META:PHI in Primary Care: Implementing Best Practices for Addictions Managing Opioid Use Disorders in Chronic Pain Patients

What is META:PHI? Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration Collaborative project to implement integrated care pathways for addiction throughout Ontario Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies Goals: Improve care for patients with addictions Improve care provider experience Improve population health Reduce service use Provide sustainable care

How it works Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment RAAM clinics offer substance use disorder treatment on walk-in basis; no formal referral/appointment needed Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required) Key components: Integration of care at hospital, RAAM clinic, primary care Training, support, and mentorship from addictions specialists Capacity-building

Role of PCPs With support from META:PHI team: Follow best practices for prescribing opioids Screen and diagnose patients for substance use disorders Refer patients to treatment at RAAM clinic when necessary Take over long-term addiction care for patients (with ongoing support from RAAM clinic doctor)

Identifying and diagnosing Opioid use disorder (OUD)

OUD in pain patients OUD can occur as a complication of opioid therapy All patients on opioid therapy for chronic pain should be regularly monitored for signs of OUD Risk factors < 40 years old Male Concurrent substance use disorder (alcohol, benzodiazepines, etc.) Active mental illness (depression, anxiety, PTSD, etc.)

OUD DSM-V criteria (1) Impaired control: Opioids taken in larger amounts or for a longer period than intended There is a persistent desire or unsuccessful efforts to cut down or control opioid use A great deal of time is spent obtaining or using opioids, or recovering from their effects There are cravings or a strong desire to use opioids

OUD DSM-V criteria (2) Social impairment: There is recurrent opioid use resulting in a failure to fulfill important role obligations at work, school, or home There is continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids Important social, occupational, or recreational activities are given up or reduced because of opioid use

OUD DSM-V criteria (3) Risky use: There is recurrent opioid use in situations where it is physically hazardous Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is caused or exacerbated by opioids

OUD DSM-V criteria (4) Physiological dependence: Tolerance: There is either a need for markedly increased amounts of opioids to achieve intoxication or desired effect or there is a markedly diminished effect with continued use of the same amount of opioids Withdrawal: There is either characteristic withdrawal syndrome for opioids or opioids are taken to relieve or avoid withdrawal symptoms

Clinical features of OUD in pain patients High opioid dose for underlying condition Aberrant behaviours: Running out early, crushing/biting oral tabs, accessing opioids from other sources Strong resistance to switching or tapering Importance attached to drug outweighs analgesic benefit (e.g., “Pain is 10/10, medication only takes edge off, but I would die if you stopped it”) Binge rather than scheduled use Deteriorating mood and functioning Concerns expressed by friends/family Reports recurrent, frightening withdrawal symptoms May acknowledge immediate mood improvement after dose

Presenting a diagnosis Be clear and non-judgmental Inform patient that their opioid use is harming them and that treatment will improve their pain, mood, and functioning Do not abruptly stop opioid prescribing This puts patient at increased risk of overdose death Give patient harm reduction advice Offer treatment

OUD treatment options

Treatment options Abstinence-based treatment Structured opioid therapy Opioid maintenance therapy

Abstinence-based psychosocial treatment Treatment goal: Cessation of all opioids (sometimes including opioid agonist treatment) Advantages Often preferred by patients to long-term opioid agonist treatment Often provides participants with a sense of community Gives structure to participants’ lives Disadvantages Does not provide physical relief from withdrawal symptoms/cravings, which can last for weeks or months Increased risk of relapse and opioid overdose; patients should be given harm reduction advice

Harm reduction advice (1) Never use opioids alone Make sure you and your friends know the signs of overdose (pinpoint pupils, falling asleep, slowed/stopped breathing, bluish skin around lips or under nails) Always carry naloxone If a friend has overdosed: Shake them and call their name Call 911 Administer naloxone and start chest compressions If you are taking opioids after a period of abstinence (even a few days), take a much smaller dose than you used to

Harm reduction advice (2) Only medications obtained from a prescription and purchased at a pharmacy are guaranteed to be what they are supposed to be Many opioids (and other drugs, such as cocaine) are laced with fentanyl Fentanyl is very potent and can be lethal even in tiny amounts Do not inject opioids Do not mix opioids with other substances, especially alcohol or benzodiazepines

Structured opioid therapy (1) Opioid prescribing under conditions that limit misuse Indications Has or is at high risk for OUD Has pain condition requiring opioid therapy Only uses opioids supplied by one prescriber Does not alter route of delivery (inject/crush oral tabs) Is not currently addicted to alcohol or other drugs

Structured opioid therapy (2) Protocol Taper dose: Typically 10% of total daily dose at each visit, no more than 10% of total daily dose every 1–2 weeks Taper more slowly when 1/3 of total dose is reached Dispense small amounts frequently Do not refill if patient runs out early Monitor with office visits, pill counts, urine drug screens Switch to opioid maintenance therapy if structured opioid therapy fails (i.e., patient continues to use more than prescribed)

Opioid agonist therapy (1) Substitution of illegal and/or euphoria-inducing opioid with longer-acting, less euphoric opioid Relieves withdrawal symptoms/cravings for 24 hours Indications Has OUD Failed at/not a candidate for opioid tapering Acquires opioids from multiple sources (e.g., other doctors, friends/relatives, the street) Alters route of delivery (inject/crush oral tabs) Current risky use of alcohol or other drugs

Opioid maintenance therapy (2) Maintenance therapy has historically used methadone Full, potent opioid agonist Risk of sedation/overdose Requires a federal exemption to prescribe Another option is buprenorphine Partial opioid agonist with a ceiling effect Even very high doses rarely cause respiratory depression (unless combined with alcohol/sedatives) Binds tightly to receptors, displacing other opioids Usually combined 4:1 with naloxone as abuse deterrent Can be prescribed by any doctor in Ontario

Prescribing buprenorphine

Why prescribe buprenorphine? (1) Attending a methadone clinic is not always possible: Patient reluctance No local clinic Long waiting list Larger methadone clinics sometimes have rigid rules (e.g., frequent urine drug screens) and often do not provide counselling or primary care Evidence has demonstrated that buprenorphine in primary care settings is as effective as in specialized settings Patients often prefer receiving buprenorphine from their PCP: Less stigmatizing Patient has close relationship with PCP

Why prescribe buprenorphine? (2) Prescribing buprenorphine to a patient with OUD is much more satisfying than prescribing opioids: Patients usually feel and function better Behaviours associated with OUD (running out early, missed appointments, drug seeking, etc.) usually resolve Patients usually very grateful for PCP’s role in their recovery

Initiation Biggest risk of initiation is precipitated withdrawal Buprenorphine displaces currently attached opioids Causes rapid onset of intense withdrawal Not medically dangerous but can deter patients from treatment Before first dose, patient should have no opioid in serum and be in moderate withdrawal Measure withdrawal using Clinical Opioid Withdrawal Scale (COWS)

COWS Resting heart rate 1 2 4 Sweating 3 Restlessness 5 Pupil size (≤ 80) 1 (81–100) 2 (101–120) 4 (121+) Sweating 3 Restlessness 5 Pupil size Bone/joint aches Runny nose/tearing GI upset Tremor Yawning Anxiety/irritability Gooseflesh skin TOTAL 5–12 13–24 Mild Moderate 25–36 37+ Moderately severe Severe

Initiation protocol (1) At least 12 hours since last oral dose Patient reports typical withdrawal symptoms COWS score 12+ First dose: 4 mg SL (takes several minutes to dissolve) Reassess in 2 hours If patient improved but still in withdrawal, give another 4 mg to take in office or at home Maximum dose first day: 12 mg

Initiation protocol (2) Office induction is preferred to ensure patient does not go into precipitated withdrawal If patient cannot attend for office induction, write prescription (2 mg SL q4H PRN, up to 6 tabs over 24 hours, x 1–3 days) and give patient clear instructions: Wait at least 12–16 hours since your last opioid use Make sure your COWS score is at least 12 (give scale) Put 2 tablets under your tongue and let them dissolve Wait 2 hours and measure your COWS score again If still in withdrawal, take another 2 tablets Do not take more than 6 tablets (12 mg) in first 24 hours Next day: Take total first-day amount as single dose

24h Titration Reassess in 1–3 days Increase dose by 2–4 mg at each visit if patients reports withdrawal symptoms/cravings near end of dosing interval Optimal dose should relieve withdrawal symptoms/cravings for 24 hours without significant sedation or other side effects Optimal maintenance dose: 8–16 mg SL OD Maximum maintenance dose: 24 mg SL OD Arrange frequent office visits for counselling and urine drug screen monitoring Screen for presence of norbuprenorphine/absence of other opioid metabolites 24h

Dispensing If possible, buprenorphine should initially be dispensed daily and taken under pharmacist’s observation Especially important if patient has been accessing opioids from other sources Take-doses should be prescribed when patient is at optimal dose and has stopped unauthorized use Consider early take-home doses if patient… Acquires opioids only from physician Does not inject or crush oral opioid tablets Does not buy, sell, or use illicit drugs

Prescriptions Specify pharmacy and send by fax Specify observed and take-home doses

At each office visit Ask about withdrawal symptoms or cravings Sometimes minor dose adjustments required (2–4 mg) Perform urine drug screens Ask about alcohol and cannabis use (usually not tested on urine drug screen) Ask about overall mood and functioning Manage chronic medical conditions (e.g., hepatitis C) or psychiatric conditions (e.g., anxiety, depression) Perform regular screening and health maintenance (e.g., pap tests, mammograms, immunizations, etc.)

Buprenorphine failures Buprenorphine is effective for many patients However, in some cases, it does not fully relieve withdrawal symptoms or suppress opioid use If patient continues to experience withdrawal symptoms/ cravings or use illicit opioids despite an adequate dose of buprenorphine, refer to a methadone clinic that provides high-quality care

Tapering buprenorphine Indications Wants to taper At least six months without any substance use Socially stable, supportive family or social network Stable mood, good coping strategies Protocol Decrease by small amounts (1–2 mg) Leave at least two weeks between dose decreases Hold taper at patient’s request Return to original dose if opioid use restarts Provide regular support and encouragement: it is not a “failure” if taper has to be held/reversed

Wrap-up: Key Messages

Our responsibility Treating addicted patients is our responsibility as health care providers Addiction can occur as a complication of opioid therapy Addiction is the same as any other chronic illness: patients need specialist referrals, medication, treatment of co-occurring conditions, and regular follow-up Effective addiction treatments are available Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

Resources META:PHI website: www.metaphi.ca META:PHI mailing list for clinical questions and discussion (e-mail sarah.clarke@wchospital.ca to join) META:PHI contacts: Medical lead: Dr. Meldon Kahan meldon.kahan@wchospital.ca Manager: Kate Hardy kate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca