Transitioning a Pain Program Away From Chronic Opioid Prescribing

Steve (Stephen Z. Hull, M.D.)

Transitioning a Pain Program Away From Chronic Opioid Prescribing

30% of patients prescribed opioids chronically become addicted % demonstrating observed signs of addiction (Fishbain DA, et.al. Pain Medicine 2008;9(4):444–459.)

January 4, 2011 Maine plagued by painkiller habit A growing epidemic of abuse is behind an addiction treatment rate that is eight times the national average. By John Richardson State House BureauJohn Richardson

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: November 18, 2010November 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)

Ten-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life and health care utilization Study Limitations Denmark has the highest use of opioids in the world Cross-sectional epidemiological research, cannot be established a causal relationships

Ten-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life and health care utilization “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…"

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

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 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.

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 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 diagnosis 2.Exhaust interventional options 3.Functional rehabilitation a.Physical therapy/exercise b.Cognitive behavioral therapy c.Adaptive equipment d.Lifestyle change e.Medication management

Evolution Interdisciplinary Biopsychosocial Rehabilitation and Medically Managed Opioid Withdrawal

1.Patient selection evaluations a.Physiatry/pain medicine evaluation b.Psychiatry/psychology evaluation c.Addiction medicine evaluation

1.Patient selection evaluations 2.Treatment program a.2 ½ hour treatment days I.1 hour of cognitive behavioral therapy (Health and Behavior codes) II.¼ hour mindfulness exercise III.1 hour of physical exercise (Group Medical Visit coding) IV.¼ hour homework assignment

1.Patient selection evaluations 2.Treatment program a.2 ½ hour treatment days b.12 week program I.Orientation/foundational training week II.Treatment weeks i.5-week opioid taper ii.5-week opioid free III.Discharge planning week c.Open ended aftercare program

Treatment Team: 1.Patient 2.Family 3.Physiatrist/pain physician 4.Psychiatrist 5.Psychologist 6.Addiction medicine provider 7.Nurse Practitioner 8.Registered nurse 9.Physical therapy assistant/exercise instructor 10.Medical assistant 11.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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