Neuroleptics
•Antidepressants
•Anesthetics (lidocaine patch)
•Muscle relaxants
•Topicals (capsacin)
•Opioid medications/Tramadol
•baclofen pumps, lidocaine pumps
•Buprenorphine/naloxone
Complementary and
Alternative Medicine
•Acupuncture (community and schools)
•Mindfulness Based Stress Reduction and
meditation
•Community yoga classes
•SFGH Tai-chi classes
•Massage schools
•Anti-inflammatory diets and herbs
•Supplements
•Guided imagery
•Breathing exercises
Physical
•Physical Therapy/Physiatry consults
•Joint injections
•Spine injections
•Surgery
•Stretching/strengthening exercises
•Recommendations for pacing daily activity
•Heat or ice
•Trigger point injections
Cognitive and
Behavioral
•Pain Groups
•Individual therapy
•Brief cognitive and behavioral
interventions in clinic
•Visualization, deep breathing, meditation
•Sleep hygiene
•Gardening, being outdoors, going to
church, spending time with friends and
family, etc.
Questions
97
BREAK
How To Think About
Concerning Behaviors
Concerning Behaviors
• Poor functionality
• Requests for a specific
medication
• Tox (-) for drug prescribed
• Tox (+) for other drugs
• Early refill requests
• Multiple prescribers
• Hoarding
• Lost or stolen medications
• Comes for appointments
only when opi needs refill
• Neglects other aspects of
care plan
• Reports that pharmacy
“shorted” the prescription
• Alcohol/drug use
• Forgery
• over sedation (purposeful or
not)
• MVAs or other accidents
• Self-initiated dose changes
• Escalating/very high doses
• Refusal to sign ROI
• Drug cravings
• Reports “allergies”
• Refusal to take DOT
Prescribers Dilemmas
• Unproven standards
• Stigma associated
with treating patients
• Conflicting guidelines
and
recommendations
• Pressure to
prescribe opiates
and liberally treat
pain
• Wondering if pain is
real
• Epidemic of Rx
overdoses and
misuse
• Addiction long
associated with
abstinence treatment
models
• Provider disciplinary
action/malpractice
• Mistrust of self/skills
and patients
Goals in addressing concerning
behaviors
•
•
•
•
Improve pain and functioning
Reduce risks
Reduce suffering
Improve feeling of provider
effectiveness
Framework:
How to structure thinking
Benefits
Risks
Framework:
The Nursing Process
• Assess
• Diagnose
• Outcome
Identification
• Plan
• Implement and
Evaluate
Pain
Function
Concerning
behavior
Research and Risks
• Aberrant medication behavior rate: 5 %
to 24% 1
• For all patients on opioids for CNCP 2
• Abuse/addiction rate = 3.27%
• Aberrant behavior rate = 11.5%
• For all patients excluding past or
current SUD diagnosis: 2
• Abuse/addiction rate = 0.19%
• Aberrant behavior rate = 0.59%
1. Martel et al, 2007. 2. Fishbain et al, 2008.
Research and Risks
•
•
•
•
•
•
•
Younger Age 1, 2, 3, 4, 5, 6
Male gender 2, 4
Caucasian/White 1
Mental Health Disorders 1, 3, 4, 5, 6, 7
Large dose or supply 3, 4, 8
Drug Cravings 7
 relation to pain severity 2
1. Dowling et al, 2006. 2. Ives et al, 2006. 3. Edlund et al, 2010. 4. White et al, 2009. 5.
Fleming et al, 2007. 6. Reid et al, 2002. 7. Wassan et al, 2007. 8. Dunn et al, 2010.
Research and Risks
FHx SUD 1
Personal Hx SUD 1,
2, 3
Specific Drugs
• Cannabis 4, 5, 6
• Cocaine 4, 6, 7, 8
• Alcohol 8, 9
• Heroin 4
1. Webster & Webster, 2005. 2. Edlund et al, 2010. 3. Turk et al, 2008. 4. Dowling et al,
2006.
5. Reisfield et al, 2009. 6. Fleming et al, 2007. 7. Meghani et al, 2009. 8. Ives et al, 2006.
9. Dunbar & Katz, 1996.
Research and Risks
Pain, SUDs, and Functionality
• SUD reported greater disability due
to pain
• Pts w/ SUD more likely to be
prescribed an opioid analgesic
• Pts w/ SUD less likely improvement
in pain related function
Morasco et al, 2011.
Assessment
• H & P: SUD history, FHx, and
psychosocial assessment.
• Testing: UDT, other toxicology
• Risk Assessment & stratification.
Differential Diagnosis
• Psychiatric
disorders
• Cognitive
disorders
• Diversion
• Pseudo-addiction
• Opioid tolerance
• Allodynia or
opioid-induced
hyperalgesia
• Addiction/abuse
Substance Dependence
• Tolerance
• Withdrawal
• Larger amounts or longer time than
intended
• Persistent desire or unsuccessful efforts to
cut down
• A lot of time spent to obtain or recover from
use
• Important activities given up
• Substance use continues despite having a
related persistent or recurrent health
problem
Planning
• Risks dictate structure
• Structure helps
• Reduce or resolve aberrant
behaviors
• Result in self-discharge
• ID who needs higher level of
care
Elements of Structure
•
•
•
•
Visit Frequency
Refill frequency
Medication call backs
UDT
• Presence/absence of rx’d drug
• Presence/absence drugs of abuse
• PDMP
Planning
When plan is insufficient to reduce
risk: change it.
• Explain why
• Offer options
• Refer: addiction care, ORT plus pain
care, pain clinic
Opiate analgesics may not be
appropriate if…
• Pain unimproved on upward titration
• Unmanageable side effects
• Recurrent non-adherence to
treatment plan or agreement
• Non-resolution of risky drug
behaviors with tight controls
Assess the “Four A’s”
• Analgesia
• ADLs
• Adverse events
• Aberrant
Behaviors
Passik & Weinreb, 2000.
A
A
A
A
Universal Pain Precautions
1) Make diagnosis
2) Psychological
Assessment
3) Informed consent
4) Treatment
agreement
5) Pre-Intervention
assessment of
pain level and
functioning
Gourlay, Heit & Almahrezi, 2005.
6) Pharmacotherapy
trial
7) Post-intervention
assessment of pain
level and
functioning
8) Assess the “Four
A’s”
9) Review diagnosis
and co-morbidities
10) Documentation
Opioid prescription management
includes
• Both pharmacologic and psychosocial
interventions
• Regular monitoring
• Routine evaluation of treatment goals
• Patient education
• Encourage patient to engage in the
treatment process
• Inclusion of other supports for overall
health
Summary
•
•
•
•
•
•
Concerning behaviors: not always addiction
Assess and identify risks, balance with benefits
Formulate differential and diagnosis
Create plan including risk stratification
More risks indicate more elements of plan
Use a consistent, standardized approach to opioid
prescribing with all patients, e.g. “universal
precautions”
• Join a team: multidimensional psychosocial,
pharmacologic, non-pharmacologic, referrals and
resources
• Team decision making based on risks and successes
• Apply essential elements of chronic disease
management
Sources
•
•
•
•
•
Chou, R, Fanciullo, GJ, Fine, PG et al. (2009). Clinical guidelines for
the use of chronic opioid therapy in chronic noncancer pain. The
journal of pain, 10(2), 113-130.
Dowling, K, Storr, C L, & Chilcoat, H D. (2006). Potential influences
on initiation and persistence of extramedical prescription pain
reliever use in the US population. The Clinical journal of pain, 22(9),
776-783.
Dunbar, S A, & Katz, N P. (1996). Chronic opioid therapy for
nonmalignant pain in patients with a history of substance abuse:
report of 20 cases. Journal of pain and symptom management,
11(3), 163-171.
Edlund, M J, Martin, B C, Fan, M, et al. (2010). Risks for opioid
abuse and dependence among recipients of chronic opioid therapy:
results from the TROUP study. Drug and alcohol dependence,
112(1-2), 90-98.
Fishbain, D A, Cole, B, Lewis, J, et al. (2008). What percentage of
chronic nonmalignant pain patients exposed to chronic opioid
analgesic therapy develop abuse/addiction and/or aberrant drugrelated behaviors? A structured evidence-based review. Pain
medicine, 9(4), 444-459.
•
•
•
•
•
•
•
•
•
•
Fleming MF, Balousek, SL, Klessig, CL, et al. (2007). Substance use disorders in a
primary care sample receiving daily opioid therapy. The journal of pain, 8(7), 573-582.
Gourlay, D L, Heit, H A, & Almahrezi, A. (2005). Universal precautions in pain
medicine: a rational approach to the treatment of chronic pain. Pain medicine, 6(2),
107-112.
Ives, T J, Chelminski, P R, Hammett Stabler, C A, et al. (2006). Predictors of opioid
misuse in patients with chronic pain: a prospective cohort study. BMC health services
research, 6, 46-46.
Jamison, R N, Ross, E L, Michna, E, et al. (2010). Substance misuse treatment for
high-risk chronic pain patients on opioid therapy: a randomized trial. Pain, 150(3), 390400.
Martell, B A, O'Connor, P G, Kerns, R D, et al. (2007). Systematic review: opioid
treatment for chronic back pain: prevalence, efficacy, and association with addiction.
Annals of Internal Medicine, 146(2), 116-127.
Meghani, S H, Wiedemer, N L, Becker, W C, et al. (2009). Predictors of resolution of
aberrant drug behavior in chronic pain patients treated in a structured opioid risk
management program. Pain medicine, 10(5), 858-865.
Morasco, B J, Corson, K, Turk, D C, et al. (2011). Association between substance use
disorder status and pain-related function following 12 months of treatment in primary
care patients with musculoskeletal pain. The journal of pain, 12(3), 352-359.
Passik, S D. (2009). Issues in long-term opioid therapy: unmet needs, risks, and
solutions. Mayo Clinic proceedings, 84(7), 593-601.
Passik, S D, & Weinreb, H J. (2000). Managing chronic nonmalignant pain:
overcoming obstacles to the use of opioids. Advances in therapy, 17(2), 70-83.
Paulozzi, L J, Budnitz, D S, & Xi, Y. (2006). Increasing deaths from opioid analgesics
in the United States. Pharmacoepidemiology and drug safety, 15(9), 618-627.
•
•
•
•
•
•
•
•
•
•
Reid, M C, Engles Horton, L, Weber, M B, et al. (2002). Use of opioid
medications for chronic noncancer pain syndromes in primary care. Journal of
general internal medicine, 17(3), 173-179.
Reisfield, G M, Wasan, A D, & Jamison, R N. (2009). The prevalence and
significance of cannabis use in patients prescribed chronic opioid therapy: a
review of the extant literature. Pain medicine, 10(8), 1434-1441.
Savage, S R. (2002). Assessment for addiction in pain-treatment settings. The
Clinical journal of pain, 18(4 Suppl), S28-S38.
Savage, S R. (2009). Management of opioid medications in patients with chronic
pain and risk of substance misuse. Current psychiatry reports, 11(5), 377-384.
Sehgal, N, Manchikanti, L, & Smith, H S. (2012). Prescription opioid abuse in
chronic pain: a review of opioid abuse predictors and strategies to curb opioid
abuse. Pain physician, 15(3 Suppl), ES67-ES92.
Turk, D C, Swanson, K S, & Gatchel, R J. (2008). Predicting opioid misuse by
chronic pain patients: a systematic review and literature synthesis. The Clinical
journal of pain, 24(6), 497-508.
Warner, M, Chen, L H, Makuc, D M, et al. (2011). Drug poisoning deaths in the
United States, 1980-2008. NCHS data brief, (81), 1-8.
Wasan, A D, Ross, E L, Michna, E, et al. (2012). Craving of prescription opioids
in patients with chronic pain: a longitudinal outcomes trial. The journal of pain,
13(2), 146-154.
Webster, L R, & Webster, R M. (2005). Predicting aberrant behaviors in opioidtreated patients: preliminary validation of the Opioid Risk Tool. Pain medicine,
6(6), 432-442.
White, A G, Birnbaum, H G, Schiller, M, et al. (2009). Analytic models to identify
patients at risk for prescription opioid abuse. The American journal of managed
care, 15(12), 897-906
When and How to Taper Opioids
When to discontinue opioids
• Treatment goals not met/opioid trial
failed
• Insufficient improvement of
pain/function/quality of life
• Significant non adherence to treatment plan
• Risks/harms outweigh benefits
• Intolerable/dangerous side effects
• Concerning/dangerous behaviors
suggesting:
• Active substance abuse (opioid, other)
• Diversion
• Psychiatric instability
When/Where to taper opioids
• When
• Patient taking medication
• Physiologic dependence
• Safe to do so
• If clearly unsafe or illegal behaviors, stop and
assess for withdrawal
• Where
• “Although there is insufficient evidence to
guide specific recommendations on optimal
strategies, a taper … can often be achieved
in the outpatient setting in patients without
severe medical or psychiatric comorbidities.”
Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic
Noncancer Pain. J Pain 10(20), 2009, 113-130.
Where/How to taper opioids
• Assess patient’s opioid use, medical
problems, and psychosocial issues
• Involve other team members
• Provide written instructions
Where/How to taper opioids
• Consider referral to methadone
treatment program if opioid abuse
• Consider referral to addiction
medicine/ substance abuse or
psychiatric treatment if (risk of)
unsafe behaviors (e.g., suicidality,
lack of impulse control)
How to taper opioids
• “Evidence to guide specific
recommendations on the rate of
reductions is lacking, though a slower rate
may help reduce the unpleasant
symptoms of opioid withdrawal.”
• Factors that may influence rate:
• reason for discontinuing
• medical/psychiatric comorbidities
• withdrawal symptoms during process
Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic
Noncancer Pain. J Pain 10(20), 2009, 113-130.
How to taper opioids – rules of
thumb
• One taper regimen (Univ of Mich Health
System):
• Decrease 10% of original dose every week until
20% remains, then 5% of original dose until off
• Other considerations:
• Amount of opioid necessary to prevent
withdrawal is 20% of previous day’s dose
• Convert multiple medications to 1 medication,
then taper
• Reduce dose 20-50% because of incomplete cross
tolerance
• Taper faster at higher doses (>200mg morphine),
slower when reach 60-80mg morphine/d
• Some suggest the longer the treatment, the
slower the taper
Opioid taper - example
• MSSR 60mg 3x daily plus MSIR 30mg 1
q4hr (DNE 3/d)
• Total daily dose: 60X3=180,
30X3=90→270mg
• Initial taper
• 100% to 20% initial dose → 270mg to 54mg
• 10%/wk →27mg/wk (round to 30mg/wk)
• Final taper
• 5%/wk →14mg/wk (round to 15mg/wk)
• MSSR pill strengths: 15, 30, 60, 100,
200mg
Opioid taper - example
Week
Total dose morphine/ day (mg)
Script
1
240 (begin 10%/wk taper)
2
210
3
180
MSSR 60mg 3xd #21
MSIR 30mg 2xd prn #14
MSSR 60mg 3xd #21
MSIR 30mg 2xd prn #7
MSSR 60mg 3xd #21
4
150
5
120
6
90
7
60
8
45 (begin 5%/wktaper)
MSSR 15mg 1 pill 2xd + 2 pills qhs
#28
MSSR 15mg 3xd #21
9
30
MSSR 15mg 2xd #14
10
15
MSSR 15mg 1xd #7
11
0
MSSR 15mg 3 pills 2xd + 4 pills qhs
#70
MSSR 15mg 3 pills 2xd + 2 pills qhs
#56
MSSR 15mg 2 pills 3xd #42
Managing Withdrawal Symptoms
• Rarely life
threatening
• May persist up to
6 mos
• Treat
symptomatically
• Provide “kick pack”
or have pt return if
symptoms
• Avoid opioids or
benzodiazepines
Managing Withdrawal Symptoms
Symptom
Anxiety, restlessness
Insomnia
Nausea
Dyspepsia
Diarrhea
Pain, fever
Autonomic symptoms
(rhinorrhea, sweating,
hypertension, tachycardia)
Medication
hydroxyzine 25mg q6h prn,
diphenhydramine 25mg q6h prn
hydroxyzine 25-50mg qhs,
diphenhydramine 25-50mg qhs
metoclopramide 10mg q6h prn
CaCarbonate 500mg 1-2 q8h prn
mylanta 1-2 tsp prn
loperamide 1-2 prn diarrhea
APAP 325mg 1-2 q6h prn,
ibuprofen 200mg 1-3 q6h prn
clonidine 0.1mg q6h prn or patch
0.1mg/24hr qwk
Other treatments/support
• Make efforts to preserve therapeutic
relationship
• Pt may not feel pain taken seriously
• Pt’s clinical situation may deteriorate
• Pt may feel poor quality of care and
threaten action
Other treatments/support
• Concerning behaviors may emerge
during taper
• May be mitigated by initial plan
• Use clear, consistent message with focus
on safety and harms/benefits
• Offer counseling/support if significant
behavioral issues
• Make psychiatric, substance abuse
referrals if indicated
Other treatments/support
• Consider others’ support (team,
provider, pharmacist)
• If threats/intimidation occur, take
appropriate steps, including
preventive actions (other staff/
security present)
References
• Agency Medical Directors Group. Interagency Guidelines on
Opioid Dosing for Chronic Non-cancer Pain.
http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf
• Chou et al. Clinical Guidelines for the Use of Chronic Opioid
Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009,
113-130.
• Group Health Cooperative. Chronic Opioid Therapy Safety
Guideline For Patients With Chronic Non-Cancer Pain.
http://www.ghc.org/all-sites/guidelines/chronicOpioid.pdf
• University of Michigan Health System. Managing Chronic
Non-Terminal Pain in Adults.
http://www.michigan.gov/documents/mdch/UM_Pain_guidelin
es_290232_7.pdf
• VA/DoD. Clinical Practice Guidelines for Management of
Opioid Therapy for Chronic Pain.
http://www.va.gov/PAINMANAGEMENT/docs/CPG_opioidther
apy_fulltext.pdf
Treating Substance Use Disorders
Stimulants, Opioids, and Alcohol
138
Stimulant Use: cocaine and
methamphetamine
Judith Martin, MD
Medical Director of Substance Abuse
Services, SFDPH
Question for you:
• A patient who is on your clinic’s
chronic pain registry tests positive for
cocaine when she comes in for her
opiate prescription. You ask her what
she has noticed about effects of
cocaine on her body. She says it
makes her heart “jump” in her chest.
• How would you explain this symptom,
and how does your clinic protocol
address a positive cocaine test?
Effects of stimulants: short term
wakefulness, increased physical activity,
decreased appetite, increased
respiration, rapid heart rate, irregular
heartbeat, increased blood pressure,
and hyperthermia.
Effects of stimulants, long term
• Can be damaging to brain, emotions,
and body.
• Cardiovascular: high pulse, BP may
lead to heart attack or stroke, leads to
atherosclerosis, myopathy
• Psychiatric: anxiety, paranoia,
depression , egocentric delusions
• Neurostimulation: formication,
excoriations, seizures, tremor
Stimulant use, treatment
• Many medications have been
tried, none clearly useful.
• CBT, incentives and MI have all
been successful.
• In the case of
methamphetamine, brain
recovery takes time.
DATs Recover with Abstinence
Volkow et al., 2001
Summary: stimulant use
• Evaluate patient’s stage of change
• Information about effects of drug
• Information about types of
treatment
• Note: overlap with psychiatric and
trauma histories, overlap with
other risk behaviors, special
urgency in cardiovascular disease.
Medically Assisted treatment
for Opiate dependence
MAT for Opiate Dependence
• Reduces overdose
• Decrease illicit opiate use
• Reduced HIV and HCV
transmission
• Reduces criminality
• Improves medical, psychiatric,
and social functioning
NIH Consensus Statement on
Opiate Dependence: 1997
• Opioid addiction is a medical
disorder that can be treated
effectively
• All should have access to opiate
agonist treatment
• Reduce unnecessary treatment
regulations
• Coverage should be a required
benefit in public insurance programs
Approved Medications
• Methadone
• Full opiate agonist
• Provided only at licensed specialized
clinics
• Buprenorphine
• Partial opiate agonist
• Office based settings
• Naltrexone
• Opiate antagonist
• Office-based settings
Methadone
• Synthetic opioid
• Full μ agonist
• Repeated administration leads to
physical dependence
• Hepatic storage and subsequent
slow release
• Linear dose-response curve
• Half life: 15 to 60 hours
Methadone
• Special Alert (2009):
Recommendations for QTc interval
screening before and during
methadone treatment
• CNS depression
• Respiratory depression
• Hypotension
• Consider synergistic effects with
sedative or alcohol abuse
CNS, central nervous system
Krantz MJ et al. Ann Intern Med. 2009;150:387-395.
Methadone Prescribing
• For pain with a DEA license
• For opiate replacement
• At licensed NTPs
• Through OBOT methadone program:
Tom Waddell and Potrero Hill Clinics
only
• Federal and State Regulations: Title 9
in California
• Setting, dose limits, dosing frequency,
drug testing, counseling (addiction)
• Liquid formulation
Methadone and Benzodiazepines
• 51% to 70% of MMTP patients use
benzodiazepines (similar to
buprenorphine patients and heroin
users not in treatment)1-3
• 18% to 50% with problematic use1,3,4
• In studies, benzodiazepine-related
deaths for MMTP patients range
from 10% to 80%5-8
1Gelkopf
M et al. Drug Alcohol Depend. 1999;55:63-68; 2Stitzer ML et al. Drug Alcohol Depend.
1981;8:189–199; 3San L et al. Addiction. 1993;88:1341-1349; 4Ross J, Darke S. Addiction. 2000;95:17851793; 5Maxwell JC et al. Drug Alcohol Depend. 2005;78:73-81; 6Lintzeris N, Nielsen S. Am J Addictions.
2010;19:59-72; 7Williamson PA et al. Med J Australia. 1997;166:302-305; 8Zador D, Sunjic S. Addiction.
2000;95:77-84.
Methadone: Contraindications
• MAOIs: MTD within 14 days of MAOI
increase the risk of serotonin
syndrome1,2
• Phenothiazines: additive effects include
ileus, cardiac arrhythmias (QT
prolongation), CNS depression,
psychomotor impairment1,3
• Venlafaxine: cardiac arrythmias (QT
prolongation), serotonin syndrome,
NMS4
• Ziprasidone: additive effects5
1Roxane
Laboratories, 2009; 2Gillman PK. Br J Anaesth. 2005;95:434-441; 3Baxter
Healthcare Corporation. Phenergan (prescribing information. 2009; 4Wyeth
Pharmaceuticals Inc. (venlafaxine) prescribing information. 2009; 5Pfizer Inc. (ziprasidone)
prescribing information. 2009.
Methadone: Drug Interactions
• CYP450 system: metabolized at
3A4, 2B6, 2C19, and (lesser) at
2C9, 2D61,2
1Roxane
Laboratories. Methadone hydrochloride prescribing information. 2009; 2Mallinckrodt
Inc. Methadose Oral Concentrate (methadone hydrochloride oral concentrate) prescribing
information. 2009.
Methadone: Drug Interactions
• CYP inhibitors
• Fluoxetine and norfluoxetine: CYP3A4, 2D6,
2C9. No clinically significant interaction in
vivo1,2
• Fluvoxamine: CYP3A4 and 2C9. Watch for
methadone toxicity due to increase methadone
levels. When stopping fluvoxamine watch for
methadone withdrawal2,3
• Quetiapine: increased methadone levels
(CYP2D6)4
• Grapefruit juice: moderate inhibitor at
CYP3A42
1Bertschy
G et al. Ther Drug Monit. 1996;18:570-572; 2McCance-Katz EF et al. Am J
Addict. 2009;19:4-16; 3Perucca E et al. Clin Pharmacokinet. 1994;27:175-190;
4Uehlinger C et al. J Clin Psychopharmacol. 2007;27:273-278.
Methadone Drug Interactions
Methadone may inhibit metabolization at
CYP2D6
• Desipramine: levels may double or more1,2
• Risperidone: 2D6 substrate, may have
potential for adverse drug interaction, but
no clinically significant reports of such and
no human pharmacokinetic studies3
• Phenothiazines: 2D6 substrate, consider
potential for adverse drug interaction4
1Kosten
et al. Am J Drug and Alcohol Abuse. 1990;16:329-336; 2Maany et al. Am J Psychiatry.
1989; 146:1611-1613; 3McCance-Katz et al Am J Addict. 2009;19:4-16; 4Ereshefsky et al. Clin.
Pharmacokinet. 1995; 29(Suppl 1):10-18.
Methadone Drug Interactions
CYP inducers
• St. John’s Wort: CYP3A4 and
2C91-3
• Carbamazepine, phenytoin, and
barbiturates: CYP3A4. Lower
methadone levels and lead to
opiate withdrawal4,5
1Izzo
AA. Int J Clin Pharmacol Ther. 2004;42:139-148; 2Puzantian T. Drug Interactions
of Methadone and Psychiatric Medications; information brochure presented to staff
and faculty of UCSF at San Francisco General Hospital. 1997; 3McCance-Katz EF et
al. Am J Addictions. 2009;19:4-16; 4Bell J et al. Clin Pharmacol Ther. 1988;43:623629; 5Perucca E. Br J Clin Pharmacol. 2006;61:246-255.
Reduced Methadone Levels
Consider:
• Risk for relapse to illicit opioids
• Non-adherence to prescribed
medications
McCance-Katz EF, Mandell TW. Am J Addict. 2010;19:2-3.
SF Methadone Clinics
• Ward 93*
• BAART Market Street*
• BAART Turk Street*
• Westside*
• Bayview-Hunter’s Point*
• Fort Help
• VA Ft Miley
*Referrals through COPE
COPE
• Eligibility: Title 9, CHN, not MediCal
• Referral to COPE: phone 552-6242
• COPE assessment: toxicology &
pregnancy testing, counseling and
medical visits per Title 9; DADP
exception
• Goal: methadone intake ASAP
• Funding limits
Buprenorphine
• Semi-synthetic derivative of thebaine
(an opium alkaloid)
• Partial μ agonist, antagonizes κ
receptor
• High binding affinity and slow
dissociation for μ receptor
• Sigmoidal dose-response curve: ceiling
effect
• Half life: 37 hours
• Side effects: sedation, CNS
depression, hypotension
Buprenorphine Prescribing
• FDA approved in 2002 for opiate
replacement, schedule III
• Buprenex (FDA 1985),
Suboxone*, Subutex
• Requires 8 hours special
training and DEA “waiver”
• MDs only..no mid-levels
• Office-based setting
• OBIC Clinic
Buprenorphine: Safety
• Hepatic impairment1
• Monitor CYP3A42
• Monitor with other CNS depressants
• BZD-BUP drug related deaths reported as
high as 80%.
• Deaths associated with IDU BUP and
concomitant BZDs and neuroleptics3-5
• Phenothiazines: enhance the hypotensive
effect?6
• Alcohol: enhanced CNS depression
1Zuin
M et al. Dig Liver Dis. 2009;41:38-e10; 2Reckitt Benckiser Pharmaceuticals Inc. Suboxone prescribing
information. 2010; 3Kintz P. Clin Biochem. 2002;35:513-516; 4Lintzeris N, Nielsen S. Am J Addict. 2010;19:59-72;
5Lai SH, Yao YJ, Lo DS. Forensic Sci Int. 2006;162(1-3):80-86; 6Thioridazine. Harrison’s Practice.
http://www.harrisonspractice.com/practice/ub/view/DrugMonographs/156600/5/thioridazine. *Reckitt Benckiser
Pharmaceuticals Inc. Suboxone film prescribing information. 2010.
OBIC
• Referral to OBIC: phone 5526242
• Intake:
• orientation appointment
• Induction appointment
• Stabilization. All OBIC notes in
LCR.
• Transfer back out to the
community: integrated care
OBIC Services
• Induction and stabilization
• Counseling and education:
individual and group
• Provider Education and Support
• “Safety net” re-stabilization PRN
• PRN health and mental health
assessments and referrals.
• Ancillary services PRN: pharmacy,
UDT, counseling
IBIS: Integration Flow
“any door the right door”
Primary
Care
Mental
health
Care
OBIC
Specialty
Care
PsychoSocial
Services
Naltrexone
• 1984: FDA approval for opiate
dependence
• Opiate antagonist
• No significant drug interactions
(opioids)
• Black box warning: dose-related
hepatocellular injury is possible: avoid
in acute hepatitis or liver failure
• Patients should be opioid-free for a
minimum of 7 to 10 days
Naltrexone
• Most appropriate for those highly
motivated and frequently monitored
• Poorly accepted by patients
• Long duration of action (24-72
hours) permitting less than daily
dosing (TIW)
• Oral form 50mg tablet
(25mg on day 1)
• I.M. 380mg Q 4 weeks
Fram et al J Sub Abuse Treatment 1989; 6:119-122.
Alcohol and Opioids
Oh My!
James J. Gasper, Pharm.D., BCPP
San Francisco Department of Public Health
Community Behavioral Health Services
170
Alcohol: Scope of the Problem
• Alcohol abuse is common in chronic
pain patients
• About 40% (5 % current, 35 % past)
• Preceded pain by average of 15 yrs
• Alcohol use is dangerous in
combination with opioids
• Present in about 50% of heroin deaths and
30% of methadone deaths
• Deaths occur at lower opioid and alcohol
blood concentrations
Katon W, et al. Am J Psychiatry 1985;142:1156-1160.
Hickman M, et al. Addiction 2008;103:1060-1062
Approach
Problematic Alcohol Use
Address Opioid
Hold/taper
Restrict supply
Refer to methadone
maintenance
Address Alcohol
psychosocial
interventions
pharmacotherapy
Pharmacotherapy
Detoxification:
• Medically assisted detoxification
may be needed
Maintenance:
• Naltrexone contraindicated with
concurrent opioids
• Available options: disulfiram,
acamprosate, topiramate
Evidence
• A few small studies of disulfiram
use in methadone maintenance
• “Reinforced Disulfiram”
• Methadone dose contingent on
taking disulfiram
• (N=25) 2% of days spent
drinking vs. 21%
Liebson IA, et al. An Int Med 1978;89:342-344
Alcohol Treatment:
Opioid Dependence Pathway
Disulfiram
Acamprosate
or
Disulfiram + Acamprosate
Topiramate
CBHS Alcohol Dependence Guidelines 8/6/2009
Principles of Motivational
Interviewing
Matt Tierney, NP
Motivational Interviewing is:
• A collaborative and goaloriented style of
communication with
particular attention to the
language of change
Rollnick S & Miller WR (2013). Motivational interviewing: helping people
change. (3nd Ed.) Guilford Press: New York
Spirit of MI
• Partnership
• Acceptance
• Absolute worth
• Accurate
empathy
• Autonomy
support
• Affirmation
• Compassion
• Evocation
MI: Four key processes
Develop commitment to
change AND formulate a
Planning concrete plan of action
Evoking
Elicit client's own
motivations for
change*
Focusing
Develop and maintain a specific
direction
Engaging
Establish a helpful connection and working
relationship
MI is Not
• Based on the Transtheoretical Model
of change
• A way of tricking people into doing
what you want them to do
• A solution for all clinical dilemmas
• Decisional balance, equally exploring
pros and cons of change
• A form of CBT
• Easy to learn
Miller & Rollnick, 2008 & 2013
MI is about Exploring
… the discrepancy
between current
behavior and a
core value. A
powerful
motivator for
change when
explored in a safe
and supportive
atmosphere.
Common MI Traps
1)
2)
3)
4)
5)
“Expert” trap
“Question-answer” trap
“I rectify gaps in knowledge.”
“Fear is a motivator” trap.
“I just need to tell them clearly what
to do.”
Ethics and MI
Three conditions that present ethical
complexities in MI:
1. When client’s aspirations are dissonant
with the interviewer’s or institution’s
goals of what is in the client’s best
interest
2. When the interviewer has an
increasing personal investment in the
direction the person takes
3. When the nature of the relationship
includes coercive power of the
interviewer to influence the direction
the client takes
Miller & Rollnick, 2008 & 2013
The Case
• 51 yo woman here to renew opioid
prescription
• Pain began 3 years ago after a car
accident
• 7/10, constant aching in the low
back. No red flags.
• PMH: COPD, Depression
• SH: lives alone, on disability, smokes
tobacco, recently cut down to 1/2ppd
• No h/o illicit drug use
The Case
• FH: Father died of cirrhosis, h/o
breast cancer on mother’s side
• Meds:
•
•
•
•
morphine SR 30 mg TID
oxycodone IR 15 mg q6 PRN BTP
bupropion 300 mg daily
inhalers for COPD
The Case
• After attending a conference on
pain management, you realize that
you have not asked about alcohol
use.
• 4 or more drinks in a day in last
year? No.
• Drinks 1 beer a night, 7 days/week.
• Drinking not more than intended; no
risk of bodily harm.
Motivational
Interviewing Skills
How do you increase motivation?
Sharing information without
generating resistance
Ask-Tell-Ask
• Open ended question, listen to
patient
• Respond with additional advice or
information
• Ask how that advice or
information lands for the patient
“ASKING”
“TELLING”
“ASKING”
Change talk
Any speech in favor of changing a
target behavior.
The more a patient engages in
change talk, the more likely he or
she is to change.
Change Talk
• Desire: I want to…
• Ability: I can…
• Reasons: I should change
because…
• Need: I really need to… I have to
• Commitment Talk: I’m going to…
I intend to… I will… I plan to…
• Taking Steps: I started…
Find the change talk
I want to stay clean and sober. But I
can’t get a job because of this court
thing, and so I have to live with my
brother who drinks all the time.
Find the change talk
I want to stay clean and sober. But
I can’t get a job because of this court
thing, and so I have to live with my
brother who drinks all the time.”
Find the change talk
I don’t want to die of lung cancer,
but everyone has to die sometime.
Find the change talk
I don’t want to die of lung
cancer, but everyone has to die
sometime.
Reflections
Listen for the meaning in what
someone is saying and repeat it
back to them
Types of reflection
•
•
•
•
•
•
Repeating
Paraphrasing
Reflect feeling
Reflect values
Double sided
Amplified
Case
Part 1 continued
Two major predictors of a
patient’s likelihood to change are
• The amount of change talk that
occurs in the visit
• The patient’s sense of selfefficacy
Affirmations
Reflective Listening Exercise
•
•
•
•
•
•
Repeating
Paraphrasing
Reflect feeling
Speaker
Reflect values
Double sided
Amplified
Reflector
Reflector
One thing I like about myself is…
Small Group Practice:
Motivational Interviewing
Case
Part II
Your Tasks
1. Affirm patient’s decision to engage in
more intensive monitoring
2. Share your concerns about the
potential harms of mixing alcohol
and opioid analgesics in the setting
of COPD
3. Learn the patient’s perspective
4. Provide information on reducing
alcohol through self-management
strategies
Your Tools
• Use reflective listening to find out what
the patient thinks about her drinking
• Use Ask-Tell-Ask to give information on
• her risk of opioid analgesic overdose in the
setting of alcohol and COPD
• strategies to reduce her alcohol
consumption.
• When you find something to affirm in the
patient’s behavior, express your
affirmation of the patient’s strengths
and ability to care for herself.
Small Group Practice:
Difficult Conversations
Case Part 3
Difficult
Conversations
At this point, the case will
become more complicated and
the provider decides to
discontinue opioids.
Your Tasks
1. Explain why observed behavior raises your
concern for alcohol use disorder
2. Inform the patient that you cannot safely
prescribe opioid analgesics; benefits no
longer outweigh risks
3. Develop an opioid analgesic taper plan
4. Listen for signs that patient wants to
change her behavior
5. Offer information and referral for alcohol
treatment and/or depressed mood
6. Maintain your primary care relationship
Your Tools
• Maintain a non-confrontational stance:
avoid arguments; resist the righting reflex
• Stay 100% in “Benefit/Risk” mindset
• Share decision making: include patient in
treatment planning
• Respect her autonomy
• Use reflections and affirmations to
reinforce patient’s strengths and any
change talk
• Use Ask-tell-ask to provide information
about alcohol treatment
Navigating the intersection
between pain and addiction:
SFHP’s role in supporting a system of safe,
effective, patient-centered pain management
Kelly Pfeifer, MD
Chief Medical Officer
[email protected]
214
Beth’s story
• 38 years old, erratically employed
• Anxious and depressed – “counseling doesn’t
help”
• Chronic LBP s/p MVA
• 8 Vicodin/day --> 180 mg daily
of Morphine over 5 years
• Ativan for anxiety
• Some concerning behaviors:
• 1 urine positive for cocaine
• 1 drug test refused
• Didn’t follow through with
PT or behavioral referral
215
Outcome
Found dead of accidental overdose:
•
•
•
•
Methadone
Ativan
Morphine
Cocaine
What did the PCP do wrong?
• According to Chou and
Portland clinics:
•
•
•
•
•
•
Combined benzos and opiates
Continued opiates after positive cocaine UDS
Untreated depression and anxiety
Methadone clinic client (not known)
Poor indication (opiates not effective in chronic LBP)
Over 120 mg a day
217
“We are not accountable for
everything that leads up to drug
deaths – poverty, addiction,
childhood trauma, despair.
But we are responsible. With our
pens, we are writing the drugs into
the hands of 8th graders”
Amit Shah, previous Medical Director,
Multnomah County Public Health Clinics
218
Based on MMWR: 1:9:35:161:461
CDC/MMWR report
Opiate deaths in SF in 2 years
Numbers of people in
San Francisco
261
Admitted for substance abuse treatment
2,349
Emergency Department Visits
9,135
Self-reported drug abuse or dependence
42,021
Self-reported nonmedical use of opiates
120,321
Myth # 1
• More opiates means
better pain relief
220
No change in pain score with
large opiate increases
J. Pain 2013. Vol 14 (4): 384
Myth # 2
• We know when our patients
are misusing meds
222
PCPs can’t accurately
assess misuse
• 72% misuse in SFGH chronic pain cohort
• No concordance between PCPs’
opinions and participants’ self-reports of pastyear misuse:
• Missed 38% of those who WERE misusing
• Misjudged 46% of those who WEREN’T misusing
(often based on race)
Vijayaraghavan M, Penko J, Guzman D, Miaskowski C, Kushel MB. Primary Care Providers'
Judgments of Opioid Analgesic Misuse in a Community-Based Cohort of HIV-Infected Indigent
Adults. J Gen Intern Med. 2011;26(4):412–8.
223
Myth # 3
• We know when our patients are
diverting meds
224
The incentive to divert is
overwhelming
• Typical yearly income for
patient on SSI: $13,000
• Typical street value:
• $1 per mg
• $370 mg a day or
$135,000 per year
• Selling 10% of meds
doubles income
Can I get
some
Vicodin?
This is the
Oxy corner.
Vicodin is next
block.
225
Partnership Health Plan
• Formulary implemented in Marin in
2009
• Local cop:
“Within months the level of Oxycontin on
the street had dropped dramatically”
226
Mike’s story
• Occasional marijuana use as a junior,
heavy use as a senior
• Tried Vicodin at State College… liked it
• 2nd most common drug of abuse for
8th graders
• Got too expensive; switched to heroin
• Now homeless
227
There is a lot of drug
on the streets
• 585 mg of morphine equivalents
prescribed per SF resident in 2010
• Enough opiates for each San
Franciscan to take the equivalent of
1 Vicodin every 6 hours for a month
CURES data, courtesy of James Gaspar
228
Should we consider a dose
ceiling in San Francisco?
• There is evidence that
high doses of opiates:
• Do not improve pain; may make it
worse J Pain, 2011. Vol 12(2): 288.
• Increase death rates (JAMA 2011:30(13): 13151321; Annals of Internal Medicine, 2010:152: 85-92; Arch Intern Med.
2011:171(7): 686-691)
• Increase depression, and increase
pain perception (hyperalgesia) (General
Hospital Psychiatry 34 2012, 581-587)
• There is evidence that lowering
doses reduces mortality and pain
scores
Am J Ind Med. 2012 Apr;55(4):325-31.
J Opioid Manag 2:277-282, 2006
230
“We are not at fault…. But we
are responsible”
Medicaid patients have six times the
death rate of the general population
when given opiates
231
Current approach
• Practice Improvement Program
measure
• For 2013: applies to only 6 clinics with
30 or more high-dose patients
• Requires all providers to agree to
consistent best practices
• Requires population management:
• Updated pain management agreement in
last 12 months
232
• Urine Drug Screen in last 12 months
Potential steps for SFHP
• 2014: expand Practice Improvement
Program measure
•
•
•
•
All clinics
Providers agree to consistent protocols
Panel management of pain patients
Opiate Oversight Committees
• Spread opportunity for technical
assistance for clinics
• Registries
• Opiate Oversight Committees
233
Possible future directions
for SFHP
• Should we implement lock-in programs?
• One pharmacy
• One prescriber
• Should we implement dose limits?
• PA requirements for high-dose patients?
• Waive PAs for clinics with good pain
management infrastructure?
234
Are dose limits manageable?
• 487 SFHP members in DPH or
SFCCC clinics on >120 mg morphine
equivalents daily
• Only 6 clinics with over 30 on the list
• 21 prescribers
have >6 patients on the list
• For these 21 prescribers:
• range 7 – 26 patients
• average 13 patients
235
Why would providers ask SFHP
to take this role?
• SFHP could
provide structure
to liberate
providers from
policing and
judging role
“Budget cuts – I’m good cop and bad cop.”
236
Mission of SF Safety Net Pain
Management Workgroup:
We aim to create a consistent system of
patient-centered, effective and safe pain
management across the safety net.
I welcome your feedback.
Thank you!
[email protected]
237