Treating Acute Pain in Patients with Opioid Use Disorder ......•Stigma (Chronic pain, addiction)...
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Treating Acute Pain in Patients with Opioid Use Disorder in the Emergency Department Dr. Maureen Allen CCFP-EM(PC) FCFP Assistant Professor Emergency Medicine Dalhousie university March 7-8, 2019
Transcript of Treating Acute Pain in Patients with Opioid Use Disorder ......•Stigma (Chronic pain, addiction)...
Treating Acute Pain in Patients with Opioid Use Disorder in the Emergency
Department
Dr. Maureen Allen CCFP-EM(PC) FCFP
Assistant Professor Emergency Medicine
Dalhousie university
March 7-8, 2019
No Disclosure
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What I Hope You Learn:
• Approach to acute pain in patients receiving opioid agonist therapy. (Methadone/Suboxone)
• Risk management strategies to minimize harm.
• Common barriers to effective pain management in the emergency department.
Rick
• 47 yo male
• Dx: FOOSH: Colle’s fracture
• Hx: IVDU, HCV +, OUD (Beganwith non-medical use)
• Rx: Methadone 125mg (Daily witnessed)
• UDT: +EDDP, +BZD
Shelly
• 32 yo mother of 3
• Dx: Appendicitis
• Hx: Opioid use disorder (Began with medical use), CNCP (Fibromyalgia)
• Rx: Suboxone 24mg SL
• UDT: + Bup
How we MANAGE PAIN MATTERS!!!
• Undertreatment can contribute to significant morbidity
• Overuse of high risk medications can also contribute to morbidity and death (opioids, BZD, sedative-hypnotics)
• It’s also about the “tools” or “habits and behaviours” we give patient’s to manage their suffering
Managing safety Managing
suffering
Oyler DR, et al. Non Opioid Management of Acute Pain Associated with Trauma: Focus on Pharmacological Options. J Trauma Acute Care Surg.
79(3):475, September 2015
Barriers to effective Pain Management in the Emergency Department
• Tools (Pain scales)
• Stigma (Chronic pain, addiction)
• Language, vocabulary (“addict”, “drug seeking”)
Mendiola CK, et al. An Exploration Of Emergency Physicians’ Attitudes Toward Patients With Substance Use Disorder. J Addict Med 12(2):132, March/April 2018
2010: Framework
STEP 1 View pain scales as SUFFERING scales
STEP 2 What TYPE of pain
ACUTE PAINAcute Pain Protocol
CHRONIC PAIN CHRONIC PAIN
FLARE-UP
CANCER PAIN OR PAIN AT EOL
PALLIATIVE CARE SERVICES
STEP 3Any interventions
indicated?
STEP 4Any alternative
therapies indicated?
STEP 5 What medication is available?
STEP 6Are there concerns of
problematic use, addiction or diversion?
Allen MA. A Community based-approach to the treatment of Pain and Addiction. Canadian Journal of Rural Medicine. 2014. 19(1)Allen MA, Jewers MH, McDonald JS. A Framework for the Treatment of Pain and addiction in the Emergency Department. Journal of Emerg Nursing. November. 2014.
What is the RISK of Opioid use disorder when opioids are used to manage Acute Pain ?
NNH1:7864
ADDICTION needs:1. Time
2. Repetition3. Vulnerable brain DIVERSION more of a
concern
Heins SE, et al, EARLY OPIOID PRESCRIPTION AND RISK OF LONG-TERM OPIOID USE AMONG US WORKERS WITH BACK AND SHOULDER INJURIES: A RETROSPECTIVE COHORT Injury Prev 22(3):211, June 2016
BIOLOGY/GENES ENVIRONMENT
DRUG/SUBSTANCE
BRAINMECHANISM
ADDICTION
Risk Factors Contributing To SUD• Chaotic home• Parent’s use and
attitudes• Academic• Role models
• Early use• Availability• Cost
• Genetics• Gender
• Route of administration• Effect of drug• “Clinical inertia”
• Mental health disorders• Brain memory
Individuals with a Lived Experience of ADDICTION FEAR
WITHDRAWAL
WORSENING PAIN
The Pain-Addiction-Anxiety Pathway: Alarm state
The Brain Decides“Amygdala” (Neighbour hood watch)
Fight, flight, freeze
The Amygdala is driven by….
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FEAR (ANGER) UNCERTAINTY UNPREDICTABILITY
As a Health care provider you can…
•Make them feel safe and cared for• Prepare them for what to
expect•Reassure them (manage pain
and prevent withdrawal)• But also..manage expectations
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Acute Pain
• More about tissue damage or potentialdamage
• Has the acute warning function of physiological nociception
• 0-3 months
• Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003. • Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.
Time
PainIntensity
10
00/10
3 monthsInjury
Illness
Surgery
Unknown
Chronic “persistent” pain
• More about CNS
• Pain that persists beyondthe expected time of healing that lacks the acute warning function of physiological nociception
• > 3 months
Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003. Treede RD, Rief W, Barke A et al. A classification of chronic pain for ICD-11. Pain. 2015 Jun; 156(6): 1003-1007.Treede RD, Jensen TS, Campbell JN et al. Neuropathic pain: redefinition and a grading systems for clinical and research purposes. Neurology 2008:70: 1630-5.
PainIntensity
TimeInjury
Illness
Surgery
Unknown
10
0
>3 months
5/10
Chronic Pain “Flare-up”
• NOT caused by a new condition or progression of a pre-existing condition
• Investigations unchanged
• Often confused with ACUTE pain
PainIntensity
Time
0InjuryIllnessSurgeryUnknown
Daily baseline pain5/10
Flare-up Pain15/10
• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.
• Belgrade M, St. Marie B. Understanding and Managing Flares in Chronic Pain. Fairview Pain Management Centre.
PHARMACOLOGY TREATMENT GOALS
ACUTE PAIN
80-90% Pain reduction
Minimize Sedation
Improve Function
CHRONIC PAIN AND
CHRONIC PAIN FLARE-UP
30-40% Pain reduction
Avoid Sedation
Improve Function
CANCER PAIN OR PAIN AT THE END OF
LIFE
80-100% Pain reduction
May Cause Sedation
May Compromise Function
Treatment goals
Managing Pain in Patients Receiving Medical Assisted Therapies for OUD
• Opioid agonist(Methadone, Suboxone)
METHADONE
• Synthetic mu agonist
• Developed by the German’s in WW 2
• Potency misunderstood
• 1960’s resurfaced (opioid/heroin addiction)
• Inexpensive Analgesic
Antitussive (Prolong QTc)
Properties
• Mu and delta receptor agonist
• NMDA receptor Antagonist
• Inhibits re-uptake of norepinephrine and serotonin (SNRI)
Lynch ME. Pain Res Manag 2005: 10(3):133-44
X
Confusion regarding clinical use
Methadone
Addiction
Cravings and withdrawal
90-120mg
Chronic pain
Function
45mg
EOL
Pain
30-35mg
Pharmacokinetics
• Oral bioavailability 80%
• Lipophilic (PO; SL; PR; Buccal)
• Rapid absorption (Analgesic effect 30-60 minutes)
• 60-90% protein bound
• Steady state ~10 days
• Metabolized in liver to INACTIVE metabolites
• Excreted thru gut and kidneys unchanged
Challenges and controversy’s
• Prolonged QTc (marker for TdP)
• Central sleep apnea
• Low testosterone
• Stigma
QTc in MMT: Cochrane Review: 2013
• To evaluate the efficacy and acceptability of QTc screening to prevent cardiac-related morbidity and mortality in Methadone Maintenance Therapy (MMT).
• 872 pertinent records.
• Their finding:
• “No evidence has been found to support the use of the electrocardiogram (ECG) for preventing cardiac arrhythmias in methadone-treated opioid dependents.”
The Cochrane study, at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008939.pub2/abstract
Cochrane Review cont’d
• QTc prolongation is “not a safety concern per se,” but a “sharply imperfect” surrogate marker for the risk of TdP.
• A QTc longer than 500 milliseconds—considered the threshold of increased danger—is found in about 2 percent to 16 percent of MMT patients.
• But the prolongation isn’t necessarily due to methadone; liver disease, low potassium levels, and therapy with a variety of drugs also prolong QTc.
The Cochrane study, at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008939.pub2/abstract
Buprenorphine-Naloxone (Suboxone)
• Partial mu-opioid agonist
• High affinity (prevent binding of other mu agonist making them less effective)
• To over ride this you need strong conventional opioid at higher than normal dosing
• Naloxone (tamper resistant)
Buprenorphine-Naloxone
• Ceiling effect to both it’s euphoriant potential and it’s toxicity
• Safe-er in overdose
Managing Pain: Important principles for Patient’s on OAT
• CONTINUE opioid agonist therapy
• Establish realistic Goals of care
• Consider “split-dosing” OAT (stable, close oversite)
• What if they can’t swallow?
• Retrospective case series
• 2013-2015
• 30 patients
• Palliative care program
• Rural community, hospital and nursing home
• Oral to atomized dosing the same
• 10mg/ml; 50mg/ml
Interventions
• Clinical actions that have the ability to modify the pain experience
Alternative therapies
• Therapeutic practices that have the healing effects of medicine but are not based on a scientific model
ACUPUNCTURE VS INTRAVENOUS MORPHINE IN THE MANAGEMENT OF ACUTE PAIN IN THE ED Grissa, M.H., et al, Am J Emerg Med 34(11):2112, November 2016
Medications
• Elia N, Lysakowski C, Tramer MR. Does multimodal analgesia with acetaminophen, nonsteroidal anti-inflammatory drugs, or selective cyclooxygenase-2inhibitors and patient-controlledanalgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296-304.
• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.• Belgrade M, St. Marie B. Understanding and Managing Flares in Chronic Pain. Fairview Pain Management Centre.
How Complicated can it be?
Pharmacological choices• Acetaminophen (Tylenol)
• NSAID’s (Advil, Aleve etc)
• TCA (Elavil)
• Anticonvulsants (Lyrica, Gabepentin)
• Broad spectrum antidepressants
(Duloxetine, Effexor)
• Calcitonin
• Topicals
• Opioids
• Cannabinoids
• Lidocaine, Ketamine etc...
• Low dose naltrexone
• Gamma hydroxybutyrate (GHB)
• Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.• CALCITONIN FOR TREATING ACUTE PAIN OF OSTEOPOROTIC VERTEBRAL COMPRESSION FRACTURES: A SYSTEMATIC REVIEW OF RANDOMIZED, CONTROLLED TRIALS Knopp, J.A., et al, Osteoporosis
Int 16:1281, October 2005• *CHOICES BEFORE OPIOIDS for CNCP: DALHOUSIE CPD Academic detailing service, April 2018. http://www.medicine.dal.ca/departments/core-units/cpd/programs/academic-detailing-service.html
Multi-modal Analgesia: Acetaminophen and NSAID’s
• Cochrane data base• Moore, (2015)• Pain reduction at 6 hours• Several analgesia (OTC)• Most effective was a combination
(SA) (Acetaminophen 500mg/Ibuprofen 200mg) NNT: 1:6 (Success rate 67%)
• If you double the dose NNT 1:5 (Success rate 70%)
• Single dose medication (Ibuprofenbetter than Acetaminophen)
• Moore RA, et al. Non-prescription analgesic(OTC) oral analgesic for acute pain-an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015 Nov 4;1(11): CD010794 PMID: 26544675.• Chang AK, et al. Effect Of A Single Dose Of Oral Opioid And Nonopioid Analgesics On Acute Extremity Pain In The Emergency Department. JAMA 318(17):1661, November 7, 2017
Multi-modal Analgesia: Low dose Ketamine (LDK)
• Gottlieb, (2018)• Meta-analysis• 8 articles. Total 609 patients. (6 RTCTs
and 2 observational)• Dose range LDK was 0.1-0.5mg/kg IV.
Comparative group was IV Morphine 0.05-0.1 mg/kg)
• Results: No significant difference in pain scores at 30min
• Increase adverse events LDK group (15.4% vs 4.4%) agitation, hallucination that were self-limited
• Gottlieb M, et al. Is Low-Dose Ketamine An Effective Alternative To Opioids For The Treatment Of Acute Pain In The Emergency Department? Ann Emerg Med 72(2):133, August 2018
Multi-modal analgesia: Calcitonin for compression fractures
• Knopp, (2012)
• Systematic review and meta-analysis
• Acute and Chronic pain
• 5 RTCs
• 246 patients
• IM/IN/PR (Salmon calcitonin)
• Effective analgesia acute pain not chronic
• Few side-effects
• Cost and optimized dosing not evaluated
• IN spray: 50-100mcg daily
• Knopp JA, et al. Calcitonin for treating acute and chronic pain of osteoporotic vertebral compression fractures: A Systematic Review of Randomized Controlled Trials.Osteoporosis. Int 16:1281, October 2012
If Discharged: How much opioid and for how long?
• It depends
• Chai et al (2017)
• Acute fracture in 15 opioid-naïve patients (mean age 45 years; 60% male)
• As few as six pills (5mg oxycodone) may be sufficient for acutely painful conditions
Chai PR, et al. Oxycodone Ingestion Patterns In Acute Fracture Pain With Digital Pills. Anesth Analg 125(6):2105, December 2017
If Opioids used: How much and for how long?
• Duration (3 days)
• Quantity (<10)
• Non-euphoriant
• Non-combination
• Oxycodone; Hydromorphone (More euphoriant)
• Recommended: IR Morphine
• Daily witnessed dispensing
How much SA opioid is enough for BTP?
• It depends….
• What else is in the mix?
• Hypnotic-sedatives?
• Liver or Renal Disease?
• Elderly?
• 1-1.5 times normal dosing
Managing safety Managing
suffering
Oyler DR, et al. Non Opioid Management of Acute Pain Associated with Trauma: Focus on Pharmacological Options. J Trauma Acute Care Surg.
79(3):475, September 2015
Rick
• 47 yo male
• Dx: FOOSH: Stable Colle’s Hx: IVDU, HCV +, OUD (Began with non-medical use)
• Rx: Methadone 135mg (UDT +EDDP +BZD)
• Pain intensity 6/10
Talking Points (Pain Specific)
Interventions: Splinting early
Alternative Therapies: Breath, acupuncture
Medications: Procedural sedation (Fentanyl, propofol)
Risk Management (Safety) Morphine IR, Tylenol, NSAID, Bowel regieme
ACUPUNCTURE VS INTRAVENOUS MORPHINE IN THE MANAGEMENT OF ACUTE PAIN IN THE ED Grissa, M.H., et al, Am J Emerg Med 34(11):2112, November 2016
Shelly
• 32 yo mother of 3
• Dx: Appendicitis
• Hx: Opioid use disorder (Began with medical use), CNCP (Fibromyalgia)
• Rx: Suboxone 24mg SL (UDT + cocaine)
• Pain intensity 12/10
Talking Points (Pain Specific)
Interventions: Anesthesia (blocks)
Alternative Therapies: Breath, distraction
Medications: (Fentanyl, IV Morphine)
Risk Management (Safety) Morphine IR, Tylenol, NSAID, Bowel regime
Summary
• How we talk with patient’s about pain matters
• Develop a systematic approach to pain
• Communicate, communicate, communicate!!
• Be open, curious and non-judgemental
• Manage risk with the patient to keep them and the community safe
Managing safety Managing
suffering
The complexity of pain andsuffering
PHYSICAL
SOCIAL SPIRITUAL
TOTAL PAIN
Kross E, Berman M, Mischel W, et al. (2011) Social rejection shares somatosensory representations with physical pain. Proceedings ofthe National Academy of Sciences, 108, 15: 6270-6275.
EMOTIONAL
VIEW PAIN SCALES as
SUFFERING SCALES
Talking Points
• Listening
• Acknowledging suffering
• Re-framing role of pain
• Reassuring (cared for)
• Recognizing that the pain experience is Influenced by many factors
Pain scales..
• CTAS: “Sets the tone”• Can lead to stigma and over
medicating• Accurately reflects the
intensity of pain the patient is experiencing (subjective)
• Don’t always tell us what’s going on in the patient’s tissue
• Why is this?
Opioid Use Disorder: Extent of the problem
TOTAL # OF CANADIAN DEATHS
FROM SARS
44
CANADIAN DEATHS PER WEEK FROM OPIOID
OVERDOSE
49
Reality Check
• Fatalities are on the rise
• ¾ Fentanyl or Fentanyl analogues (2013: <300 deaths/year, 2018: ~1000 )
• Increase in male 30-39 years
• 94% accidental (unintentional)
Mortality trends
• Increase shift toward 1st time users
• Those with CNCP (Historically LT drug users
• Canadian seniors: 30% of all deaths in 2017 >50 yo
• >65yo had highest rate of hospitalizations (stay longer >8d)
Talking to patients about Pain
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Universal
Majority(Pain experiences)
OK
Some(Pain experiences)
“Disruptive pain experience”
Persistent (chronic) pain
• 1:5 (1:4 elderly)• ~200,000 NS• ~30,000 PEI• ~190,000 NB
Survival
Pain circuitryre-wired
(neuroplasticity)
What Tools do we have to manage pain?
• “Talking Points”
• Interventions
• Alternative therapies
• Medication
• Breath
• Safety: Risk stratification
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