Opiate Use in the Treatment of Chronic Pain

1
Opiate Use in the Treatment of Chronic Pain

• Michael C. Welch, MD
• James Ansel, PhD
• October 15, 2011

2
A case

• 53 y/ o w male being seen for the first time by a
  colleague . His pcp is off giving a lecture
  somewhere. He is 10 minutes late for his 15
  minute appointment.
• Im just here for my lortab script Doc. I take 12
  a day (10/500).
• PMHx back injury in his 20s. On disability due
  to pain. Has been on lortabs for 10 years.
  Multiple allergies to pain meds. Hx of gerd,
  cant take nsaids. Smokes 3 ppd, Drinks 4-5
  glasses of wine daily.

3
My x ray Doc
4
Looks painful

• What to do?
• Give him a script and have him follow up next
  month with his pcp?
• Take a history?
• Do a physical?
• Arrange for a comprehensive functional
  assessment?
• Get a urine drug screen?
• Your nurse knocks Your next patient is roomed
  and ready

5
Endorphins
6
Endorphins
7
Morphine
8
Opiate Positives

• Safe
• Well tolerated
• Withdrawal is safe abet unpleasant
• Effective (although less so for neuropathic pain)

9
Opiate Negatives

• Well tolerated/ cause euphoria
• Abuse potential/diversion risk/aberrant use
• 10-20 of patients exposed to opiate therapy will
  have trouble coming off
• Government oversight is schizophrenic mandate to
  treat legitimate pain vs. significant regulatory
  burden to prevent diversion and abuse.

10
And finally

• Their chronic use has not been shown to improve
  function!
• Insufficient resources exist to treat opiate
  addiction in the office setting.

11
The Bottom Line

• Least favorite/rewarding aspect of most FPs
  practice (97 of attendees surveyed at AAFP 2009
  meeting)
• No reliable way to measure pain
• Even the definition of pain can be elusive

12
How do chronic opiate patients come under our
care?

• Initiated by us existing patients whose
  symptoms are not controlled by other measures.
  Fairly straightforward but rare in my experience.
• Inherited more common and frequently more
  problematic. May be from specialists because
  pain has become chronic or from other physicians
  both local and with patient relocation. Records
  are usually tardy

13
The challenge - moving from a givem what they
want and movem out paradigm

• Identify legitimate chronic pain patients who may
  need chronic opiate treatment and develop a
  treatment plan that maximizes their
  functionality.
• Be mindful of aberrant behavior and know how to
  deal with it.

14
Oh, Give me a Home, A medical Home

• The current interest in Patient Centered Medical
  Homes and the resultant move away from numbers
  seen to numbers helped (ACO) may if sustained
  provide a better framework for the comprehensive
  treatment of chronic pain (from which 60 million
  of us suffer)

15
Assets

• PHQ-9 screen for depression phq9 NCIS.doc
• DIRE-evaluate risk of addiction with opiate use
  DIRE Score.doc
• Comprehensive Functional Assessments - as
  initial screen and to monitor response to your
  treatment plan.
• Pain Contracts
• Urine drug Screens

16
The Institute for Clinical Systems Improvement

• This is a great web site (www.icsi.org)
• Their 2009 Paper Assessment and Management of
  Chronic Pain is available as a pdf file at this
  web site. It contains a wealth of information
  and most of these instruments. It was invaluable
  in preparing this talk. Please download it and
  look through it.

17
Their goal of treatment

• An emphasis on improving function through the
  development of long term self management skills
  including fitness and a healthy lifestyle in the
  face of pain that may persist.
• Medications are not the sole focus or treatment
  in managing pain and should be used only when
  needed to meet overall goals of therapy in
  conjunction with other treatment modalities

18
Minimizing problems

• Careful patient selection and close monitoring of
  all non malignant pain patients on chronic opiate
  is necessary to asses their effectiveness and
  watch for signs of misuse (aberrant use accounts
  for as high as 20 of all patients whereas
  outright diversion is felt to be less than 2).
• Dont feel compelled to prescribe opiates if you
  are uncomfortable. OK to get a 2nd opinion.

19
Four types of chronic pain

• Neuropathic, inflammatory, muscle,
  mechanical/compressive (Overlap exists)
• Neuropathic opiates tend not to work well
  although methadone and tramadol, which are spinal
  NMDA (Update on the neurophysiology of pain nmda
  antagonists.doc) inhibitors may be effective.

20
Four types of chronic pain

• Fibromyalgia is a subset of neuropathic pain.
  Except for tramadol, opiates play no role.
• Muscle pain, mechanical/compressive pain and
  inflammatory pain tend to respond.

21
Opiate basics

• Diagnosis (try to establish type of pain)
• Care plan
• Regular visits with follow up response to
  treatments and documentation
• Written agreement

22
Consider opiates if

• Pain (even neuropathic) not responsive to initial
  therapies
• Equal or better therapeutic index than
  alternatives
• Medical risks low
• Responsible patient
• Part of an overall management plan

23
The 4 As

• Analgesia
• Adverse effects
• Activity
• Aberrant behavior

24
Prior to prescribing in the ideal world

• Complete comprehensive biopsychosocial
  assessment Pain history and exam opiate
  assessment tool(dire)review of past medical
  records especially pain meds.
• Screen for and address co-morbidities depression,
  anxiety, PTSD, ect.

25
Behaviors suggesting diversion or aberrant use

• PMH of abuse or prescription drug misuse
• Repeated unsanctioned dose escalations
• Non-adherence to other recommendations
• Unwillingness or inability to comply with
  treatment plan
• Social instability
• Unwilling to adjust at risk activities
• Unexpected findings on UDS

26
Specific opiate issues

• Codeine- 5-10 of Caucasians wont respond. High
  incidence of gi side effects. Possible infant od
  if taken while nursing.
• Fentanyl Patch- not for acute pain or in opiate
  naive patients. Protect from heat.
• Meperidine (Demerol) I dont use it
• Methadone- long half life (90-120 hours) qt
  prolongation, arrhythmia's. Check ecg at start,
  1 mo, then yearly
• Avoid dilaudid (hydromorphone).

27
Duration of action

• Short acting
• Hydrocodone/APAP
• Oxycodone
• Morphine
• Codeine

• Long acting
• Extended release versions of these meds.
• Methadone
• Fentanyl Patch
• Buphrenorphine

28
Non Opiate adjuncts meds

• Tricyclic antidepressants
• SNRIs duloxetine, milnacipran
• Anticonvulsants (Gabapentin, pregabalin topamax
  for headaches)
• Vitamin D if levels low
• Glucosamine\chondroitin for oa
• SAMe for fibromyalgia and depression
• CoQ10 for adolescent migraine

29
Non Opiate adjuncts other

• Anti-inflammatory diet
• Relaxation response/ meditation.
• Exercise