Toronto Medical Rounds in Addiction: Pain and Chemical Dependency: An approach to the patient with both “legitimate pain” and a substance use disorder

Pain and Chemical Dependency: An
approach to the patient with both
“legitimate pain” and a substance
use disorder
Wiplove Lamba MD FRCPC Dip ABAM
lambaw@smh.ca
October 1, 2014 – ADDICTION rounds

Disclosures
• No conflicts of interest

Objectives
• Understand the basics of a pain and chemical dependency
assessment, including: risk factors, pain assessment,
rationalizing pharmacotherapy, universal precautions and
treatment recommendations.
• Discuss topics such as:
– perioperative management of the patient taking buprenorphine,
– “prisoner’s dilemma” in limiting prescription drug abuse, and
– accounting for “opioid debt.”
• Engage in a discussion about what services are needed for
our inner city patient population to help them get care for
both conditions in different treatment settings (family
practice, addiction medicine clinic, or inpatient medicine
and surgery).

Outline
• PAIN and CHEMICAL DEPENDENCY assessment
• Perioperative buprenorphine management
• Tips for Acute Pain Management of MMT, SMT
• Prisoner’s dilemma
• Pain Connect - Ottawa

Outline
• What I’m not covering
– Comprehensive opioid and non-opioid treatment
strategies
– Methadone/suboxone/structure opioid therapy
initiation/induction/maintenance
– (Some of these can be found at
www.suboxonecme.ca, CPSO guidelines for
methadone/buprenorphine, McMaster Guidelines
for opioids in chronic non-cancer pain)

Actual Objective
• Engage the group in a discussion

Exercise (5 min)
• Groups of 2
• Share the story of a case you worked with
where the following may have been there
– Pain
– Potential or clear substance use disorder
– Transference/counter-transference issues
– System difficulties to get care needed
– Feelings of helplessness within the patient/within
the care provider/both

Think about
• What was the clinical setting?
– Community
– Addiction medicine clinic
– Family practice
– Inpatient
• What was your role?

Pain and Chemical Dependency
• Clinical Case
– 45 yr old male, referred for stimulant use to
addiction service
– ++ paranoid, symptoms improved with addition of
atypical antipsychotic while in hospital
– History shows a significant chronic pain and
addiction history

• Clinical Case
– Discharged from hospital on daily dispensing
medications (short acting and long acting opiates)
as he was on prior to coming in.
– was offered buprenorphine/methadone – not
interested

• Clinical Case
– Further visits reveal aberrant behaviour
– GP managing pain meds
– Agrees to get collateral sent

• Clinical Case
– Collateral shows numerous pain consultations and
medication trials
• Was up to 6 tabs of 80 mg oxycontin q6h plus
breakthrough 100 mg of IR morphine q 4 h
• Some suggested increased the dose
• Some suggested no indication for opioid therapy
• Previous trial of methadone (>100mg) with numerous
pain meds for breakthrough pain (long acting and short
acting hydromorphone)

• Clinical Case
– Further history reveals numerous pain conditions
including

• Clinical Case
including
• Cancer

• Clinical Case
including
• Cancer (in remission)
• HIV and HIV related pain conditions
• Osteomyelitis
• Hx of avascular necrosis
• Chronic LBP

• Clinical Case
– Think about how your clinical opinion about the
use of opioids changes based on the diagnoses
the patient has

• Clinical Case
including
• Cancer
• HIV and HIV related pain conditions
• Osteomyelitis
• Hx of avascular necrosis
• Chronic LBP

• Diagnosing Addiction
– C = lost of CONTROL
– C = COMPULSION to use
– C = continued use despite negative
CONSEQUENCES
– C = CRAVINGS

• Assessment
– RISK ASSESSMENT
• Scales – CAGE, SOAPP, ORT, UDT, interview
– Actual risk is determined over time
“Pain and Prescription Opioid Abuse” Gourlay CSAM review Course 2014

• Assessment
– Clinical Approach
• What is the nature of the problem?
– Is the pain problem alone, an addictive disorder, or a bit of both?
» Which is dominant?
• What is the nature of the pain?
– Acute, chronic, acute on chronic
– Nociceptive, neuropathic
• Is the current pharmacotherapy rational
– Is it doing more to the patient than for the patient?
• Do I have
– The experience to deal with this problem?
– Resources to deal with it?

• Assessment
– Rationalize Pharmacotherapy
• Sometimes better to achieve pharmacologic stability
than abstinence
– Short acting is problematic
– hyperalgesia
• Retry previously ineffective agents
• Consider non-opioid therapeutics
• Avoid previous drugs of “misuse”

• Universal Precautions
– Thoroughly inquire about drug and alcohol history
– ORT/CAGE/etc
– Set boundaries around medication use
– Identify aberrant behaviour
– Triage – primary care, specialist support, tertiary
care
– Assess opioid responsiveness

• Assessment
– Set limits carefully from the outset
• Easier to loosen than to tighten
• Limits should be flexible and reasonable
– If set too tightly, patient must step outside them
– Assess risk initially and periodically
• Risk is dynamic in pain and addiction continuum
– Appropriate monitoring
• Urine Drug testing
• Frequent follow-up
• Interval/contingency dispensing

• Gourlay-isms

• Gourlay-isms
– “Opioid Debt”
– “Withdrawal – mediated pain”
– “legitimate pain does not stop risk”
– “un-wise to make pseudo-addiction diagnosis in a
someone with an addiction history”

• WITHDRAWAL MEDIATED PAIN
• Ask about withdrawal symptoms:
– How long has the patient been able to go without opioids?
– Was he or she uncomfortable during this period?
– Has the patient ever used opioids to avoid withdrawal or relieve
withdrawal symptoms?
• Determine whether your patient is experiencing withdrawal-
mediated pain. Consider withdrawal-mediated pain in patients who
report:
– intense magnification of their pain as the opioid wears off
– diffuse myalgias (“pain all over”)
– dysphoria
– severe pain and withdrawal symptoms in the morning, with quick
relief after taking the opioid.
https://knowledgex.camh.net/primary_care/toolkits/addiction_t
oolkit/opioid_toolkit/Pages/faq_assess_patients.aspx

• Buprenorphine in perioperative management
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014

(why people don’t use it)
– It isn’t an Analgesic
– It has a Ceiling effect for analgesia
– It blocks the effect of other opioids

• Analgesic?

• Ceiling effect?

• Opioid blocking
– “While patients are taking opioid pain
medications, the administration of buprenorphine
generally should be discontinued. Note that until
buprenorphine clears the body, it may be difficult
to achieve analgesia with short acting opioids”
• “Clinical guidelines for the use of buprenorphine in the
treatment of opioid addiction” TIP 40 SAMHSA

– Opioid blocking effect?
• Unclear where evidence came from
• Anecdotally
• Information from patients that go for dental procedures
from pregnant patients suggest the blocking effect is
not a concern

– General approach for chronic pain patients
• Regional/neuraxial anesthesia
• Ketamine
• Pre-op celecoxib
• Pre-op pregabalin
• Ketorolac
• Local at incision
• Continue baseline opioids plus analgesic dose
– Consider lowering buprenorphine in patient’s on high doses

• Medication Assisted Therapy (MAT) Patients
(in hospital)
– Buprenorphine or Methadone

• MAT Patients in hospital
• MISCONCEPTIONS
– Maintenance dose provides analgesia
– Use of opioids may result in addiction relapse
– Have to watch for respiratory depression with
MAT and additional opiates
– Pain reporting is manipulating or drug seeking

• MAT Patient in hospital
– Methadone
• Continue methadone, Confirm dose
• Continue dose or reduce if needed
• May divide methadone dose
• Provide additional short acting if indicated
• At discharge provide with a last letter dose
– Buprenorphine

– Buprenorphine (2 options)
• Stop buprenorphine
– Start full agonist and/or methadone/long acting
• Continue buprenorphine
– Use additional buprenorphine or full agonists
– Maximize non-opioids
– divide buprenorphine dose (q8h)
– For patient’s on high dose buprenorphine, lower the dose, but
keep them on it. Use opioids for pain

• On Discharge
– Avoid writing one script for post discharge supply (daily or
q2day dispensing
– Involve sober family member or signficiant other to either
dispense or monitor
– Supply enough until followup appointment to reassess pain
– Coordinate with other providers

Prisoner’s Dilemma
Cooperate Defect
Cooperate Both Cooperate:
Physician provides treatment
Patient stays in treatment
Controlled substances are well managed
Physician cooperates,
patient defects
Increased prescription
diversion
Compromised provider
reputation
External controls on
physician decision making
Defect Patient cooperates, physician defects
Physician refuses to treate (permanent
realiation, east of management)
“opioid refugees”
Neither cooperate
Physician refuses to treatet
Patient does not get
treatment
Controlled substances not
dispenses
“The Complex patient” Anna Lembke - CSAM review course 2014

• Strategies
– Always mean
– Always nice
• Axelrod’s winning strategy
– “tit for tat”
– 4 lines of BASIC

• Tit for Tat
– Cooperate Cooperate
– Cooperate Defect
– Defect Defect
– Defect Cooperate

• Be Nice (never be the first to defect)
• Be Forgiving (be willing to cooperate if
cooperating is offered)
• Be Retaliatory (willing to defect if others
defect against you)
• Be Clear (transparent about your strategy)

• - frame shift – addicton a disease
• -method to detect defectors – ODB profile,
UDS
• Reward for cooperation –

PAIN CONNECT - Ottawa
• Dr. Catherine Smyth And Dr. Lisa Bromley
• Very long waitlist for chronic pain consultations
>12 months
• Most were patients on high dose opiates
• “It’s very rewarding work. I came to that
conclusion that we need to do things differently
in order to have an impact with chronic pain.
Show GP how to do what we are doing. A lot of
the consults were relatively unnecessary. “

• Find GP with several referrals, then go to clinic
• Educational component
• Read over the charts the night.
• Most discussions were focused on opioids and
interventions. Most GP did not understand
anesthesia procedures
• 3 patients in am, then had other cases to
discuss in lunch hour.

• Family docs fill in a referral form.
• Pain history questionnaire, 12 page. Detailed
information and mental health history.
• Standardized questionnaires
• SOAP, ORT, insomnia severity index, insomnia,
Pain catastrophizing index,
• summarize, provide extensive reports.
• Provide long term treatment plan

• Multimodal approach. First on statement –
– “can’t fix pain, but can improve function and establish goals of the patient that
are functional and realistic.”
– Some we have done everything we can. Pushing dose is making things worse.
• Divide up management into pharmacotherapy, interventions (odd patient
would be a good candidate for a spinal cord stimulataor or steroids), self
management programs and exercise.
• Fair number of family physicians wanted help with detox with opioids.
They can prescribe it, but scared to get rid of it.
• Slow titration vs rapid detox on suboxone. Present both as option.
• INITIATION Stop long acting 2 days in advance, short acting 1 day in
advance then at 8 am for pain clinic, in withdrawal, COWS scale, UDT, and
then confirm that not taken opioids in past 12 hours, then first dose under
tongue 4 mg.

• EXAMPLES
• 1 patient today in precipitated withdrawal, team
found helpful. Required extra suboxone, tordol,
lidocaine.
• Usually uneventful, 8 mg total, some get 12,
prescription faxed to community pharmacy,
• Only methadone patients down to 30 mg.
• Other patients, fentanyl pathc 200 mcg,
• 16-24 dilaudid a day.

• If they truly meet criteria for substance
dependence, then connect to Addiction
Medicine Physician - Dr. Bromley
• Most have been on opioids forever, hard to
wean off, may have some misuse, but not
criteria for addiction.

• Most of them, it’s quite clear that pain is no
different
• With 6months to a year for a taper, sometimes
patients forget
• “Realize that a lot of their pain is withdrawal
mediated and opioid mediated pain.”

• New initiatives – Dr. Smyth
– E-consult
– Emerg department, orphan patients
– Pain preceptorship program

PAIN CONNECT
• Think about the patients that we see in our
clinical practice
• What can we do to help them get the care
that they need for both conditions?
• What is the knowledge that I need to get in
order to manage these patients?
• Are there colleagues that can be helpful in this
journey?

References
• Review Course
– California Society of Addiction Medicine Review
Course and Complex Pain workshop 2014
• www.pcss-o.org (or www.pcss.mat.org)
– Provider’s Clinical Support Systems for Opioid
Prescribers (free webinars from APA, AAAP, AMA,
etc)

Toronto Medical Rounds in Addiction: Pain and Chemical Dependency: An approach to the patient with both “legitimate pain” and a substance use disorder

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Toronto Medical Rounds in Addiction: Pain and Chemical Dependency: An approach to the patient with both “legitimate pain” and a substance use disorder