Transcript Inflammatory depression: Teasing out precipitating versus

Preventing and treating narcotic dependence in
our IBD patients
Eva Szigethy MD, PhD
Associate Professor of Psychiatry, Pediatrics and Medicine
Director, Visceral Inflammation and Pain (VIP) Center
Division of Gastroenterology
[email protected]
Szigethy: Disclosures
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Grants: NIMH, NIH, CCFA
Consultant: Merck, Abbvie, iHope Networks
Royalties: APPI
Honorarium from GI Health
• Off-label drugs will be discussed and identified
as such.
Objectives: Opioids for Chronic
Abdominal Pain in IBD
• Rates of use
• Benefits of use
• Risks of use
• Alternatives
Pain: Fifth Vital Sign
• Pain standards of the Joint Commission on
Accreditation of Healthcare Organizations
– Pain assessment/management a priority in daily
practice
– Pain intensity, temperature, pulse, respiration, BP
– Patients’ rights: full pain work-up when pain is not
easily characterized or treated
JCAHO 1999,2000; IOM 2011
Negative aspects of pain as a 5th vital sign
• Increasing prescription drug abuse and deaths
• Unclear that increased opioid use has resulted in
proportional improvement in management of pain
Mehendale et al., 2013
Opioids- what?
• Opioid receptors: G proteincoupled receptors throughout
body
• Mu (analgesia, GI)
• Delta (GI, respiratory)
• Kappa (dysphoria, sedation)
• Natural (morphine)
• Semi-synthetic (heroine,
oxycodone, hydromorphone)
• Synthetic (fentanyl)
Opioid Use in IBD
• Used acutely after surgical resection of the
intestinal tract and to treat pain due to
inflammation/obstruction in IBD.
• 5–21% of patients with IBD are on chronic
narcotics in the outpatient setting.
• 20-70% inpatients with IBD use narcotics
• Risk factors: CD, substance abuse, psychiatric
diagnoses, IBS, history of trauma, female gender
Edwards 2001; Cross 2005; Hanson 2009; Long 2011; Szigethy 2014
Benefit of Opioids for chronic noncancer pain?
• Limited evidence of efficacy for neuropathic
pain and chronic back pain and headaches.
• No studies supporting efficacy of long-term
opioids for chronic abdominal pain.
• Poor outcomes and high side effects for
chronic opioid use for break-thru pain.
Kalso 2007; Chao 2009; Manchikanti 2011; Fine et al., 2010; Devulder et al., 2009
Opioid Side Effects
• Side effects
– Nausea/vomiting
– Sedation
– Constipation
– Urinary retention
– Pruritis
Opioids- Risk
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Physical dependence
Addiction
Overdose/death
Tolerance: Repeated exposure leads to reduced
therapeutic effect
• Opioid-induced hyperalgesia: enhanced pain
response to opioids (narcotic bowel syndrome).
– Biphasic mu receptor
– NMDA (glutamate) activation
– Spinal inflammation
Fernanes 1977; 1997; Vinik 1998; Chu 2006; Hay 2009; Ossipov 2003; Drossman & Szigethy,
2014; Grunkemeimer 2009; Kurlander 2014
Opioid risk management
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State rules and regulations
Random toxicology screens and pill counts
Opioid treatment agreements
Communication with PCPs and pharmacies
Ongoing review and documentation of pain relief,
functional status
• Risk assessment instruments: SOAPP-R (Screener
and Opioid Assessment for Patients w/Pain),
COMM (Current opioid misuse measure), ABC
(Addiction behaviors checklist)
• Take home message- have a risk
management plan
Non- Opioid Pain Management
‘Chronification’ of Pain as a Disease
Pathology:
Pathophysiology of Maintenance:
-Muscle atrophy,
weakness;
-Bone loss;
-Immuno-compromise
-Depression
-Radiculopathy
-Neuroma traction
-Myofascial sensitization
-Brain, SC pathology (atrophy, reorganization)
Psychopathology
of maintenance:
-Encoded anxiety
dysregulation
- PTSD
-Emotional
allodynia
-Mood disorder
Acute injury
and pain
Central
Sensitization
-Neuroplastic
changes
Disability
-Less active
Neurogenic
Inflammation:
- Glial activation
- Pro-inflammatory
cytokines
- blood-nerve barrier
dysruption
Peripheral
Sensitization:
New Na+ channels
cause lower threshold
-Kinesophobia
-Decreased
motivation
-Increased
isolation
-Role loss
RM Gallagher, Pain Med,
2009
Education about Brain-Gut-Pain Connection
PSYCHOLOGICAL
Mood
Cognitions
Suffering
Disability
Suicide
PHYSICAL
Inflammation
Obstruction
Surgery
Peripheral
nerve
damage
Srinath and Szigethy 2012
Psychosocial Interventions
• Cognitive behavioral therapy (CBT) reduced
arthritis pain, fibromyalgia, IBS, headaches
• Meditation and mindfulness techniques
reduce pain perception and suffering.
• Hypnosis improved acute and chronic pain
across a variety of conditions including IBS and
IBD.
• Need adequate dose- 8-12 sessions
Astin 2002,Knittle 2010, Glombiewski 2010; Andrasik 2007; Elkin 2007; Kok 2013;
Tang 2013; Palsson & Whitehead 2014; Patterson & Jensen, 2003
Pharmacological (off-label): Visceral Pain
CLASS
TYPE
MECHANISMS for PAIN CONTROL
Antidepressants
TCAs
Increased NA, SE, endogenous
opioid release, anti-inflammatory?
SNRIs
Stimulants
Methylphenidate
D-amphetamine
Influence NE, SE, DA, endogenous
opioids
Mood stabilizers Gabapentin/pregabalin Central voltage-gated calcium
channels?
Atypicals
Quetiapine?
DA, SE, Adrenergic antagonism
Glutaminergic
Memantine ?
Glutamate antagonism
Antiinflammatory
Doxcycline ?
Central or peripheral inflammation
Ford, 2008; Drossman 2002; Taylor 2007; Houghton 2011; Grover 2009; Szigethy and
Drossman, 2014
Rational Approach to Chronic pain
• Address false expectations or beliefs of patients
• Provide neurobiological explanation of patient’s
symptoms
• Provide information/rationale aligned with
patient’s interests/concerns
• Negotiate treatment plan
– Benefit in 4-6 weeks
– Most side effects decrease in 1-2 weeks
– Consider previous drugs that works and family history
of drug response
• Doctor-patient relationship key
Procedural Interventions for Chronic
Abdominal Pain ???
• Nerve blocks
• Surgical Interventions- ablation
• Infusion- pumps and intrathecal
• Stimulation units
• Acupuncture
Algorithm for Opioid Detoxification for Patients with Narcotic
Bowel Syndrome in IBD
• Build a strong therapeutic relationship to improve motivation and
reduce resistance.
Phase 1 • Teach behavioral interventions for pain management
Outpatient • Begin appropriate alternative non-opioid pain medications (TCAs,
SNRIs, SSRIs)
Phase 2
Inpatient
• 10-33% daily reduction of i.v. morphine equivalent
• Clonidine for withdrawal symptoms; Benzodiazepines for extreme
anxiety
• Continue non-opioid pain medications (TCAs, SNRIs, SSRIs)
• management of bowel motility
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Phase 3
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Outpatient •
Continue behavioral interventions
Continue non-opioid pain medications
Treat comorbid psychiatric symptoms and conditions
COORDINATION WITH IBD MEDICAL TEAM
Drossman and Szigethy, 2014 in press
Abdominal pain scores improve but high
recidivism (Phase 2 only)
60
50
Visual
Analog
Scale
(0-100)
40
30
20
10
0
Pre-detoxification
Post-detoxification
Stayed off
narcotics
Went back on
narcotics
n=39
n=37
n=13
n=10
Drossman DA et al. Am J Gastro 2012;107:1426
3 month follow-up
Challenging clinical situations in
managing chronic pain
• Misrepresent symptoms
• Failure to comply with
medical directives
• Repetitive failure of
response to
interventions
• Time-consuming
• Induce “difficult
feelings within the
clinician.
Hahn 2000; Jackson 1999; Koekkoek 2011
• Severe Axis I
psychopathology
• “Abrasive” personality
traits (Axis II clusters B &
C)
• Childhood adversity
(“primed nervous system”)
• < 10% of our
patients…but…
Managing Challenging Clinical Situations:
Suggestions
• Clear explanation of expectations from treatment onset
• Empathic listening and repeat back what you heard
• Setting consistent limits and clear verbal and written
instructions
• Validate anger but redirect toward their helplessness not their
helpers
• Re-channel entitlement into realistic expectations of good
care
• Arrange regular appointments not based on worsening.
• Manage your countertransference
Groves, 1978
So can Prometheus be unbound?
Yes with interdisciplinary approach
Opioid overuse pain syndrome (OOPS)- Mehendale et al., 2013