Transcript Opiate Use in the Treatment of Chronic Pain

Opiate Use in the Treatment of
Chronic Pain
Michael C. Welch, MD
James Ansel, PhD
October 15, 2011
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.
• I’m just here for my lortab script Doc. I take 12 a
day (10/500).
• PMHx: back injury in his 20’s. On disability due to
pain. Has been on lortabs for 10+ years. Multiple
allergies to pain meds. Hx of gerd, can’t take
nsaids. Smokes 3 ppd, Drinks 4-5 glasses of wine
daily.
My x ray Doc
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”
Endorphins
Endorphins
Morphine
Opiate Positives
•
•
•
•
Safe
Well tolerated
Withdrawal is safe abet unpleasant
Effective (although less so for neuropathic
pain)
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.
And finally
• Their chronic use has not been
shown to improve function!
• Insufficient resources exist to treat
opiate addiction in the office setting.
The Bottom Line
• Least favorite/rewarding aspect of most FP’s
practice (97% of attendees surveyed at AAFP
2009 meeting)
• No reliable way to measure pain
• Even the definition of pain can be elusive
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
The challenge - moving from a
give’m what they want and
move’m 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.
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)
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
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.
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
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%).
• Don’t feel compelled to prescribe opiates if
you are uncomfortable. OK to get a 2nd
opinion.
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.
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.
Opiate basics
• Diagnosis (try to establish type of pain)
• Care plan
• Regular visits with follow up response to
treatments and documentation
• Written agreement
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
The 4 A’s
•
•
•
•
Analgesia
Adverse effects
Activity
Aberrant behavior
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.
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
Specific opiate issues
• Codeine- 5-10% of Caucasians won’t 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 don’t use it
• Methadone- long half life (90-120 hours) qt
prolongation, arrhythmia's. Check ecg at
start, 1 mo, then yearly
• Avoid dilaudid (hydromorphone).
Duration of action
• Short acting:
–
–
–
–
Hydrocodone/APAP
Oxycodone
Morphine
Codeine
• Long acting:
– Extended release
versions of these meds.
– Methadone
– Fentanyl Patch
– Buphrenorphine
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
Non Opiate adjuncts other
• Anti-inflammatory diet
• Relaxation response/ meditation.
• Exercise