Opiate Use in the Treatment of Chronic Pain

Michael C. Welch, MDJames Ansel, PhDOctober 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