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Wsam Presentation For Opiate Guidelines
 

Wsam Presentation For Opiate Guidelines

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CME presentation at WSMA annual meeting. Problematic opioid use, questioning the concept of "pseudo-addiction", seeing chemical dependency as somewhere well along the continuum of ...

CME presentation at WSMA annual meeting. Problematic opioid use, questioning the concept of "pseudo-addiction", seeing chemical dependency as somewhere well along the continuum of problematic opioid use.

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  • Many medical students are taught that if opioids are prescribed in high doses or for a prolonged time, the patient will invariably become an addict. Therefore, the common wisdom is to prescribe the lowest possible dose at the longest possible dosing interval. As a result, opioids are frequently prescribed in doses that are inadequate and at time intervals beyond the duration of action of the drug, resulting in poor analgesia. 1 The term pseudoaddiction was first introduced by Weissman and Haddox in 1989 to describe the iatrogenic syndrome of abnormal behavior developing in direct consequence of inadequate pain management. 2 They described the natural history of pseudoaddiction as a progression through 3 characteristic phases including: (1) inadequate prescription of analgesics to meet the primary pain stimulus; (2) escalation of analgesic demands by the patient associated with behavioral changes to convince others of the pain's severity; and (3) a crisis of mistrust between the patient and the health care team. Treatment strategies include establishing trust between the patient and the health care team and providing appropriate and timely analgesics to control the patient's level of pain. 2,3 1. Schnoll SH, Finch J. Medical education for pain and addiction: making progress toward answering a need. J Law Med Ethics. 1994;22:252-6. 2. Weissman DE, Haddox JD. Opioid pseudoaddiction—an iatrogenic syndrome. Pain . 1989;36:363-6. 3. A consensus document from the American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions Related to the Use of Opioids for the Treatment of Pain . 2001.
  • There is a distinction between the patient who is physically dependent, but not out of control with medication, and the addict who is. The physically dependent person’s quality of life is improved through use of the medication, whereas the addict’s quality of life is severely impaired. Use of medication continues or increases despite adverse consequences to the addict; however, the physically dependent patients will complain or seek to deal with negative consequences, such as side effects, by trying to cut down on the medication. The addict is unaware or in denial about the problems caused by the medication; the physically dependent patient is concerned about these problems. 1 1. Schnoll SH, Finch J. Medical education for pain and addiction: making progress toward answering a need. J Law Med Ethics . 1994;22:252-6.

Wsam Presentation For Opiate Guidelines Wsam Presentation For Opiate Guidelines Presentation Transcript

  • Chronic Non-Cancerous Pain & Problematic Opiate Use Diagnostic and Therapeutic Principles with some Guidelines James K. Rotchford MD MPH Olympic Pain & Addiction Services (OPAS) Port Townsend, WA
  • Disclosure: OPAS is a private medical practice. New patients are seen primarily because of consultation request. Medicare Provider Labor & Industry Provider Kitsap Physician Service Provider
  • Objectives
    • Be familiar with issues pertinent to caring for patients who are candidates for opiate therapies and are at risk for problematic opiate use.
    • Be familiar with the clinical and theoretical overlap in helping patients with chronic pain and chemical dependency.
    • Be familiar with some guidelines for prescribing opioids to patients at risk for problematic opioid use.
  • Clinically Pertinent Questions
    • Is prescribing opioids to this patient part of the solution or part of the problem?
      • How does one answer this question?
        • Are improved pain and activity scores enough?
        • Are presence of aberrant behavior the tip off?
        • Is formal screening for past or present addictive problems the way to go?
    • Can I in the context I’m prescribing safely prescribe opioids to this patient? And for how long? Which opioids are best and which ones are available & legal to use?
    • How do I safely prescribe opioids to a patient with known addiction problems or who already is on methadone or buprenorphine ?
  • Basic Principles:
    • If risk factors are prominent treat the patient as though they are opiate dependent.
    • Limit self-medicating in patients at risk.
    • With high risk patients consider only methadone and buprenorphine ; the only proven effective agonists in opiate dependency.
    • Limit amounts and increase frequency of visits if in doubt about safety.
    • Don’t argue, show respect, and treat withdrawal aggressively. Encourage behavioral and “active” treatment modalities.
  • Further Lecture Overview
    • Contextual Issues
    • Some pertinent issues related to chronic non-cancerous pain
    • Some pertinent issues related to chemical dependency.
    • Overlap between addictive disorders and Chronic Pain
    • Discussion of Pseudo-Addiction vs problematic opioid use . Seeing Problematic Opioid Use as a continuum in terms of severity and clinical relevance.
    • Some suggested solutions
    • Some guidelines for prescribing opiates to patients with problematic opioid use concerns.
  • Contextual Issues are Important!
    • Population
      • Risk Factors
        • Pain Etiology, Psychiatric and CD co-morbidity, Social Support, Activity Engagement, third party coverage?
      • Hospital/Surgical vs. Outpatient
      • Co-morbid conditions/treatment
    • Locale
      • Rural vs. Cosmopolitan vs. Incarceration
      • Methadone Clinic vs. traditional medical, behavioral, or chemical dependency service
    • Acute nocioceptive vs. chronic painful conditions
    • Financial and other access issues
    • Legal Concerns
    • Other!
  • Contextual Issues are Important!
    • Too numerous to elaborate upon fully.
    • Well trained and experienced clinicians essential for optimal outcomes in patients with complex chronic pain and problematic opioid use, addictive disorders, and other psychiatric diagnoses.
    • Guiding principles, evidence based medicine, and objective findings are very important but flexibility based on contextual considerations and solutions are essential for optimal outcomes.
  • OPAS’s Population:
      • On longstanding opioids or being considered for chronic opioid treatment for pain or agonist therapy.
      • Co-morbid psychiatric problems are common and include active or in remission chemical dependency (ies).
      • Significant disability (GAF scores commonly in 50-60 range)
      • Financially challenged/Rural setting
      • At “End” of procedural road
      • Frequently discharged from previous medical practices
      • Multiple past traumas (Includes surgeries)
  • Other Medical Settings with unique contextual issues:
    • Primary Care Setting
    • Outpatient Orthopedic Clinic
    • Outpatient procedurally based pain management service.
    • Emergency Room/Urgent Care Settings
    • Mental Health/Behavioral settings/Methadone Clinics
    • Jail Settings
    • Inpatient Settings
    • Hospice Care
  • Chronic Non-Cancerous Pain Basic Pertinent Issues
    • A chronic relapsing disease involving primarily the Central Nervous System.
      • Patho-physiology more complex than acute pain
        • Less about nocioception
        • More about lack of proper inhibition
        • More about improper responses to “memories” or “triggers”
        • More about improper “operant conditioning” and reward system dysfunction.
      • Neuro-adaptation/sensitization at spinal & brain levels.
      • The analogy of refrigerator coming on
  • Various Models used to Explain & Treat Chronic Pain
    • Neuro-Anatomical-Physiological
      • Structural and Chemical/Pharmaceutical
    • Spiritual/Moral
      • Thorn in the Flesh
      • Punishment/Consequence to poor choices in self or others
    • Psychological
      • Behavioral
      • Somatization
    • Energetic Disturbance
    • Nutritional
    • Social
    • Addictive Model
  • Addictive Model for explaining Chronic Pain
    • It is important to understand basic neurophysiology that pain and addictions have in common:
      • Dopamine levels in Nucleus Accumbens
    • Would some patients with chronic pain have better outcomes if there condition was considered to be primarily an “addictive” disorder, possibly aggravated by opiate dependency or other chemical dependencies? This approach doesn’t deny nocioceptive pathology and other medical & psychiatric conditions!!
  • Copyright ©2001 CMA Media Inc. or its licensors Tomkins, D. M. et al. CMAJ 2001;164:817-821 Fig. 1: Schematic diagram of the human brain that highlights some of the main brain areas and neurotransmitter pathways implicated in reward processes
  •  
  • Dopamine is the “currency” which determines the response of Nucleus Accumbens: dopamine spikes within the NA occur as below to “cues” and promotes behavior accordingly
  •  
  • Addiction
    • A primary, chronic, neurobiological disease , with genetic, psychosocial, and environmental factors influencing its development and manifestations.
    • It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
    A consensus document from the American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine . Definitions Related to the Use of Opioids for the Treatment of Pain . 2001.
  • Addiction: 5Cs
    • C hronic
    • C ompulsive use
    • C ontrol—impaired
    • C raving
    • C ontinued use despite harm
  • Addiction ≠ Physical Dependency Physical dependency is a strong predictor of chemical dependency when substances that increase dopamine levels in NA are being used chronically.
    • Physical Dependency as manifested by tolerance and withdrawal are often associated with addiction
    • 2 of necessary three out of seven DSM 4 criteria for chemical dependency include tolerance and withdrawal (signs of physical dependence)
    • The vast majority of patients who are on chronic opiates for painful conditions can be considered to be opiate dependent based on DSM IV criteria.
  • Hypothesis regarding pseudoaddiction: Our ideas about pseudoaddiction in pain management stem from “neurotic” patterns particularly prominent in American culture: “ In 1919 , a Federal ruling held that treatment of addiction was “outside the realm of legitimate medical interest”. This created the conundrum that allowed physicians to treat pain but not addiction that sometimes occurs in the context of medical use. (Principles of Addiction Medicine, 2009 p. 1329, Chapter on Opioid Therapy of Pain by Savage SR et al.)
  • Is the behavior observed from patient on opioids “pseudoaddiction” or not?
    • Let’s explore the dilemma
      • Elements of dilemma?
      • Reason for dilemma
      • How to extricate oneself from it?
  • Pseudoaddiction
    • An iatrogenic misinterpretation caused by under treatment of pain that is misidentified by the clinician as inappropriate drug-seeking behavior
    • Behavior ceases when adequate pain relief is provided
    • Not a diagnosis , rather a description of a clinical interaction
    Weissman DE, Haddox JD. Pain . 1989;36:363-6.
  • Difference Between a Chronic Pain Patient & an Addict Adapted from: Schnoll SH, Finch J. J Law Med Ethics . 1994;22:252-6. Addiction is a disease; medication compliance is not addiction Yes No Denial about any problems Yes No Use continues in spite of problem No Yes Medications improve quality of life Yes No Out of control with medications Addiction Physical dependence
  • DSM 4 Criteria for Chemical Dependence & Typical Justifications for lack of Validity in Chronic Pain patients
    • Tolerance
      • Expected with prolonged analgesic use
    • Withdrawal
      • Expected with prolonged regular analgesic use.
    • Used in greater amounts or longer than intended
      • Emergence of pain may demand increase dose or prolonged use.
    • Unsuccessful attempts to cut down or discontinue
      • Emergence of pain may deter dose taper or cessation
    • Much time spent pursuing or recovering from use
      • Difficulty in finding proper pain management
    • Important activities reduced or given up
      • Valid Criteria – activity engagement expected to increase not decline with pain treatment.
    • Continued use despite knowledge of persistent physical or psychological harm.
      • Valid Criteria – limited harm anticipated from analgesic opioid use for pain.
  • Differential Dx. Of Misuse of Analgesic Opioids by Savage et al.
    • Misunderstanding of instructions
    • Self-medicating of:
      • Mood/stress
      • Sleep
      • Disturbing Memories
      • Undertreated Pain
      • Other
    • Effective use for reward or euphoria
    • Compulsive use due to addiction
  • Addictive Model for Chronic Pain
    • Pain effects the reward system in ways similar to drugs of abuse including opioids.
    • In patients with a chronic pain disorder there is often a strong personal or family history of an addictive disorder.
    • The same areas of the brain involved in “suffering” modulation strongly correlate with those involved in modulating addictive disorders.
    • Pain has all through history been treated by substances that have addictive properties; opiates, alcohol, and marihuana.  Indeed, in some patients stimulants such as amphetamines help modulate pain.
  • Addictive Model of Pain (Cont.)
    • Complex bio-psycho-social factors are involved in etiology and maintenance of both addictions and chronic pain.
    • The same psychiatric conditions which predispose one to chronic pain are very similar to those associated with a predisposition for addictive disorders. That is: affective disorders, personality disorders, anxiety disorders, PTSD, ADHD, and sleep disorders.
    • Effective treatment approaches have much in common between the two disorders; counseling, education, motivation, support, along with appropriate pharmacological and nutritional support .  Family support/dynamics need to be addressed in both addiction and chronic pain.
  • Addiction Model (Cont. #3)
    • Both conditions are often considered shameful with people with chronic pain often being accused of malingering or of having weak natures. Patients with addictions clearly are looked down on and often face criminal proceedings.
    • Relapses are quite common with both conditions and preparation for relapse is a prerequisite for good outcomes. 
    • Standard imaging or biological markers are often unable to confirm the diagnoses.  Observation, interviews, history, and contextual issues are prominent in establishing the diagnoses. Both clearly involve “subjective” experience.
  • Addiction Model for Chronic Pain (Cont. #4)
    • Both appear to benefit from similar behavioral approaches, including spiritual growth and stress reduction.
    • Addiction has been broadly defined as maintaining a relationship with someone or something that interferes with proper self care. Using this broad definition of addiction, a relationship with chronic pain could also be considered an addiction.
    • Other!?
  • Problematic Analgesic Opioid Use - a disorder with a clinical continuum? Less than effective Use/Prescribing? Poor Pain Management/education Chemical Coping/Self Medicating Occasional Abuse Regular Abuse 5 C’s of Addiction Complications alone define problematic analgesic opioid use
  • Response to Problematic Analgesic Opioid Response:
    • Attempt to determine where on the continuum of problematic use the patient is and respond accordingly.
    • Often clinically impossible to know for sure
      • Even in an established Heroin Dependent individual.
        • They can have untreated pain
        • Agonist therapy generally stabilizing and helpful.
    • Respond based on risk factors and contextual issues??!!
  • Practical Considerations & Guidelines for responding to problematic opioid use.
    • Contextual Issues
    • Universal Precautions
    • Attempt to maintain relationship
    • Coordination of Care
    • Policies/Procedures
  • Practical Considerations & Guidelines
    • Contextual Issues Very Important
      • Results of formal risk assessment
      • Acute Nocioceptive Pain/Pain Etiology
      • Type and severity of chemical dependency
      • Hospitalized Patient/Surgical Patient
      • Time in “recovery” and time without any aberrant behavior
      • Age of patient
      • Co-morbid medical & psychiatric conditions/longevity etc.
  • Practical Considerations & Guidelines
    • Universal Precautions
      • Basics: required workups & follow ups, documentation, screening UA’s, consents & agreements.
      • Treat patients similarly who or at significant risk for chemical dependency as those with documented chemical dependency.
      • At risk chronic pain patients & CD patients with pain problems receive similar treatment
  • Practical Considerations & Guidelines
    • Attempt to maintain therapeutic relationship – time in treatment is primary predictor of outcome in chemical dependencies
      • Progress not Perfection
        • Tighten Reins in the context of aberrant behavior
        • Therapeutic Plan & Adjunctive Care
      • Some reasons for discharge or limiting controlled substance prescribing:
        • Patient is a danger/threat to others
        • Patient behavior interferes with helping others
        • Established diversion or illegal behavior
        • Unwillingness to get further help.
  • Practical Considerations & Guidelines
    • Coordination of Care - Integration & continuity of care essential. Ideally pcps, diagnosticians, proceduralists, mental health providers, addiction specialists, pharmacists, family, social workers, case managers, etc. are all part of an informed team.
      • Fragmentation of care is the rule!
      • Send out frequent progress notes to pertinent members of team!
      • Assume that other providers/third parties are not informed about or are highly prejudiced against the medical management of addictive disorders and the importance of managing co-morbid psychiatric issues.
  • Practical Considerations & Guidelines
    • Policies & Procedures
      • Opiate Agreement
      • Missed/late appointments
      • Payment issues
      • Scheduling & Frequency of Appointments
      • Acute pain management
      • Group Consent Form
      • Staff follows procedures and know when to ask for help.
  • OPAS Experience
      • Group/Class visits 6-10 patients
      • Counseling/Educational 30-40 minutes
    • Individual visits
      • 10-15 minutes . Medical management
      • Limit to chronic pain/addiction
    • 99215 E&M code 45 mins. with more than 50% in counseling now has become 99214 with 90853 group time.
    • Occasional need for office pick ups
    • Opiate Rx’s contingent upon adherence to other medical recommendations.
  • Clinically Pertinent Questions
    • Is prescribing opioids to this patient part of the solution or part of the problem?
      • How does one answer this question?
        • Are improved pain and activity scores enough?
        • Are presence of aberrant behavior the tip off?
        • Is formal screening for past or present addictive problems the way to go?
    • Can I in the context I’m prescribing safely prescribe opioids to this patient? And for how long? Which opioids are best and which ones are available & legal to use?
    • How do I safely prescribe opioids to a patient with known addiction problems or who already is on methadone or buprenorphine ?
  • Questions:
    • J. Kimber Rotchford, MD MPH DBAM
      • [email_address]
        • Transferring to Methadone from another opiate
        • Treating acute nocioceptive pain in the context of chronic methadone or opioid prescribing
        • Policy guidelines for an orthopedic clinic
      • www.opas.us
      • Principles of Addiction Medicine 4 th Edition, Ries et al., 2009 by Lippincott Williams & Williams, pp 1275-1353 cover Pain & Addiction.