1. Managing Chronic Pain Clinical Pearls and Practical Tools Dan Berland, MD, ABAM, FACP Departments of Medicine and Anesthesiology

2. What You Need to Take Away Take a history. You’ll get the answers. Med removal and psychology do work, but it’s hard. Utilize practice tools that are available to you. Stay within your capability. Do no harm.

3. Steps For Approaching Chronic Pain Get records Identify / treat any local pain generators Promote healthy behaviors, increased physical activity Find and treat comorbid psychiatric illness Restore sleep Use adjuvant medical therapies Consider opioid initiation or continuation

4. Clinician – Patient Communication About Treating the Pain Likely outcomes of treatment Unlikely outcomes of treatment Past experiences, influences on outcomes Role of social / psych / adjuvant therapies over opioids and sedatives – “I don’t have a miracle pill for you.” Roles and expectations of both of you

5. Relative Effectiveness of Chronic Pain Treatments Physical fitness30-60% CBT / Mindfulness30-60% TCAs / AEDs / SNRIs30-50% Opioids30-50% ? Acupuncture 10%

6. Cochrane Collaboration

7. Phases of Opioid Management And “Universal Precautions” Decision – risks vs. benefits Patient selection: Who? Who not? Indications? Contraindications? Initiation / continuation / trial phase Maintenance phase When to stop, taper, get help

8. Necessary Steps For Initiation Trial or Continuation Records Red Flags MAPS Toxicology Testing Treatment agreements – aka, “contracts” – informed consent and set expectations. Don’t patients object?

9. Controlled Medication Management Understand equianalgesic opioid dosing DrugDoseRel. Potency Morphine (MS)30 mgMS Hydrocodone30 mg= MS Oxycodone20 mg1.5 x MS Oxymorphone7.5 mg4 x MS Hydromorphone6 mg5 x MS Fentanyl15 mcg“2 x” MS Methadonevariableup to 20 x

10. Controlled Medication Management Use or continued use of opioid should be a trial What opioid to use – the case for morphine What not to use: Demerol, Stadol; Opana? Fentanyl? OxyContin? Hydrocodone? Tramadol? Consolidate treatments: Do not mix and match opioids. A role for opioid rotation? Avoid prolonged use of short-acting meds. Role for ER meds? “Rescue” PRN dosing means per month! Say no to benzodiazepines, carisoprodol (Soma)

11. Safe and effective practice Use the practice tools in the UM guideline: o Initial and return visit checklists o Assessment scales o Dosing and conversion tables Practice processes (policies?): o MAPS, testing, agreement Documentation – how many, when, how… Prescription management – exact fill dates, 28 day rx’s, no after-hours refills

12. When and Why To Taper or Remove Lack of a functional benefit – ignore pain scores! Opioid induced hyperalgesia / toxicity Non-compliance with evaluation, meds, etc. Suspicion for misuse of medication Excessivetotal dosing ≥ 100 MED ? Excessive total dosing ≥ 100 MED ? o Morphine > 90 mg/day o Oxycodone > 60 mg/day o Fentanyl > 50 mcg/hr o Methadone > 30 mg/day

13. Landing the Plane Slow and fast tapers Drug rotation? The 10% rule 25% tapers

14. An evolving role for buprenorphine Butrans ® You should know about it Suboxone ® / Subutex ® / Zubsolv / generic bup/naloxone

15. What about “medical” MJ ?

16. Case Discussions

17. Case 1 45 y/o man new to you, his former doc, a Dr. Oscar, recently “left practice” and he will soon need refills. History of fairly good health, but chronic headaches, neck pain and spasm now 5 years after a MVA. No hx surgery, physical therapy. Pain managed well on meds he needs refilled before they run out this week. He works part-time, smokes cigarettes. Asking for carisoprodol 350 mg – 1 TID, OxyContin 80 mg BID and Norco 5/325 – 2 QID. Exam – NAD, friendly, non-specific exam.

18. Managing Case 1 Obtain info – are opioids indicated? Universal Precautions – No kissing on the 1 st date ! Giving the news – no rx today Getting the urine, what to order Prescription Monitoring Program? Soma? A role for “muscle relaxants?” Mixing opioids. OxyContin ?

19. Case 2 45 year old woman seen by you tomorrow (after this conference). You have been giving her MS-ER 30 mg TID, HC/APAP 10/325 x 8/d, sometimes takes 12 and Xanax 2 mg TID for chronic abdominal pain and anxiety. She is divorced, unemployed, is worried about her bills and cannot sleep at night. Pain 8/10. She has never had unexpected drug test results, but occasionally runs out of her meds, calls early for more, cries every time seen.

20. Managing Case 2 Opioids and benzos Benzos and anxiety  benzo.org.uk – Ashton Manual Adjuvant therapy, improve sleep Are opioids indicated? Moving to a long-acting regimen Psych, Social Work interventions

21. Case 3 45 year old woman with longstanding DM2, s/p renal transplant, DM neuropathy, AVN and chronic ankle pain, burning pain in legs. Prescribed MS-ER 60 TID, Norco 7.5/325 one QID PRN “breakthrough.” Also on pantoprazole, lisinopril, glipizide, glargine, tacro. She is divorced, lives with her troubled teen, has not worked in years. Exam: 165#, evidence of peripheral neuropathy. Tender with mild allodynia.

22. Managing Case 3 Neuropathic pain and methadone Hyperalgesia, allodynia Adjuvant tx and sleep restoration Converting, then taper ? Educating the patient

23. Managing Case 3 She turns to the Dark Side: Drug EIA → + cocaine, MJ; negative opioid GCMS → + cocaine; + methadone Methadone level 22 ng/ mL (predicted: 88/176 on 25 mg divided to TID) STOP Red flags = STOP !! vs. taper

24. Dr. Phil calls you for advice: His patient is a 75 y/o woman with a history of complex GI issues including abdominal pain, visceral hypersensitivity, esophageal spasm, recurrent SBO s/p multiple, multiple surgeries, chronic constipation, myofascial back pain, degenerative arthritis, falls, ?confusion. Her next appt is in a few days. Dr. Phil would like to work out a tapering strategy for her opioid medications, which consist of MS-ER 30 mg 2-3 times per day and oxycodone 20-40 mg per day. She has been on gabapentin and nortriptyline previously, but non-compliant because they put her to sleep. Case 4

25. Why one opioid Rare PRN use. Other “breakthrough” pain options Consolidation of treatment Adjuvants How to taper Prescription management Documentation Case 4 Management

26. Remember… All roads do not lead to opioids. Opioids often don’t work and should not be a first or a last resort. Iatrogenic addiction does not help pain. Take a history. You’ll get the answers. Med removal and psychology do work. It’s hard, but rewarding.

27. Stay Grounded In Your Role: Stay Grounded In Your Role: FIRST… THEN… FIRST… THEN… Do No Harm Cure Sometimes Do No Harm Cure Sometimes Comfort Always Comfort Always

28. Essential Reading CDC Opioid Guideline 2016CDC Opioid Guideline 2016 www.cdc.gov UM Chronic Pain/Opioid GuidelineUM Chronic Pain/Opioid Guideline available at guidelines.gov Heather Ashton ManualHeather Ashton Manual benzo.org.uk The Body Keeps The Score – van der KolkThe Body Keeps The Score – van der Kolk My email: danielbe@umich.edu