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Opiate Use Disorders and Pain in the elderly: Integrating care with the pain specialist

Gabriel Paulian M.D

Christopher Ong, M.D

Yuliet Sanchez, M.D

Uma Suryadevara, M.D

No disclosures for any of the speakers!

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Where’s the pain?

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Algorithm for a general approach to the assessment of chronic nonmalignant pain

ROBERT P. JACKMAN, MD, JANEY M. PURVIS, MD, Cascades East Family Medicine Residency Program, Oregon Health and Science University, Klamath Falls, Oregon

BARBARA S. MALLETT, MD, Spinal Diagnostics, Tualatin, Oregon

Am Fam Physician. 2008 Nov 15;78(10):1155-1162.

WHO Step Ladder Approach

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Are opiates indicated in my patient?

Influences on therapeutic decisions:

Outcomes during prior therapies

Pain severity and course

Age and medical comorbidities

Reasonable alternatives

Likelihood of addiction/abuse/diversion

Critical outcomes

Pain relief

Function - physical and psychosocial

Side effects

Drug-related behaviors: abuse, addiction, pseudoaddiction, diversion

If they are indicated: what are the possible outcomes

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Barriers to Opioid Therapy

Patient-related factors

• Fear of addiction

System factors

• Availability in pharmacies

Clinician-related factors

• Poor knowledge of pain management, opioid pharmacology and chemical dependency

• Fear of regulatory oversight

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Opioid Therapy: what are my options?

Immediate-release preparations Used mainly :

opioid naïve patients

acute pain

dose finding during initial treatment of chronic pain

“rescue” dosing (breakthrough pain )

Can be used for long-term management in select patients

Dose limit?

Duration of opioid therapy—lifetime?

Tolerance

Hyperalgesia

Opioid Therapy: what else do I need to know?

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Opioid Therapy: Side Effects

Common

Constipation

Somnolence, mental clouding

Less common

Nausea -Sweating

Myoclonus -Amenorrhea

Pruritus -Sexual dysfunction

Urinary retention -Headache

Opioid Therapy

Scenario 1:

67 y/o F with PMHx of chronic knee pain secondary to severe DJD managed with OXYCODONE/APAP 5/325 1 tab po QID

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Opioid Therapy

Scenario 2:

72 y/o M with PMHx of low back pain secondary to failed back surgery managed with METHADONE 10 mg po Q 8 hrs

Opioid Therapy

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Psychiatric Comorbidities

Depression is present in more than 50% of patients with chronic pain.

Severity of pain is a strong predictor of worsening depression and health-related quality of life outcomes.

Treatment options in the context of pain: Medications (SSRIs, anxiolytics, TCAs), CBT, Complementary and alternative treatment, Lifestyle changes

Psychiatric Comorbidities: Depression

Chronic pain is an important risk factor for suicide.

Suicide Risk assessment tools in patients with pain.

Consider other treatment options if patient is at a higher risk for suicide or depression: A delicate balance!

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Psychiatric comorbidities: Anxiety

Treatment in the context of pain: Antidepressants (SNRIs, TCAs) psychological treatments, other anxiolytics.

Benzodiazepines: The main actions are hypnotic, anxiolytic, anticonvulsant, myorelaxant, and amnesic.

Adverse effects in elderly from Benzodiazepines: psychomotor impairment, occasionally paradoxical excitement, falls and fractures, intellectual and cognitive impairment.

Some Important Data:

2004 to 2008: 111% increase in the estimated number of emergency department visits involving nonmedical use of opioid analgesics.

2004 to 2008: 89% increase in such visits for benzodiazepines.

From 2007-2011: Opioid prescribing rates increased 32 percent. 2010 data: Opioid analgesics were involved in 75% of pharmaceutical overdose deaths.

cdc.gov

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Benzodiazepines

Data from the National Vital Statistics System multiple cause-of-death file: Benzodiazepines were involved in 31% of opioid-analgesic poisoning deaths in 2011, up from 13% in 1999.

Prescribing Benzodiazepines with Opiates is DANGEROUS!

Alternatives for Benzodiazepines

Substance Use Disorders: Another Comorbidity

Pain

Chronic pain

Physical dependence

Tolerance

Addiction

Pseudoaddiction

Hyperalgesia

Opioid induced hyperalgesia

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Substance Use Disorder

Addiction

Chronic pain and depression can predispose to benzoabuse and dependence

Risk increases with age and more common among patients on multiple medications

Commonly used questionnaires are less sensitive in the elderly

Opioid Use screening tools

SOAPP (Screener and Opioid Assessment for Patients with Pain-Revised)

ORT (Opioid Risk Tool)

DIRE (Diagnosis, Intractability, Risk, Efficacy Tool)

SISAP (Screening Instrument for Substance Abuse Potential)

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Ongoing assessment tools:

COMM (Current Opioid Misuse Measure)

ABC (Addiction Behaviors Checklist)

Chabal 5-Point Checklist

PMQ (Pain Medication Questionnaire)

PDUQ (Prescription Drug Use Questionnaire)

PADT (Pain Assessment and Documentation Tool)

Working together

Treatment options like CBT, Relaxation therapy and group therapy.

Treat pain and psychiatric comorbidities together.

Multidisciplinary treatment approach: best approach for pain management.