Transitioning a Pain Program Away From Chronic Opioid Prescribing.

Transitioning a Pain ProgramAway From

Chronic Opioid Prescribing

Steve(Stephen Z. Hull, M.D.)[email protected]

Transitioning a Pain ProgramAway From

Chronic Opioid Prescribing

• 30% of patients prescribed opioids chronically become addicted.

• 0.19-3.7% demonstrating observed signs of addiction (Fishbain DA, et.al. Pain Medicine 2008;9(4):444–459.)

January 4, 2011

Maine plagued by painkiller habitA growing epidemic of abuse is behind an addiction treatment rate that is eight times the national average.

By John Richardson [email protected] House Bureau

• 26% for purposeful oversedation • 39% for increasing dose without prescription • 8% for obtaining extra opioids from other doctors• 18% for use for purposes other than pain • 20% for drinking alcohol to relieve pain• 12% for hoarding pain medications

Michael Von Korff, ScD, Annals of Internal Medicine, 6 September 2011

Perspective

A Flood of Opioids a Rising Tide of Deaths

Susan Okie, M.D.N Engl J Med 2010; 363:1981-1985 November 18, 2010

National Center for Injury Prevention and Control

Chief Judge John A. Woodcock, Jr. – U.S. District Court, District of Maine

Federal Criminal Law

• No end organ toxicity• No ceiling dose• Safer and more effective than OTCs

• Addiction• Respiratory depression and overdose death• Endocrinologic dysfunction• Immune dysfunction• Opioid induced hyperalgesia

• There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks.

Major Study Limitations• Used placebo comparators• Invariably excluded patients at high risk of serious

adverse events • Trials that have been completed were generally short

term (<16 weeks)

• There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks.

• The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients.

Ten-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life

and health care utilization

Opioid Users had:•Higher pain levels•Poorer self-rated health•Higher unemployment•Greater use of the healthcare system•More maladaptive coping skills •Lower health-related quality of life (SF-36)



Study Limitations•Denmark has the highest use of opioids in the world•Cross-sectional epidemiological research, cannot be established a causal relationships



“It is remarkable that opioid treatment of long-term/chronic noncancer pain does not seem to fulfill any of the key outcome opioid treatment goals…"



“It is remarkable that opioid treatment of long-term/chronic noncancer pain does not seem to fulfill any of the key outcome opioid treatment goals: pain relief, improved quality of life, and improved functional capacity."

A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with

opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission

•At admission patients using opioids reported significantly greater pain severity and depression.•Significant improvement was found on all outcome variables following treatment and six-month posttreatment regardless of opioid status at admission.

Outcome Variable Non Showing Differences•Depression •Pain catastrophizing •Pain interference •Perceived control over pain/life •General activity •Health perception •Physical functioning •Social functioning•Role limitations related to physical problems•Role limitations from emotional factors



•At discharge, patients taking higher doses continued to report significantly greater pain severity than the non-opioid group. •Patients in the opioid cohort who completed rehabilitation and opioid withdrawal maintained treatment gains comparable to those in the non-opioid cohort.



Study Limitations•Self-selection bias•Methodology of this study precluding causal inferences suggesting patients’ functioning improved because of the opioid withdrawal

Chronic Noncancer Pain Rehabilitation With Opioid Withdrawal: Comparison of Treatment

Outcomes Based on Opioid Use Status at Admission

•No significant pretreatment differences were found between the opioid and nonopioid group regarding demographics, pain duration, treatment completion.•No significant differences were found regarding all outcome variables, including pain severity, between the opioid and nonopioid group.

Multidisciplinary rehabilitation for chronic low back pain: systematic review

•Twelve randomized comparisons of multidisciplinary treatment and a control condition.•Strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments.•Moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain.

History

Interventional Pain Management

and

Medical Pain Management

1. Confirm diagnosis2. Exhaust interventional options

3. Functional rehabilitationa. Physical therapy/exerciseb. Cognitive behavioral therapyc. Adaptive equipmentd. Lifestyle changee. Medication management

1. Patient selection evaluationsa. Physiatry/pain medicine evaluationb. Psychiatry/psychology evaluationc. Addiction medicine evaluation

1. Patient selection evaluations2. Treatment program

a. 2 ½ hour treatment daysI. 1 hour of cognitive behavioral therapy

(Health and Behavior codes)II. ¼ hour mindfulness exerciseIII. 1 hour of physical exercise

(Group Medical Visit coding)IV. ¼ hour homework assignment

1. Patient selection evaluations2. Treatment program

a. 2 ½ hour treatment daysb. 12 week program

I. Orientation/foundational training weekII. Treatment weeks

i. 5-week opioid taperii. 5-week opioid free

III. Discharge planning weekc. Open ended aftercare program

Treatment Team:1.Patient2.Family3.Physiatrist/pain physician4.Psychiatrist5.Psychologist6.Addiction medicine provider7.Nurse Practitioner8.Registered nurse9.Physical therapy assistant/exercise instructor10.Medical assistant11.Support staff

Medically Managed Opioid Withdrawal

•Pretreatment detox•Supported progressive taper (5-weeks)

• Adjuvant medication management• Suboxone induction and rapid taper

•Suboxone induction and maintenance

MJ Christie, Cellular neuroadaptations to chronic opioids: tolerance, withdrawal and addiction. British Journal of Pharmacology (2008) 154, 384–396

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Transitioning a Pain Program Away From Chronic Opioid Prescribing.

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