The Foundation for Medical Excellence 27th Annual Pain & Suffering Symposium http://tfme.org

1. Managing Pain in Patients
With or at Risk for Substance
Use Disorders
Launette Rieb MSc, MD, CCFP, CCSAM, FCFP, dip. ABAM
Clinical Associate Professor, Dept. of Family Medicine, UBC
Director, St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship
FME March 7-8, 2014, Vancouver, BC

2. Faculty/Presenter Disclosure
 Faculty: Launette Rieb
 Relationship with commercial interests:
 Grants/research support:
 UBC Clinical Scholar’s Program
 UBC Special Populations Grants
 Speaker’s bureau honoraria:
 FME (Oregon College of Physicians), CPSBC, UBC-
CPD, various health authorities, Qatar Olympic Bid
Committee, WorkSafeBC, SPH-CME
 Consulting fees: OrionHealth, Orchard Recovery
 Providence Health (St. Paul’s Hospital)

3. Learning Objectives
1. Gain an appreciation of the overlap between
chronic pain & addictive disorders and how
effective management is similar
1. Differentiate pain disorders, substance use
disorders, physiologic dependence, and pseudo-
addiction
2. Develop insight to caregiver suffering in working
with people in pain and/or addicted

4. Alarm
Sunyata
Pain is Primal

5. Nature Video Cocaine Video
Amygdala
not lit up
Amygdala
activated
Visual Cue Sets Off Alarm
PET scan – Person 1 mo. abstinent

6. Reward Pathway

9. Dopamine D2 Receptors are Lower in
Addiction
control addicted
Cocaine
Heroin
Alcohol
DA
DA
DA
DA DADA
DA
Reward Circuits
DADA DA
DA
DA
Reward Circuits
DA
DA
DA
DA DA
DA
Drug Abuser
Non-Drug
Abuser

10. Expect overvaluation of analgesics
 Opioids, benzodiazepines, stimulants and
cannabinoids trick brain systems
 Expect overvaluation of these medications
even in patients without true addiction
 Plan to evaluate effectiveness of these
medications by objective (functional) criteria

11. Substance Use Disorder? Look again.
 Pseudo – addiction
 Pain relief seeking not drug addiction
 May finish meds early
 May double doctor or go to emerg
 Often iatrogenic:
 Not dosing on the ½ life of med
 Inadequate amount
 Unrealistic expectations for pain relief
 Should disappear with dose stabilization +
education. If not …perhaps addiction is occurring

13. Depression and Chronic Pain
 Serotonin (5-HT) and
norepinephrine (NE)…
 Key mediators of mood
 Part of the body’s
endogenous analgesic system
Opiates
– Cortex
Lateral Hypothal.
Thalamus
Amygdala
Medulla
NE
5-HT
– GLU
Substance P +
GABA
Interneuron –
Nociceptor
A
A, c

14. Adverse Childhood Experiences
(ACE) – within first 18 years of life
 ≥ 4 ACE categories = 4-12x  risk of SUD
 1. Emotional abuse
2. Physical abuse
3. Sexual abuse
4. Emotional neglect
5. Physical neglect
6. Mother treated violently
7. Household substance abuse
8. Household mental illness/suicide attempt
 9. Parental separation or divorce
10. Incarcerated household member

15. Memory
Meaning
Magnification
Sunyata

16. Chronic Substance Use and also Chronic
Pain Produce a Different Nervous System
 Long term brain changes:
 Metabolic activity
 Neurotransmitter release
 Gene expression
 Receptor sensitivity & availability
 Cue responsiveness
 Behavioral and cognitive changes

17. Goals of Treatment (Pain & SUDs)
 Reduction of suffering
 Correction of sleep disturbance
 Reduction of anxiety and depression
 Restoration of function
 Elimination of unnecessary dependence
on medications

18. The 5As – Functional Assessment
1. Activities of daily living
 Work, self care, mobility, leisure, sport, sleep
2. Analgesia
3. Adverse effects
4. Affect
5. Aberrant drug-related behaviors
 + Accurate medication log
 + Ask relatives/friends/coworkers

19. Sleep/Mood Issues with SUD/Pain
 Education, sleep hygiene, exercise, caffeine elim.
 Cognitive therapy, social support
 Meds for sleep cycle regulation +/- pain
 Benzodiazepines contraindicated
 Tricyclic or tetracyclic antidepressant
 Antipsychotics
 For pain +/- mood
 SNRIs (duloxetine, venlafaxine)
 For primary mood issues
 SNRIs or SSRIs (citalopram, paroxetine, sertraline)

20. Addiction to Pain Medications
 Those at highest risk:
 Active SUD
 Past Hx of SUD
 Family Hx of SUD
 Active psychiatric illness
 Early childhood trauma history
 Youth
 Past minor injuries requiring prolonged opioid Rx
 Tight contracts, follow-up, and collateral

21. Opioids - tips
 Studies show analgesia up to 20-30%
 Fantasy of perfect analgesic control
 Watchful dose = 200 mg
Morphine Equivalent Daily Dose (MEDD)
 Reduce the affective component of pain
 “I still feel the pain but I don’t care”
 Noradrenalin suppression in LC, calming

 Withdrawal can be very painful & drive use

22. Canadian Opioid Guidelines (Furlan 2010)
Best Practice for Opioid Therapy
 Complete history, physical, differential Dx
 Risk assessment SUD, psychiatric issues
 Medication review + urine drug screen
 Appropriate trial of non-opioid alternatives
 Pre/post-opioid pain and function questions
 Treatment agreement: 1 MD, visits, scripts
 Taper off benzodiazepines first
 Sufficient trial of opioid, establish efficacy
 Use Opioid Manager + PharmaNet each visit

23. Canadian Opioid Guidelines
Patients at High Risk for SUD
 Prescribe only for well-defined somatic or
neuropathic pain conditions
 Relatively contraindicated in headache and fibromyalgia
 Start with lower doses and titrate in small
dose increments
 Monitor closely for signs of aberrant drug
related behaviors

24. Patient in Recovery and Acute Pain
 53 year old male teacher, 10 years sober from
alcohol dependence, with appendicitis
 He expresses fear of relapse if given opioids post op
 Can try non-opioid options first (med and psych)
 If no opioid – you can revisit if decompensating
 If opioid tried – short scripts, discuss warning signs
for relapse, collateral info, firm sunset clause
 Increase supports – family, friends, 12 step, etc.

25. Canadian Opioid Guidelines
For Patients with Opioid Dependence
 THREE options only
 Methadone or buprenorphine treatment
 Structured opioid therapy – e.g. once daily
morphine – daily witnessed ingestion until stable
 Abstinence based treatment
 N.B. Relapse can be triggered by…
 Stress
 Pain
 Exposure to any addictive substance

26. Patients on Methadone or with SUD
 Mild to moderate acute/chronic pain treatment
 High dose NSAIDs and acetaminophen
 TCAs, SNRIs, neuromodulators (beware of street
value of gabapentin)
 Topicals, ice/heat, myofacial release techniques
 stress reduction/mindfulness/breathing techniques
 Counselling, AA, NA, social engagement
 Exercise
 Sleep hygiene

27. Patients on Opioid Maintenance
 Severe Acute/Chronic Pain Treatment
 Consider all of the items on previous slide
 Split methadone q6-8h and increase as needed
 And/or …Additional opioid trial:
 Oxycodone, hydromorphone, fentanyl, witnessed inj.
 Sunset clause if acute pain
 Explore perceived disability and meaning
 In hospital get pain service or anesthesia to see
 Procedures: nerve root blocks, epidurals, ketamine
infusions, sympathetic blocks, regional blocks

28. Precautions if Any Active SUD
 Bubble pack medications
 Random call backs for pill counts
 RANDOM urine drug screens
 Look for illicit substances, ensure taking prescription
 Include ethyl glucoronide (ETG) – 3-5d past alcohol use
 Put onto once daily formulations with daily
witnessed ingestion at the pharmacy (no carries)
 Taper off opioids if drinking alcohol or on benzos

29. Random UDT Indicated for Those Treated
with Opioids - Katz 2003
 21 % of patients receiving opioids with NO
aberrant behaviors had…
 Positive urine drug screen for illicit drugs or for non-
prescribed controlled substances.
 14 % of patients receiving opioids with
significant aberrant behaviors had:
• Negative urinary drug screen for the medication
prescribed.

30. 45 year old female cook presents with hand pain after
a first degree grease burn treated yesterday in emerg.
She drinks 3-4 glasses of wine/night at work, then
binges at home. You suggest…
1. Referral to a plastic surgeon
2. Acetaminophen, NSAID and PPI with referral
for an addiction assessment
3. Opioids can be given first line since severe
pain can trigger more drinking
4. Medical marijuana is a good choice since it is
unlikely to interfere with alcohol metabolism

31. 19 year old street entrenched youth shooting
heroin is hit by a car as a pedestrian and
sustains a femur fracture requiring
instrumentation. What would you suggest for
pain management over the next few months?
1. Gabapentin and acetaminophen
2. Oxycodone/acetaminophen prn with a clear
sunset clause after 3 months
3. High dose methadone maintenance,
naproxen, and housing referral
4. Venlafaxine and meloxicam

32. When to Suggest Opioid Taper?
 Patient on opioids without significant
improvement in pain and function
 Safety sensitive position
 Spread of pain in the absence of disease
progression - allodynia and hyperalgesia
 Active substance abuse/dependence where
harm reduction is either not a consideration
or not viable
 Patient requests to come off

33. Essentials for Med Prescribing
 Identify those at highest risk
 Negotiate a clear behavioral contract
 If a chemical reinforcer is tried
unsuccessfully – STOP
 Focus on function
 Early (sustainable) return to work
 It is OK to refer on for assistance

34. We Feel Our Patients’ Pain
 Mirror Neurons activate seeing others in pain
 So no wonder we are uncomfortable!
 We empathize, then we…
 Try to stop their suffering – write a prescription
 We protect ourselves (and push patient away)
 Get angry and fire them
 Cut them off emotionally
 Give them a script to get them out of the office

35.  Instead we need to become more comfortable
in acknowledging the suffering in ourselves
and others
 And make sure our prescribing is not a
reaction to our own empathic suffering

36. Medications are a fantastic tool,
but if they are not working…
 Review the diagnosis – Repeat Hx/Px
 Tolerance, opioid induced hyperalgesia,
substance dependence or diversion?
 Screen for depression, anxiety, and PTSD
 Explore perception of disability & meaning
 Consider somatoform disorders
 Avoid iatrogenic pain and suffering

37. Perceived Disability
Sunyata

38. Recovery from Pain and Addiction
 Patient responsibility (active self management)
 Recovery is largely non-pharmacological
 Essential to recognize and correct negative
cognitive distortions (leading to dysphoria)
 Identify and practice recovery/happiness skills:
aerobic exercise, balance, altruism, social
interactions, accountability, spiritual growth,
meditation, nutrition, and fun
Essentials of Happiness
Recovery is unlikely in the intoxicated/impaired patient

40. Thank you!

41. References
 Ballantyne J, Shin N. Efficacy of opioids for chronic pain: A review
of the evidence. Clin j Pain. 24 (6) July/Aug 2006
 Furlan A. et al. Opioids for chronic non-cancer pain: A new Canadian
guideline. CMAJ early release May 3, 2010 www.cmaj.ca and
http://nationalpaincentre.mcmaster.ca/opioid/
And http://nationalpaincentre.mcmaster.ca/opioidmanager/
 Drugs for pain. Treatment guidelines from The Medical Letter, vol. 8
(issue 92) April 2010
 Chou R. et al. Opioid Treatment Guidelines. Journal of Pain, vol 10,
No 2 (February), 2009: pp 113-130, see www.sciencedirect.com
 Nuckols et al. Opioid Prescribing: A Systematic Review and Critical
Appraisal of Guidelines for Chronic Pain. Annals of Internal Med.
Nov. 2013

42. References, continued
 Katz, NP et al. Random UDT Indicated for Those Treated with Opioids J
Anesth Analg 2003 October; 97 (4): 1097-1102
 Gabapentin for pain: New evidence from hidden data. Therapeutics
Initiative, 75, July-Dec. 2009
 Malinoff, H. Medical Management of Patients Withdrawn from High
Dose Opioid Therapy for Chronic Pain. Paper presentation, American
Society of Addiction Medciine Med-Sci Conference, April 19-22, 2012,
Atlanta Georgia
 Butler D and Moseley L. Explain Pain. Noigroup Publications, Adelaide,
Australia (2003)
 Ziegler P. Safe Treatment of Pain in the Patient With a Substance Use
Disorder. Psychiatric Times (CMP Medica), 24(1), 2007
 Saarela et al., Compassionate Brain: Humans detect intensity of pain from
another’s face. Cerebral Cortex. 2007:17: 230-7.

43. References, continued
 Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for
acute and chronic pain in adults. Cochrane Database of Systematic
Reviews 2009, Issue 3. Art. No.: CD007076. DOI:
10.1002/14651858.CD007076.pub2
 Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T.
Antipsychotics for acute and chronic pain in adults. Cochrane Database of
Systematic Reviews 2013, Issue 9. Art. No.: CD004844. DOI:
10.1002/14651858.CD004844.pub3
 Eccleston C, Palermo TM, Williams AC de C, Lewandowski A, Morley
S, Fisher E, Law E. Psychological therapies for the management of
chronic and recurrent pain in children and adolescents. Cochrane
Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003968.
DOI: 10.1002/14651858.CD003968.pub3
 Martin-Sanchez et al. Systemic Review and Meta-analysis of Cannabis
Treatment for Chronic Pain. Pain Medicine Vol 10 (8) 2009: 1353-1368

44. References, continued
 Duehmke RM, Hollingshead J, Cornblath DR. Tramadol for neuropathic
pain. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.:
CD003726. DOI: 10.1002/14651858.CD003726.pub3
 Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane
Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005454.
DOI: 10.1002/14651858.CD005454.pub2
 Wiffen PJ, Derry S, Moore R, Aldington D, Cole P, Rice AS C, Lunn
MPT, Hamunen K, Haanpaa M, Kalso EA. Antiepileptic drugs for
neuropathic pain and fibromyalgia - an overview of Cochrane reviews.
Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.:
CD010567. DOI: 10.1002/14651858.CD010567.pub2
 National Institute on Drug Abuse (NIDA) Teaching Packet No. 5:
“Bringing the Power of Science to Bear on Drug Abuse and Addiction”
http://www.nida.nih.gov/pubs/teaching/Teaching5/Teaching4.html

45. References, continued
 Lunn MPT, Hughes RAC, Wiffen PJ. Duloxetine for treating painful
neuropathy or chronic pain. Cochrane Database of Systematic Reviews
2009, Issue 4. Art. No.: CD007115. DOI:
10.1002/14651858.CD007115.pub2
 Zhou M, Chen N, He L, Yang M, Zhu C, Wu F. Oxcarbazepine for
neuropathic pain. Cochrane Database of Systematic Reviews 2013, Issue
11. Art. No.: CD007963. DOI: 10.1002/14651858.CD007963.pub2
 Hadley G, Derry S, Moore R, Wiffen PJ. Transdermal fentanyl for cancer
pain. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.:
CD010270. DOI: 10.1002/14651858.CD010270.pub2
 Quigley C. Hydromorphone for acute and chronic pain. Cochrane
Database of Systematic Reviews 2013, Issue 9. Art. No.: CD003447.
DOI: 10.1002/14651858.CD003447
 Rieb, L. Spreading pain with neuropathic features may be induced by
opioid medications. This Changed My Practice. UBC CPD, Sept. 13,
2011 http://thischangedmypractice.com/

46. References, continued
 Chaparro L, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk
DC. Opioids compared to placebo or other treatments for chronic low-
back pain. Cochrane Database of Systematic Reviews 2013, Issue 8. Art.
No.: CD004959. DOI: 10.1002/14651858.CD004959.pub4
 McNicol ED, Midbari A, Eisenberg E. Opioids for neuropathic pain.
Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.:
CD006146. DOI: 10.1002/14651858.CD006146.pub2
 Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C,
Schoelles KM. Long-term opioid management for chronic noncancer
pain. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.:
CD006605. DOI: 10.1002/14651858.CD006605.pub2
 Derry P, Derry S, Moore RA, McQuay HJ. Single dose oral diclofenac for
acute postoperative pain in adults. Cochrane Database of Systematic
Reviews 2009, Issue 2. Art. No.: CD004768. DOI:
10.1002/14651858.CD004768.pub2