Spotlight Case July 2008 Dependence vs. Pain

2 Source and Credits This presentation is based on the July 2008 AHRQ WebM&M Spotlight Case –See the full article at –CME credit is available Commentary by: Adam J. Gordon, MD, MPH University of Pittsburgh School of Medicine –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Bradley Sharpe, MD –Managing Editor: Erin Hartman, MS

3 Objectives At the conclusion of this educational activity, participants should be able to: Define opioid dependence and opioid withdrawal syndrome Describe the treatment of opioid withdrawal syndrome including the use of Clinical Opioid Withdrawal Scale (COWS) and pharmacologic treatments Appreciate the stigma associated with opioid dependence and the potential impact on the quality of care provided

4 Case: Dependence vs. Pain A 56-year-old man with a long history of heroin use presented to the hospital with abdominal pain, nausea, and vomiting. He said he had been using less heroin than usual because of the gastrointestinal complaints and felt his symptoms were probably from heroin withdrawal. On initial evaluation, he was dehydrated but his vital signs were unremarkable, and his abdominal exam was benign. Complete blood count, liver function tests, amylase, and lipase were all normal. An upright KUB radiograph showed no clear cause for his abdominal pain.

5 Case: Dependence vs. Pain (2) Admitted for treatment of dehydration and opiate withdrawal, the patient was given intravenous fluids, methadone, and low doses of morphine for the abdominal pain. Later in the evening, he complained of increasing diffuse abdominal pain. He also complained of excessive yawning and increased lacrimation. On physical examination, he was tachycardic, tachypneic, and generally restless, but had a non-tender abdominal examination. He was given increased methadone to treat presumed worsening opiate withdrawal.

6 Opioid Dependence Defined as a maladaptive pattern of use of illicit or prescription opioids leading to significant impairment or distress as manifested by the presence of 3 or more of the diagnostic criteria in past 12 months See Notes for reference.

7 Diagnostic Criteria for Opioid Dependence 3 or more of following criteria in past 12 months  Physical dependence  Tolerance  Taking opioids in larger amounts or for longer periods than intended  Desiring to cut down or control use  Dedicating a large amount of time to procure opioids or recover from their effects  Giving up important activities because of use  Using opioids despite knowledge of harm See Notes for reference.

8 Scope of the Problem More than 3 million Americans have used heroin in their lifetime In 2000, up to 1 million individuals addicted to heroin in US 2 million people used prescription pain relievers for non-medical reasons in % of 12 th graders report using hydrocodone within the past year See Notes for references.

9 Medical and Societal Costs Illicit opioid use associated with significant harm to individuals Strains health care system Major medical and psychiatric illnesses often co-exist with opiate addiction, such as depression, hepatitis, HIV Violence and crime can also be associated

10 The Presented Case The patient in the case likely has the disorder of opioid dependence The patient presented with symptoms consistent with classic opioid withdrawal

11 Diagnostic Criteria for Opioid Withdrawal Three or more symptoms that include  Dysphoric (negative) mood  Goosebumps or sweating  Nausea or vomiting  Diarrhea  Muscle aches  Yawning  Runny nose or watery eyes  Fever  Dilated pupils  Insomnia

12 Opioid Withdrawal Symptoms may be severe, cause significant distress, and often impair functioning Many opioid dependent individuals continue to use opiates only to avoid withdrawal Opioid withdrawal is generally managed in the outpatient setting in methadone treatment facilities (licensed Opioid Agonist Therapy [OAT] programs)

13 Treating Opioid Withdrawal Methadone and buprenorphine are available to treat opiate withdrawal and provide longer term maintenance for opiate dependence For patients hospitalized with acute medical illness, primary concern should be stabilizing the patient –Short “detoxification” course of opioids Emerging research has outlined protocols See Notes for references.

14 Issues in Present Case In this case, the provider’s original working diagnosis was opioid withdrawal syndrome Even if this diagnosis is suspected, complete history and physical examination, as well as appropriate lab studies, should be performed

15 Issues in Present Case (cont.) Patient’s yawning, lacrimation, tachycardia, tachypnea, restlessness, and non-tender abdominal exam are consistent with opioid withdrawal However, overt abdominal pain is rare Prescribing intravenous morphine would not be treatment of choice for opioid withdrawal Important to look for other causes of his abdominal pain and worsening condition

16 Other Factors in Diagnosis and Treatment Patients with opioid dependence may present with comorbid conditions such as HIV, Hepatitis C, or skin infections These disorders may require specific treatment, or may influence the treatment of other illnesses

17 Case (cont.): Dependence vs. Pain Despite the methadone increase, the patient’s abdominal pain persisted and worsened. Overnight, a covering physician was contacted about the abdominal pain. The nurse told the physician that the patient had asked for something stronger for the pain.

18 Case (cont.): Dependence vs. Pain Because the daytime physician had earlier described the patient as a “strung-out shooter,” the covering physician believed the patient was either drug seeking through his complaints of pain or not receiving enough methadone. Instead of re-evaluating or re-examining the patient, the covering physician ordered another increase of methadone. The patient continued to have diffuse abdominal pain and tachycardia overnight.

19 Case (cont.): Dependence vs. Pain In the morning, the patient’s abdominal pain became severe, his tachycardia worsened, and his blood pressure decreased—indicating a possible infection (septic shock). The patient was given aggressive intravenous fluids. An abdominal computed tomography (CT) scan revealed a perforated colon, likely from diverticulitis. The patient then underwent successful colonic resection and was discharged from the hospital 2 weeks later.

20 What Went Wrong Patient’s worsening in the face of opioid agonist therapy should have triggered the covering physician to consider another diagnosis Unfortunately, providers may have negative perceptions about patients with alcohol or drug disorders Such stigma may contribute to misdiagnosis or delays in diagnosis, as well as worse health outcomes See Notes for references.

21 Relapse Rates in Chronic Illness Comparing alcohol/drug disorders with other chronic diseases (e.g., diabetes, hypertension), relapse rates to unhealthy behavior are similar Adherence to MD recommendations in hypertension generally poor –< 40% of patients adhere to antihypertensive regimens –< 30% of patients adhere to diet or behavioral changes 50%-70% of patients with hypertension experience relapse of disease annually Similarly, alcohol and other drug use disorders have relapse rates between 40%-60% See Notes for references.

22 Disorder as Chronic Illness Alcohol and other drug disorders may be considered chronic medical illnesses requiring ongoing care and not just “quick fixes” Effective, evidence-based treatments are available, and providers should appropriately screen, identify, and treat these patients

23 Improving Quality of Care for These Patients Improved education in substance abuse disorders for trainees and practicing clinicians may also improve the quality of care Hospitals and health care systems should consider structured mechanisms to ensure appropriate treatment of opioid dependence and opioid withdrawal

24 Take-Home Points Opioid dependence is a chronic, treatable medical condition The clinical opioid withdrawal scale (COWS) can be a useful objective measure of opioid withdrawal Methadone and buprenorphine treatments are available for treatment of both opioid dependence and opioid withdrawal syndrome Providers should be suspicious of atypical presentations of opioid withdrawal and evaluate patients accordingly