Upload
vuonganh
View
215
Download
0
Embed Size (px)
Citation preview
Managing Patients with Pain, Psychiatric Co-Morbidity &
Addiction
October 23, 2010
John A. Renner Jr., MD, CAS Division of Psychiatry
Boston University School of Medicine
Slide 1: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Managing Patients with Pain,
Psychiatric Co-Morbidity &
Addiction
John A. Renner Jr., MD, CAS
Division of Psychiatry
Boston University School of Medicine
October 23, 2010
Renner Psych Co-Morbidity
DR. JOHN RENNER: Good morning. By way of disclosure, I just want to mention that I have some stock
in Johnson & Johnson. This is the material that we’re going to cover with the talk today.
Slide 2: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Roadmap
• Prevalence of Co-Occurring Psychiatric
Disorders and Addiction in Chronic Pain
Patients
• Treating Co-Occurring Psychiatric Disorders in
Chronic Pain Patients
• Diagnosing Addiction and Substance Abuse in
Chronic Pain Patients
• Treating Co-Occurring Addiction in Chronic Pain
Patients
We’ll begin by discussing the prevalence of co-occurring psychiatric disorders and addiction in chronic
pain patients; then talk a little bit about how you treat co-occurring psychiatric disorders; then shift to
diagnosing addiction and substance abuse in chronic pain patients; and finally, treating co-occurring
addiction in chronic pain.
Start with prevalence.
Slide 3: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Psychiatric Co-Morbidity &
Chronic PainCONDITION Current Incidence in
Chronic Pain Patients
Incidence in the General
Population
Depression 45 % 5 %
Anxiety Disorders 16.5 % to 50 % 3 % to 8 %
Personality Disorders 31 % to 81 % 10 % to 18 %
PTSD 20 % to 34 % 1 % general population
20 % combat veterans
3.5 % to 15 % in civilians
with trauma
Substance Use Disorders 15 % to 28 % 10 %
Somatoform Disorders 97 % in CLBP patients in
inpatient rehab program
unknown
This slide captures some of the more common psychiatric disorders and gives you some indication of
how common this is in chronic pain patients. You’ll see with depression, significantly more depression
than in the general population, similarly in anxiety disorders, personality disorders, PTSD the range can
be from 20% to 34%. There you have to look at the populations that you’re comparing this to. Only 1%
of the general population has PTSD, but if you work at the VA where I am, 20% of combat vets are going
to have PTSD, and civilians with trauma the range is 3% to 15%, so it can be a common problem.
Substance use disorders, it ranges to about 10% in the general population but almost three times as high
in individuals with chronic pain problems. Somatoform disorders, we really don’t have good data for the
incidents in the general population, but in chronic low back pain patients and in-patient rehab, it goes as
high as 97%, so there’s really an undetermined range with somatoform disorders.
Slide 4: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Pain & Depression
• Among patients with Major Depressive Disorder
(MDD), a significantly higher proportion reported
chronic (i.e., non-disabling or disabling) pain than
those without MDD (66% versus 43%, respectively).
• Disabling chronic pain was present in 41% of those
with MDD versus 10% of those without MDD.
Arnow BA et al Psychosomatic Medicine 2006;68:262-268
This slide captures some of the data on pain and depression. Among patients with major depressive
disorder, significantly higher proportion reported chronic pain than those without that. They’re at 66%
versus 43%. Disabling chronic pain was present in 41% of those with major depression versus only 10%
of those without major depression, so again, you can see the higher risk in the chronic pain patients.
Slide 5: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Pain, Depression & Anxiety
Compared to pain patients without MDD,
patients with co-morbid MDD and disabling
chronic pain had
• significantly poorer quality of life,
• greater somatic symptom severity,
• a higher prevalence of panic disorder and
• a six-fold greater prevalence of anxiety
Arnow BA et al Psychosomatic Medicine 2006;68:262-268
The other point that I want to make is that there’s a very high co-morbidity between depression and
anxiety disorders. People with chronic pain, major depression, have poor quality of life, increased
somatic symptoms, higher prevalence of panic disorder, and more than six-fold greater prevalence of
anxiety disorders, so very high co-occurring incidents of depression and anxiety disorders.
The depression may be more obvious to you, but if you get any sense that your patient is depressed, you
need to screen them for that and then you need to also ask questions about anxiety disorders. They are
going to be very common in the same patients.
Slide 6: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Psychiatric Co-Morbidity & Chronic Pain
Summary
• There is a high incidence of depression, anxiety
disorders and substance abuse disorders in
chronic pain patients
• Depression and various anxiety disorders are
often seen in the same patient
• Attention to assessment and treatment of chronic
pain and concurrent depression/anxiety and
substance use disorders seems necessary for
the best outcomes
I think if you have any suspicion at all, particularly about depression in chronic pain patients, I think it’s
really important as part of your standard management that you screen them for depression and anxiety
disorders and substance use disorders.
Slide 7: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Roadmap
• Prevalence of Co-Occurring Psychiatric
Disorders and Addiction in Chronic Pain Patients
• Treating Co-Occurring Psychiatric Disorders
in Chronic Pain Patients
• Diagnosing Addiction and substance Abuse in
Chronic Pain Patients
• Treating Co-Occurring Addiction in Chronic Pain
Patients
How do you treat co-occurring psychiatric disorders in chronic pain patients?
Slide 8: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Optimized Antidepressant Therapy and Pain
Self-management in Primary Care Patients
with Depression and Musculoskeletal Pain: A
Randomized Controlled Trial
• Optimized antidepressant therapy along with a pain self-management program produced significant reductions in depression severity and moderate reductions in pain severity and disability at 12 months
• Reductions in depression and pain were seen
early (1 month) and sustained
Kroenke K, Bair M, Damush T et al. JAMA 2009; 301(20): 2099-2110.
First of all is that you really want to optimize self-management of the pain and depression. This looks at
one trial where they optimized antidepressant therapy by combining it with the pain self-management
program. That produced significant reduction in the depression severity, moderate reduction in the
pain severity; so interestingly enough, you’re probably going to see better response to depression than
you are necessarily to see improvement with the pain. If you do see improvement with depression,
you’ll probably see it relatively early within the first or second months of treatment.
Slide 9: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Comparing Antidepressants
Nefazodone Fluoxetine Sertraline Paroxetine Citalopram Venlafaxine Bupropion
Efficacy yes yes yes yes yes yes yes
+ Sleep helps
Anxiety helps helps
Sexual
Dysfct
Min. 58% 61% 68% 69% Min.
Weight none yes yes yes yes yes none
The second point I would want to make is that for treating both the depression and co-occurring anxiety,
you’re most common pharmacotherapy is probably going to be the SSRIs. Though this slide compares a
variety of antidepressants, you’ll see that the efficacy across this range of antidepressants is fairly
comparable. They’re all effective. Nefazodone, or Serzone, probably works best in terms of improving
sleep. It works best in terms of reducing anxiety. Paroxetine is the only other SSRI that has a very
specific benefit for anxiety. One of the problems with nefazodone is panic damage. There is a black box
warning with this drug, but in patients who can tolerate it; it may be a very effective drug to use.
As you can see with all of these drugs, there are problems with sexual dysfunction, problems with
weight gain, except for bupropion and nefazodone, so there are side effects that you need to be
concerned with all of these medications, but I’d look particularly at using paroxetine and nefazodone as
medications that maybe helpful with patients with co-occurring pain, depression, and anxiety.
Slide 10: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
General Principles:
Management of Psychiatric Co-Morbidity in
Chronic Pain Patients
• Standard pharmacotherapy for depression and anxiety
– Choose non-abusable medications
–Adequate doses for adequate time
• Refer for Cognitive Behavioral Therapy
• Caution with benzodiazepines
– State low; go slow
–Non-refillable prescriptions
– Monitor carefully
Pick standard antidepressant meds that you’re comfortable with. Make sure you’re using adequate
doses and patients need to be on them for at least a month if you’re going to see an adequate response.
You always, whenever possible, want to combine antidepressant therapy with cognitive behavior
therapy. There’s no question that the treatment outcome is improved if you combine cognitive
behavior therapy, plus the antidepressant. In some cases, you may want to use benzodiazepines, but
here because of the risk benefit you want to start with low doses, go carefully. Monitor their
prescriptions more carefully, and just be aware that there may be a higher risk for abuse.
Slide 11: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Anxiety Disorders:
The Role of Benzodiazepines
• Comprehensive literature review
• Efficacy demonstrated for: Generalized Anxiety
Disorder, Panic Disorder and Agoraphobia
• Probably efficacy for: Social Phobia, Alcohol-induced
anxiety disorders
• Little evidence of added risk for medication abuse or
increased relapsed BUT avoid use in primary sedative-
hypnotic addicts
Posternak, Mueller. Am J Addict. 2001;10:48-68
If you look at the questions about when should you consider benzodiazepines, there is efficacy for
treating general anxiety disorder, panic disorder, and agoraphobia. There’s probable efficacy for social
phobia. Alcohol-induced anxiety disorders and there’s really little added risk for medication abuse or
increased relapse, except in individuals who are primary sedative-hypnotic addicts.
If you’ve got any individual with a clear cut history of prior benzo abuse, those are the people you really
have to be extremely careful about and avoid use; otherwise, the increased abuse of benzos is not very
different in psychiatric patients or in addicted patients. It is slightly higher in those two groups than in
the general population, but not dramatically so. I think there’s some over exaggerated concern about
using benzodiazepines. By and large, they should never be your first choice with pain patients, and they
should only be considered if patients have failed to respond to less abuse able medications.
Slide 12: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Treatment RecommendationsPsychiatric Treatment in Patients with
Chronic Pain
• Psychiatric medications
Depression – SSRIs; Nefazodone
Generalized Anxiety Disorder – Buspirone; SSRIs
Panic Disorder – SSRIs; Nefazodone
Social Anxiety – Paroxetine
PTSD – SSRIs & Prazosin
Bipolar – Valproate
This slide just lists the variety of psychiatric conditions and the most common medications that we
would recommend for their use. There certainly are other options but these are the most common: For
depression, start with the SSRIs. If they don’t work, I would consider nefazodone; with generalized
anxiety disorder, buspirone in higher doses than is normally prescribed and SSRIs; panic disorder, again,
SSRIs and nefazodone; social anxiety, paroxetine; for PTSD, paroxetine and citalopram. Prazosin is very
effective for PTSD-induced nightmares*; and for bipolar disorder, my first choice would be valproate.
*Off-label use.
Slide 13: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Treatment RecommendationsPsychiatric Treatment in Patients with
Chronic Pain
• Counseling
Cognitive Behavioral Therapy (CBT)
Motivational Enhancement Therapy (MET)
Twelve Step Facilitation (TSF)
Cognitive Processing Therapy (CPT)
• Self health groups (i.e., AA, NA)
I would also, again, emphasize the importance of adding cognitive behavior therapy. Cognitive
processing therapy is a new approach that we’re using for PTSD and that’s of particular benefit in that
subset of patients. Also, if you have any concerns about potential abuse or people with prior addiction
histories, I would make sure they’re still connected with AA or NA.
Slide 14: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Roadmap
• Prevalence of Co-Occurring Psychiatric
Disorders and Addiction in Chronic Pain Patients
• Treating Co-Occurring Psychiatric Disorders in
Chronic Pain Patients
• Diagnosing Addiction and Substance Abuse
in Chronic Pain Patients
• Treating Co-Occurring Addiction in Chronic Pain
Patients
Let’s move more specifically to diagnosing addiction and substance abuse in chronic pain patients.
Slide 15: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Hierarchy of Risk for Abuse of
Opioids
• Active opioid dependence
• History of opioid dependence
• Abuse of other drugs or alcohol
• Inadequately treated pain symptoms
• Other psychiatric co-morbidity
• Family history of drug/alcohol dependence
First of all, you need to be aware of what your risks are. First of all, any active opioid dependence is
obviously a situation where you’re going to get concerned, but that doesn’t mean that you’re really
going to deny treatment to people. You just need to be much more cautious. If someone has a history
of opioid dependence though they’re not currently in trouble, that just puts them at higher risk. Risk of
any other classes of drugs puts them at risk.
Inadequately treated pain syndromes; this I think is something that physicians often don’t consider and
sometimes while they’re well intended, they are overly conservative in treating pain in individuals with
addiction histories. I think the reality is that by under treating pain in these patients, you’re actually
more likely to precipitate new drug abuse. I think that you need to really be sure that despite their
history they get adequate treatment for current and existing pain problems. Any other psychiatric co-
morbidity will simply increase the risks, and any family history of drug or alcohol dependence will
increase the risk.
Slide 16: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Diagnostic Challenges:Opioid Addiction in Pain Patients on Opioid Therapy
“Opioid Dependence”
3 or more criteria occurring over 12 months
• Tolerance – YES
• Withdrawal/physical dependence – YES
• Taken in larger amounts or over longer period – MAYBE
• Unsuccessful efforts to cut down or control – MAYBE
• Great deal of time spent to obtain substance – MAYBE
• Important activities given up or reduced – MAYBE
• Continued use despite harm – MAYBE
APA DSM IV-TR 2000
This slide lists the requirements, according to DSM IV, for the diagnosis of substance abuse and in this
case opiate dependence. There are seven criteria. You have to have three criteria present at the same
time during one 12-month period. Tolerance and withdrawal are going to be present in all of these
patients if they are on chronic opiate treatment. The other behaviors all are sort of various reflections
of the loss of control that was mentioned earlier, so you only need one of these other behaviors plus
tolerance and withdrawal in order to meet the criteria for opiate dependence.
Slide 17: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Diagnostic Challenges:Opioid Addiction in Pain Patients on Opioid Therapy
The 4 C’s of “Addiction”
• Loss of Control
• Use Despite Consequences
• Compulsive use
• Craving
Savage SR 2002
This is the same slide that you saw earlier.
Slide 18: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Roadmap
• Prevalence of Co-Occurring Psychiatric
Disorders and Addiction in Chronic Pain Patients
• Treating Co-Occurring Psychiatric Disorders in
Chronic Pain Patients
• Diagnosing Addiction and Substance Abuse in
Chronic Pain Patients
• Treating Co-Occurring Addiction in Chronic
Pain Patients
For the latter part of this talk, I want to look at managing co-occurring addiction in chronic pain patients.
Here, I just want to stress again the fact that someone is addicted does not mean they’re ineligible for
pain treatment. We certainly see lots of people in our addiction programs that have a great deal of
difficulty getting adequate medical care because many physicians really avoid treating them. I think you
really need to learn how to manage these patients because the problems are often legitimate and the
treatment need is quite real.
Slide 19: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
You do have to consider how you’re going to adapt the care for the patient if there is a risk for addiction.
Some of the next slides sort of generously borrowed from Jeff Baxter so he was helpful in putting this
information together. First of all, you have to consider the setting, whether you can manage them in a
primary care setting or where they need to be referred to a specialty care or pain management
program.
Team care is always helpful. If you have a mental health consultant, a psychiatrist, a psychologist,
someone who can provide ancillary therapy, you’re probably going to do better by coordinating that
care. As has been mentioned, many times you want to do risk-benefits analysis as you assess for
opiates. You want to really look first if there’s any real risk and history, are there non-pharmacological
ways to treat the problem? If non-pharmacological treatments don’t work, move up to pharmacological
treatments but don’t begin with opiates. You want to have a clear risk hierarchy in terms of how you
choose the approach for treatment.
You always want to be careful with the supply of medications. As was discussed earlier, in some cases
weekly meds are best but that may not be realistic. You do want to monitor them and make sure that
they are secured. If there is any real history for addiction, you should consider whether or not you want
to refer the patient back for addiction treatment, or at least make sure you know that that’s available,
and they know it’s acceptable for them to participate in that treatment. Finally, as mentioned before,
direct supervision pill counts, monitoring them, prescription monitoring program.
Adapting Care for Patients at Risk for
Addiction
• Setting of care• primary vs. specialty care; team care
• Selection of Treatment• Risk/benefit assessment for opioids
• Adjuvant meds and modalities
• Supply of Medications• Weekly? Secured? Supervised?
• Refer for Addiction Treatment• Sponsor, family, addiction treatment program
• Supervision and Monitoring• Pill counts, drug screens, collateral info.
Slide 20: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
There are various ways that you can approach managing these patients. In one situation you want to
continue the current modality, but you really want to change the structure of care that you’re providing.
In that case, you may want to add other pain therapists. You may want to add physical therapy, other
approaches to managing the pain. You may want to add mental health treatment and look for a
psychiatrist who has experience with addiction and pain. They are not always available, but I think if you
can find someone with that experience, it will be more helpful.
Lastly, you might want to consider a pain specialty provider, but as was discussed earlier, that can often
be complicated, so you need to be sure what it is you’re looking for and that you’ve accessed someone
who’s going to help you manage the patient.
Adapting Care for Patients at Risk for
Addiction
• Setting of care• primary vs. specialty care; team care
• Selection of Treatment• Risk/benefit assessment for opioids
• Adjuvant meds and modalities
• Supply of Medications• Weekly? Secured? Supervised?
• Refer for Addiction Treatment• Sponsor, family, addiction treatment program
• Supervision and Monitoring• Pill counts, drug screens, collateral info.
Continue Modality, Change Structure
Require treatment with:
•Adjuvant pain therapy providers
• physical therapy, chiropractic
•Mental health/psychiatry
•Addiction specialty provider
•Pain specialty providers
Slide 21: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
You may need to consider simply increasing the level of care. This slide describes one program that’s
been available in one VA where they developed an opiate renewal clinic. Here, this model has actually
been quite successful. It’s pharmacy run. They have pain management as part of a team. Patients are
educated about pain management and there’s a strong connection to primary care providers. They had
over 300 patients who were referred to this clinic in a 2-year period. Over 50% at the time of referral
had aberrant behaviors related to their control of pain meds. As you’ll see, over the course of those two
years, at least half of those patients improved, so this clinic was really beneficial for the patients who
were having difficulty controlling their meds.
About half of the patients that were referred to the clinic did not have aberrant behaviors and they
continued to do well over the course of two years. This is a specialized program that certainly any
facility that deals with large numbers of pain patients should consider.
Adapting Care for Patients at Risk for
Addiction
• Setting of care• primary vs. specialty care; team care
• Selection of Treatment• Risk/benefit assessment for opioids
• Adjuvant meds and modalities
• Supply of Medications• Weekly? Secured? Supervised?
• Refer for Addiction Treatment• Sponsor, family, addiction treatment program
• Supervision and Monitoring• Pill counts, drug screens, collateral info.
Continue Modality, Change Level of Care
Opioid Renewal Clinic (Urban VA setting)• Pharmacist-run prescription management clinic
• Pain Specialty NP supported by pain team
• Education on opioid management
• “Support primary care providers”
335 pts. referred over 2 years
• 51% (171) had aberrant behaviors on referral• 45% (77) improved adherence, behaviors resolved
• 38% (65) self discharged
• 13% (22) referred for addiction treatment
• 4% (7) tapered
• 49% (164) w/out aberrant behaviors did fine
Weidemer NL Pain Medicine 2007
Slide 22: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
You also can look at what you might do with sort of existing programs to try and beef them up in a sense
to make them more adequate to manage this type of patient. In a primary care setting, you may want
to really increase the M.D. time because you can’t manage these patients with sort of rapid in and out
visits. They do take time, and they need to know that you’re concerned about them. That’s very
difficult to do if you’re feeling very rushed.
You may want to add nurse care managers. You may want to add psychology care managers; sort of
increase your team. You want to make sure that all the providers are well educated about chronic pain
management; that you’re all working from the same agenda, that there are treatment plans that
everyone is comfortable with. For the patients, they need phone contact information. They need to be
educated too about what it is you’re trying to do, what’s the best way to manage chronic pain. You
need to make sure that you talk with them about the risks. If they have any psychiatric history or if
they’re presenting any psychiatric pathology, you make sure that they understand the appropriateness
of screening for depression or anxiety disorders.
If you can integrate group treatment activities or workshops into your general program, that’s
particularly helpful and sometimes groups of chronic pain patients are quite useful as ways of expanding
the care available to patients and helping them live with their problems and understand how you best
can manage the medications. In most of these case settings, I think that this type of increased level of
care will result in better outcome, less disability, and improved mental health.
Continue Modality, Change level of Care
Primary care based collaborative treatment enhanced with
• 20% FTE internal medicine physician
• Full-time psychologist care manager
For providers:
• 2 educational sessions
• Develop treatment recommendations
For patients:
• Phone contact + print materials
• Assessment with care manager
• Mental health co-morbidity screenings
• Goal setting and review of expectations/fears
• Group treatment/workshops
• Pain specialty care/consults with team internist
• Improvements in pain, disability, mental health
Dobscha SK JAMA 2009
Slide 23: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
The next few slides are going to talk about managing patients when you decide you have to terminate
opiate treatment. There can be a whole range of reasons for this consideration. In some cases, the
patient simply is physically better, but they may be physically dependent and you may need to taper
them off the medication. In other cases, as Jane described, I think inadequate pain control, lack of
efficacy, you finally reach the decision that in a risk-benefit assessment, the risks now outweigh the
benefits.
If there is clear loss of control; are there abuse or opiate dependence; and if there is out of control of
other drugs. You cannot really safely continue prescribing potent opiates to individuals whose
alcoholism is totally out of control or whose benzodiazepine abuse is out of control.
Change in Treatment Modality
Consider termination of opioid treatment:
• Opioid treatment no longer required
• Inadequate pain control – lack of efficacy
• Out of control opioid use/abuse
• Out of control abuse of alcohol, benzodiazepines or
cocaine
Slide 24: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
These are categories where you decide you really want to terminate treatment. This may happen
involuntarily or it may happen on a voluntary basis. Even with an involuntary withdrawal, I would go
slow, stick to a regular schedule, and make sure the patient understands it, and that you really go with
it.
In some emergency situations, you may actually have to hospitalize a patient. If the patient is
threatening, as was mentioned before, you may want to immediately terminate care. If there is
recurrence of pain, and here, I think the most critical thing for the patient and you to understand is
terminating the treatment with opiates does not necessarily translate into terminating your treatment;
in fact, this will go much better if the patient understands that this is just one element of care that you
are planning to change.
If the patient understands that you still have a commitment to work with them, and that there are other
ways of managing their pain, and that you’re going to continue to do that, I think you will find it much
easier to get them off the opiates. I think the degree to which the patient feels like they’re being
abandoned, that is just going to up their level of problems that you’re going to have as you try to taper
the opiates. It’s really important that they understand that if pain recurs, you’re going to reconsider
things, but there are other approaches for the pain, and that you’re approaching all of this in a more
rational way.
I’ll show you an opiate withdrawal scale in a second. I think patients need to know that you’re going to
use scales, that you’re going to have a rational way of managing their meds, and that you’re not just
doing this in an arbitrary way because you don’t like them and you want to get rid of them, or you want
to get them off the meds. I think if they understand that there’s logic to what you’re doing, I think they
will relax a little and you’ll find it easier to do.
Challenges
• Involuntary Withdrawal• Set a reasonable schedule and stick to it
• Emergency Termination
• Recurrence of pain• Overlap of pain and withdrawal symptoms
• Assess withdrawal intensity with scale
• Psychiatric instability• Overlap of pain and psychiatric symptoms
• Threatening behavior• “if you don’t prescribe it I will just have to get it on the street”
• “I’m calling my lawyer”
I think you may expect an increase in psychiatric symptoms as you bring them off of opiates. Opiates in
particular are very good antidepressants, and it’s not surprising to see an increase in depression and you
may want to consider increasing psychiatric treatment at that time. You also need to understand you
don’t tolerate threatening behavior. My experience, however, with most patients, when you begin to
get that edge, don’t overreact. I think the more you can be laid back and just make it very clear that
threatening, screaming, yelling, is not going to achieve the goals they have and that I can work with you,
you don’t need to do that. I think you’ll find that patients are going to be more reasonable.
Slide 25: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
You want to be very clear that you’re not abandoning the patient. If you do need to terminate
treatment, you really need to make sure you’ve clearly documented the reasons. I think you clearly
need to document other options where the patient’s been referred for addiction treatment or to other
appropriate changes. Make sure you put all of that in writing. As you’re continuing to proceed,
particularly if you’re simply just stopping the opiates, again, clearly make sure the patient understands
that coming off of meds is not the end of treatment and does not represent your denial of treatment to
them.
You may need to see the patient actually more frequently and monitor how you’re doing and being
more careful with them. In some sense, I think in the worst case scenarios, giving people lots of pills is
an excuse not to see them. In the best case scenario, eliminating the pills and reducing the pills may
translate into more care and more frequent care and better attention; that may be the best way to do it,
but I think you have to understand that they will interpret that in a way and they’ll understand what
you’re doing.
Avoiding “Abandonment”
• Documentation of risk/benefit discussion and why treatment
discontinued
– Allow for medically appropriate taper
• Restate commitment to continue to work with patient on
pain and addiction if needed
– Refer to specialty pain treatment providers
– Alert patient to addiction treatment resources
• See patient frequently and monitor for progress and safety
• Copy to patient and to chart
Fishbain DA Pain Medicine 2009
Slide 26: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
If you’re trying to withdraw someone from opiates, you need to have some sense of which patients are
going to have the most difficulty, and you can predict in some cases the severity of withdrawal. Patients
who have been on high potency opiates for long periods of time are more likely to have symptoms.
Patients who have been on shorter acting opiates are more likely to have symptoms, so you can predict
that to some degree.
Determination of Withdrawal Risk
• Exposure to steady state level of
medication
– Neuro-adaptation to opioids
• Higher intensity withdrawal from:
– Higher steady state levels
– Longer term exposure
– Faster rate of medication clearance
• Long vs. short half life agents
Slide 27: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
This slide gives you a sense of the intensity of opiate withdrawal. Here you’re comparing heroin to
buprenorphine to Methadone, and you can see that heroin withdrawal, abrupt withdrawal, much more
severe, but relatively short acting. Methadone is much longer but less severe. So longer acting opiates
are not going to be as severe as the short-acting opiates in terms of withdrawal symptoms, but they will
last longer.
For patients who are truly addicted, not just physically dependent, but addicted in the more pathological
sense, you’ll find that the slow gradual withdrawal may be the most difficult thing for them to tolerate.
Even though symptoms aren’t severe, the lengths of the symptoms are often difficult for them, and they
need a lot of support during that time period.
Opioid Withdrawal Timing/Intensity
Kosten and O’Connor, 2003
Slide 28: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
One way to do this is to use clinical opiate withdrawal scales. This is an example of the COWS. This is
probably the most commonly used scale. Here, the benefit of this is that it: (1) Gives you a very
objective way of measuring severity; (2) It gives you a way of deciding whether you need to treat
patients at all; (3) Whether you need to increase the dose; (4) It gives you a target of where you’re going
in terms of reducing the severity of symptoms. The major benefit, here again, it’s reassuring to the
patient. They know you care. They know you’re tracking things. They know you’re making decisions
based on objective evidence rather than just I’m trying to get rid of you and get you out of my office. I
would recommend learning how to use scales like this if you’re going to withdraw people and they are
complaining of ongoing symptoms.
Clinical Opioid Withdrawal Scale
(COWS)
• Pulse rate
• Sweating
• Restlessness
• Pupil Size
• Bone/joint aches
• Runny nose/tearing
• GI upset
• Tremor
• Yawning
• Anxiety/irritability
• Gooseflesh
5-12 Mild
13-24 Moderate
25-36 Moderately severe
≥ 36 Severe
Wesson DR, Ling W 2003
Slide 29: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
This slide looks at tapering long-acting opiates. One model is to reduce the medication by 10% to 20%
each week. Depending on the formulation of the meds, this may be a little bit more difficult. The rate
of decrease may really be determined by how severe their withdrawal symptoms are. You may want to
add a supply of short-acting meds for some sort of breakthrough symptoms, so you’re gradually tapering
the long-acting opiates and giving them a small supply of short-acting opiates, or give them comfort
meds. I’ll show you that in a second.
Tapering Long-acting Opioids
• Decrease by 10-20% each week
–Pill formulations may dictate amount of drop
in dose
–Rate of decrease determined by
circumstances of withdrawal
• Allow supply of short acting medications to
treat “breakthrough” symptoms
–Build up alternative pain treatment modalities
–Comfort medications
Slide 30: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
For tapering individuals who are on short-acting opiates, first of all, you have to consider whether you
need to taper at all. The symptoms may be relatively short-lived and you may be able to get them off
quite quickly, particularly if there is physiologic presence at all, if there’s physiologic dependence. You
may want to decrease the strength of tablets over every week. You may want to do this simply by pill
count just to eliminate one pill on a particular schedule.
One option may be to transfer them to a longer-acting opiate. This becomes more complicated. You
will have less intense withdrawal symptoms with longer acting opiates, but if you haven’t had a lot of
experience doing this, it may be complicated to try and do that.
Tapering Short-acting Opioids
• Decide if you need a taper at all (is there
physiological dependence?)
• Decrease strength of tablets each week
• Decrease by a specific number of tablets each week
• Consider substitution with long acting medication,
then taper???
• Rate of decrease determined by circumstances of
withdrawal
• Build up alternative pain treatment modalities
• Comfort medications
Slide 31: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Another option is to add Clonidine. Clonidine can be used to moderate some of the opiate withdrawal
symptoms. Understand that it works best with the physiologic symptoms associated with opiate
withdrawal. Clonidine is not particularly effective with psychological symptoms or with craving. So you
may have a patient where you’re reducing the physiologic symptoms with Clonidine, yet they still have a
lot of cravings, so you need to be prepared for that.
You need to be concerned by hypotensive effects, particularly on an outpatient basis, initial dose of 0.1
mg p.o., monitor blood pressure. I would not go over these recommended limits over 24 hours, so you
just need to be careful to not get into difficulty with that. It’s a little easier to manage with the
transdermal patch.
Treatment: Clonidine
Oral Dosing
• Initial dosing: 0.1 mg po
Watch BP carefully
• Titrate up to 0.1 to 0.3 mg
po q4-6 hours, then taper
• Risk: HYPOTENSION
• Effective adjuvant to other
meds listed
Transdermal (Patch)
• More steady levels of med;
avoid cyclic hypotension
and rebound.
• Dosed one patch per week
($10/patch).
• Dose range: 0.1-0.4 mg
• 24-48 hours to start to
work-- can use oral
clonidine initially while
waiting for effect.
Slide 32: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
This is a list of comfort meds. I won’t go through all of this. I think you’re all familiar with these things,
but these are all medications that you can add to help the secondary symptoms of opiate withdrawal.
The only things that I would be concerned about are the sleep aids and the benzodiazepines. It’s safe to
use them, but you just need to make sure, particularly with the antidepressants for sleep, that the
patients are aware that they should not increase the dose beyond what you are recommending. I would
really try to avoid benzodiazepines as add-ons at this point in care. I think that could be quite risky to
add that in at this stage.
“Comfort Meds”
• Ibuprofen 600 QID
• Dicyclomine (Bentyl) 20 mg
QID for stomach cramping
• Pseudoephedrine 30-60
mg QID
• Antiemetics: Tigan 250 mg
po/ 200 mg IM q6-8 hours
• Muscle relaxants: Robaxin
500-750 mg up to QID
• Antidiarrheals:
– Kaolin with Pectin;
– PeptoBismol (Bismuth HCL)
– Loperamide (immodium)
less effective
• Sleep aids
– Trazodone 50-100 mg
– Doxepin 25-50 mg
– Amitriptyline 50mg
• ??? Benzodiazepines
Slide 33: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Again, sort of the psychological aspects of managing outpatient opiate withdrawal. The patient’s going
to be distressed. They are going to need extra support, extra time, extra attention, but you may be
surprised in some circumstances to see that their function actually improves as you lower the dose.
Reinforce the notion that you’re going to continue to work with the patient. You have other options
besides opiates and that you’re not going to abandon them. See the patient regularly to monitor their
progress.
Clinical Approach to
Outpatient Opioid Withdrawal
• Anticipate the patient’s distress
• Function may improve on lower dose
• Reinforce commitment to work with patient
• Describe steps to minimize withdrawal symptoms
• Describe safer pain management you will pursue
• Maximize non-opioid modalities
• Refer to specialty pain treatment
• Describe options if withdrawal doesn’t work
• See patient frequently to evaluate progress and
monitor for safety
Slide 34: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Inpatient detox may be an option for some patients, but the current reality is it’s usually relatively short
term. It may not have long term benefits. I think that it’s easy to get people off drugs; like opiates, you
can do it very quickly in a hospital but the real problem is how they do after they get out of the hospital
in preventing relapse. So I would reserve this only for very unsafe patients or patients who are quite
unstable.
Inpatient Detoxification
• Usually patient initiated and voluntary
• Short length of stay: 4-5 days
• Insurance coverage varies
• Diagnosis of opioid addiction, not just physiological
dependence
• Addiction focused, not pain
• Nursing managed
• No labs/Xrays/Pharmacy
• Reserve for the most unstable or unsafe
–May be difficult to place patients with serious mental health or
medical co-morbidities
Slide 35: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
The last few slides, I want to talk about the option of referring patients to long-term opiate treatment,
either Methadone or buprenorphine. In Methadone, you have to get daily doses in the clinic. It’s
important to understand that a single daily dose of Methadone is very adequate for controlling
withdrawal symptoms and craving, but it does not control pain or no more than 6-8 hours as Dr. Alford
went over in his earlier presentation.
Opioid Agonist Treatment (OAT)Methadone Program
• Daily observed dosing of opioid medication
• Single daily dose - inadequate for pain control
• Monitoring for drug and alcohol use
• Dosing titrated to withdrawal symptoms
• Gradual taper over time
• Mandated behavioral tx
• May be long waits for admission
Slide 36: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Dosing is monitored very carefully. There may be long waits for admission. It may be very disruptive to
the patient to attend the clinic every day. Why do we do it? We do it because it works. It’s the most
effective control and treatment that we have for opiate dependence. It prevents relapse, reduces extra
drug use, shows significant improvement in mental and physical health, and greatly reduces the death
rate associated with opiate addiction.
Why Methadone Maintenance?Because it Works…
• 80-90% relapse to drug use
without it
• Increased treatment retention
• 80% decreases in drug use,
crime
• 70% decrease all cause death
rate
• 50% + reduction in health
care costs
NIH Consensus Statement JAMA 1998
Slide 37: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Another option, particularly for chronic pain patients, this may prove to be the more effective option is
buprenorphine*. It can be available in an office based setting. It’s a partial opiate agonist. The main
advantage with buprenorphine is your ability to fine tune the dose and to divide the dose during the
day. Under standard buprenorphine maintenance treatment, patients get a single dose in the morning;
however, since they are taking the dose home, they can divide that dose during the day. We’ve
discovered with a number of chronic pain patients that buprenorphine provides adequate control of
both their pain symptoms and it eliminates the addiction symptoms.
I think that over the next few years, we’re probably going to see an expanded practice role for
buprenorphine for dealing particular with the more difficult patients with legitimate chronic pain and
clear cut history of addiction. It’s available in sublingual tablets, and now a sublingual film strip only in
two doses, 8 mg and 2 mg. Providers need 8 hours of training in order to prescribe buprenorphine, but
it’s been highly effective in a large number of difficult patients. I would strongly encourage any of the
primary care physicians here who work with these patients to get the training to use buprenorphine. I
think you’ll find it’s worthwhile.
*Off-label use.
Opioid Agonist Therapy (OAT) Buprenorphine
• Partial opioid agonist
– Lower overdose risk
– ? Lower intensity withdrawal
• Formulated with naloxone
• Office-based treatment
• Patients control dosing
times
• No “take home” restrictions
• Maintain or detox
• Split dosing may provide
adequate pain control
• Weaker agonist activity
• Blocks out other opioids
• 8 mg and 2 mg doses only
• Sublingual formulation only
• Limited prescriber availability
• Limited insurance coverage
• Must be in withdrawal to
initiate treatment
Slide 38: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
Just a few caveats; if you’re referring patients to opiate agonist therapy, either Methadone or
buprenorphine, as standard practice, that is single doses of Methadone, single daily doses of
buprenorphine; that is not adequate for patients with real pain control. The legal constraints on
Methadone dispensing in clinics makes it very difficult to manage pain patients in that particular setting.
It’s important to recognize that neither of these drugs treats other addictions besides opiate
dependence.
They don’t treat alcoholism. They don’t treat cocaine dependence. They don’t treat benzo dependence.
You may need to supplement with other opiates if patients are on buprenorphine or Methadone.
Patients on Methadone and buprenorphine develop tolerance. They may develop new pain syndromes.
They may need extra management of those symptoms for conditions that occur. It’s not easy to directly
transfer patients. From buprenorphine, you have to be in opiate withdrawal before you get the first
dose, and with methadone you have to build up the Methadone dose very slowly and there may be a
long wait before you can get into a Methadone treatment.
Transitioning pain patients to OAT other caveats
Not pain treatment
• Patients should not expect analgesia
• Addiction recovery focused, not pain focused treatment
environment
• Must meet DSM IV criteria for opioid addiction
• not just abuse of other drugs
• Required behavioral treatment/drug testing
• Concomitant opioid pain meds not allowed
No direct transfer of care or dosing
• Most patients must be in withdrawal to start (Bup)
• Must start from low dose and gradually build up (methadone)
Slide 39: Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction
This slide just gives you some references for finding treatment. SAMHSA has a treatment facility locator
on their website; Massachusetts State Hotline; Buprenorphine Treatment, sort of references of
Massachusetts Hotline there and the SAMHSA Hotline and lastly, the National Alliance of Advocates for
Buprenorphine Treatment, that final website also has referral information and information for patients.
I think we’ll stop now for questions. Thank you.
[Applause]
Finding Treatment
• SAMHSA Treatment Facility Locator
–http://dasis3.samhsa.gov/
• Massachusetts State Helpline 800-327-5050
–www.helpline-online.com
• Buprenorphine Treatment
–MA State hotline: 617-414-6926
–http://buprenorphine.samhsa.gov/
–www.naabt.org