How to Successfully Complete a Narcotic Tapering with Functional Restoration

Fernando Branco M.D. F.A.A.P.M.R.

Medical Director

Rosomoff Comprehensive Rehabilitation Center

and Brucker Biofeedback Center

Miami Jewish Health Systems

Disclaimer: I have no financial relationship in regard to the content of this presentation

Disclaimer

I am the Medical Director of the Rosomoff Comprehensive Rehabilitation Center at MJHS

This Presentations does not

contain off-label and/or investigational use of drugs or products

Conundrums of Chronic Pain Care:

• Avoid Overuse of Narcotics • Functional Restoration

• Return to Work • Treat Psychological and Physical

Problems • Avoid Overuse of Interventional

Treatments • More Deaths from prescription drugs than

illicit drugs, Fort Lauderdale had more Pain Clinics than McDonald’s

P A I N

• Can’t see it

• Can’t measure it

• Can’t diagnose it on x-ray or MRI

• 75% of general population will have abnormal MRIs – bulging or herniated discs or narrowing…..and NO PAIN.

Pain Cycles

Drug Addict? Drug Abuse?

Excessive use of a drug for purposes for which

it is not medically intended.

The Risk of Addiction

• Published rates of abuse and/or addiction in chronic pain populations are 3-19%

• Known risk factors for addiction to any substance are good predictors for opioid abuse

Ives et al 2006 Reid et al 2002

Michna et al 2004 Akbik et al 2006

1. Past cocaine use, h/o of alcohol or cannabis use

2. Lifetime history of substance use disorder

3. Family history of substance abuse, history of legal problems and drug and alcohol abuse

4. Tobacco dependence 5. History of severe depression

and anxiety

Addiction is

• A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations

Savage SR et al JPain Symptom Manage 2003

• A clinical syndrome: – Loss of control – Compulsive use – Continued use

despite harm – Craving

Pseudoaddiction

•Opiophobia •Overestimate potency and duration of action

•Fear of being scammed •Fear of addiction potential Morgan J 1985

Smith 1989

Yellow Flags • Complaints of more medications needed • Drug hoarding • Requesting specific pain medications • Openly acquiring similar medications from other providers • Occasional unsanctioned dose escalation • Nonadherence to other recommendations for pain therapy

Passik SD Mayo Clinic Proc 2009

Red Flags

• Deterioration in functioning at work and socially • Illegal activities – selling, forging, buying from

nonmedical sources • Injecting and snorting medication • Multiple episodes of “lost” or “stolen” scripts • Resistance to change therapy despite adverse

effects • Refusal to comply with random drug screens • Concurrent abuse of alcohol or illicit drugs • Use of multiple physicians and pharmacies

Passik SD Mayo Clinic Proc 2009

Narcotic Cycle Patients need higher doses to achieve results =

TOLERANCE Eventually lack of pain relief may lead to steady increases in amount and types of pain medication

Long term use of narcotics leads to “OPIOD INDUCED ABNORMAL PAIN SENSITIVITY”

Narcotics

Eliminate production of your own body’s

ENDORPHINS Shut the endorphin system down

Lead to HYPERalgesia and HYPERsensitivity to pain

Journal of Opioid Management

“Significant pain reduction in chronic pain patients after detoxification from high-dose opioids” –

Sept/Oct 2006

21 of the 23 patients showed marked decrease in pain following tapering from narcotics!!

Publications Opioid-induced hyperalgesia: pathophysiology &

clinical implications: Journal of Opioid Management 2008

Opioid induced abnormal pain sensitivity – Current

Pain Headache Report 2006 Adverse effects of chronic opioid therapy for chronic

musculoskeletal pain – National Rev of Rheumatology 2010

Hyperalgesia in opioid-managed chronic pain and

opioid-dependent patients – Journal of Pain 2009

SERIOUS SIDE EFFECTS Narcotics slow down the action of the bowel / intestines

resulting in severe constipation almost always requiring another medication to help

relieve this symptom Urinary retention – inability to empty bladder

most often in males Hypogonadism – decreased sex drive, erectile dysfunction –

often requires need for additional meds Testosterone therapy

What is the Solution?

MYOFASCIAL SYNDROME

• Sciatica

• Neuropathy

• Sinus problems / dental pain

• Carpal Tunnel

• Migraine

Leads to misdiagnosis & incorrect tx J. Travell, 1976

Goals of Treatment

—Improve quality of life

—Restore optimum levels of function

—Reduce or eliminate pain

—Reduce or eliminate addictive pain medications

—Enable become independent of the healthcare system (related to pain)

EFFECTIVE TREATMENT

• Return to the basics: – Physical and Psychological Rehabilitation – Physical Medicine – True Multidisciplinary Approach What is the definition of insanity? "The definition of insanity is doing the same thing over and over and expecting a different result.“ Benjamin Franklin, Albert Einstein, Chinese Anonymous

Outpatient Weaning • Office • Outpatient drug “detox” program • Outpatient Comprehensive Pain Management Program (community weaning)

Patient Characteristics

• On lower opioid dose, simpler medication plan (1-2 meds), more gradual wean • Motivated • Low to medium psychosocial issues • Community social support for plan

Weaning Process

• Speed of weaning: dose decrease by 20-25% every 10-14 days • Monitoring: Urinary drug screen, pain behaviors, drug use and seeking, functional status • Support: Meds for withdrawal (temporary), physical rehabilitation (functional approach), follow-up every 1-2 weeks,

but available by phone daily, proactive check-in; cognitive behavioral approach

Case Management

• Red flags: Increased pain complaints: ”Can’t bear it,” “Carrier did not approve X,” “Equipment did not arrive,” pharmacy issues, “worrisome” symptoms.

• Actions: contact injured worker in person if possible, review treatment recommendations and symptoms management, contact treating team, return to provider if not able to assure compliance, do not approve increase in meds or new diagnostic evaluations or treatment changes unless recommended by current treatment team; disallow return to prior prescribers.

Settings

Inpatient Weaning • Residential drug “detox” program • Weaning as part of Comprehensive Pain Management Program* • Rapid detox (addressed later)

Patient Characteristics

• On high doses of opioids and/or complex drug regimens or needs more rapid detox • Not motivated or resistant to weaning • Medium to high psychosocial issues; history of psychiatric diagnosis, prior failed detox • Poor community social support for plan

Weaning Process

• Speed of weaning: dose decrease by 20-25% every 3 days • Monitoring: Urinary drug screen, pain behaviors, drug use and seeking, functional status • Support: Meds for withdrawal (temporary), physical rehabilitation (functional approach), follow-up every day,

available by phone daily, proactive check-in, onsite problem resolution; aggressive physical rehabilitation to separate physical from drug issues; multiple modalities to treat withdrawal

Case Management

• Red flags: Increased pain complaints, limited participation, desire to quit program, family support not adequate or detrimental, core beliefs unchanged, anger at carrier, multiple addiction issues. Post-discharge issues.

• Actions: Family engagement, clear-cut discharge pre-planning regarding pharmacy limitation, approved physicians, day-to-day problem resolution using providers from pain program. Urine drug screens. Onsite psychological support, cognitive behavioral approach.

Settings

Replacement Therapies • Outpatient: bridge to detoxification • Methadone, Buprenorphine products

Patient Characteristics

• On high doses of opioids predominantly • Indicated for addiction; very limited as a pain “solution” • Motivated wean off current meds, agrees to terms of process or case who will not wean, out of control • Low to medium psychosocial issues • Good community social support for plan

Weaning Process

• Speed of weaning: induction requires care, but is relatively quick; subsequent taper is slow • Monitoring: Urinary drug screen, pain behaviors, drug use and seeking, functional status • Support: Functional restoration, cognitive behavioral therapies, support groups (AA, NA)

Case Management

• Red flags: Lower risk of abuse if no other meds prescribed; pain complaints likely to continue. Patient may advocate to go back on pain medications. Control.

• Actions: Consider inpatient or outpatient detoxification.

Settings

■ Indications: Few, if any. Low doses of narcotics.

■ Claims: Painless, cheaper, safe.

■ Realities: Very risky (high death rate) from “coma” detoxification, does not treat root of the problem, severe withdrawals and craving on discharge without any support.

■ Risks: Death, suicide due to severe withdrawals, pain not addressed, immediately resuming use of narcotics.

■ Ideal candidate: Maybe patient with no addiction history who medically needs to be off meds ASAP.

■ The data supporting the safety and effectiveness of opioid antagonist agent detoxification under sedation or general anesthesia is limited, and adequate safety has not been established. Given that the adverse events are potentially life threatening, the value of antagonist-induced withdrawal under heavy sedation or anesthesia is not supported.

Rapid Detoxification Not proven safe or effective

Possible Symptoms of Withdrawal

—Flu-like aches and pains —Sweating, tearing, runny nose

—Chills, flushing —Goose bumps

—Ants crawling on your skin —Loss of appetite

—Headache —Anxiety

—Restlessness / Restless legs —Severe insomnia

—Nausea, vomiting, diarrhea, abdominal pain

PHYSICAL THERAPY

STRETCHING

PASSIVE

ACTIVE

HEAT ICE

NEUROMUSCULAR MASSAGE

PAIN RELIEF AIDS

SELF CARE

OCCUPATIONAL THERAPY

PREVENT

INJURY

OCCUPATIONAL THERAPY

POSTURE BALANCE

ERGONOMICS

• Human Performance Testing • Workplace Design / Analysis • Job Simulation

WORKPLACE ANALYSIS AND DESIGN

BIOFEEDBACK THERAPY

• Relaxation • Re-education • Body Mechanics • Posture

MOTOR DYSFUNCTION EVALUATION

ABNORMAL

PSYCHOLOGY SERVICES

• Evaluation • Manage behavioral crises. • Support during Tx • Individual, group, family • Self Hypnosis Training • Relaxation & Stress Management

QUESTIONS ??