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PSYCHOLOGISTS ROLE IN THE
OPIOID SAFETY INITIATIVE
Ryan Henderson
Psychologist
Team Leader Opioid Safety Program
VA Puget Sound Health Care System
DISCLOSURES
No disclosures to declare
The views expressed in this talk are those of the
authors and do not necessarily reflect the
position or policy of the Department of Veterans
Affairs or the United States government.
I am a pain psychologist with pain
medicine/management and substance use
disorder expertise, not a prescriber
GOALS
Understand history of opioids in pain management and resulting poor outcomes
Understand problematic patient/provider dynamics surrounding pain management and opioid prescribing
Discuss challenges and offer guidance for treating patients with chronic pain and OUD
Clarify roles/approaches for psychologists to improve care for patients with chronic pain on high dose opioids
OPIOIDS: PAST TO PRESENT
1980’s
Providers reluctant to prescribe opioids for terminal conditions
1990’s
Aggressive marketing of opioids by pharmaceuticals
Pain designated the 5th vital sign
2000’s
Americans, constituting only 4.6% of the world’s population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply
OPIOID OVERDOSE
DEVELOPMENT OF THE OPIOID CRISIS
DEVELOPMENT OF THE OPIOID CRISIS
OPIOID EPIDEMIC
Opioid Overdose is now the #1 cause of accidental death
The CDC has declared that we are in the middle of an epidemic of deaths from prescription drug overdose
Veterans are twice as likely to die from accidental overdose compared to the non-Veteran population
Bohnert, et al. Med Care 2011;49: 393–396;Bohnert, et al. JAMA 2011
EARLY ATTEMPTS TO IMPROVE SAFETY
2010
Opioid Management
Guidelines
Provided guidance on
factors associated with
opioid risk:
History of addiction
Higher doses
Comorbid mental
health problems
Concurrently taking
sedatives/hypnotics
RISKIEST PATIENTS ON THE HIGHEST
DOSES
OPIOIDS:
A PROBLEM OR A SOLUTION?
How do patients who are clearly at most risk end up on
the most dangerous regimens?
High desire to help, don’t know what else to do, and
want to avoid conflict… Opioids become the “solution,” not the problem
OPIOID SAFETY INITIATIVE
Launched in 2014
National mandate to improve pain management and
safety surrounding the use of opioids
Identify high risk patients
Increased monitoring
Increase Complementary and Integrative Medicine
Create collaborative programs with mental health and
primary care
Taper medically inappropriate high dose opioid patients
HIGH DOSE OPIOIDS FOR CHRONIC PAIN
Unsafe
Above 120mg Morphine Equivalence = 9x greater chance of death
Veteran risk of accidental death doubles for daily dosages above 20-50 mg MED
HIGH DOSE OPIOIDS FOR CHRONIC PAIN
Ineffective
Opioids only take the edge off, regardless of the dose
There is little evidence that long-term opioid use
improves chronic pain, function, or quality of life
Opioid induced hyperalgesia
TRENDS IN ANNUAL OPIOID PRESCRIBING RATES BY
OVERALL AND HIGH-DOSAGE PRESCRIPTIONS
All opioids High dose opioids
DEVELOPMENT OF THE OPIOID CRISIS
STATISTICALLY SIGNIFICANT CHANGES IN DRUG OVERDOSE
DEATH RATES INVOLVING SYNTHETIC OPIOIDS BY SELECT
STATES, UNITED STATES, 2016 TO 2017
STATISTICALLY SIGNIFICANT CHANGES IN DRUG
OVERDOSE DEATH RATES INVOLVING HEROIN BY
SELECT STATES, UNITED STATES, 2016 TO 2017
COMPREHENSIVE ADDICTION AND
RECOVERY ACT (CARA; 2016)
Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) Launched in 2018
National effort to increase the use of Medication Assisted Treatment (MAT) for OUD Gold standard for treating
OUD Up to 90% relapse rate
Buprenorphine/naloxone, naltrexone
Pain clinics, primary care, and mental health clinics
STEPPED CARE FOR OPIOID USE DISORDER
Self-management:
Mutual help groups
Skills application
Addiction-focused medical management in Primary Care, Pain Clinic, Mental Health
SUD Specialty Care:
Outpatient
Intensive outpatient
OTP
Residential
22
STEPPED CARE FOR OPIOID USE DISORDER FOR CHRONIC PAIN
OPIOID TAPERING IN PRIMARY CARE
Primary care is where high dose opioid problems
first surface and are initially addressed
Easy patients (e.g. agreeable, less complex)
Get tapered
Difficult patients (e.g. confrontational, complex)
Ignored
Referred to specialty services
Addictions
Pain Service
Mental Health
This is where the system breaks down
WHO’S RESPONSIBILITY IS THIS?
Pain Service
Primary CareMental Health
Addictions
Patient
THE RESULTS
Patients…
who are at risk fall
through the cracks
who need the most
support are offered the
least
get worse as a result of
our invalidating, siloed
approach to care
WHAT WE NEED TO BRING TO THE OPIOID
SAFETY INITIATIVE
#1 complaint “They don’t listen”
A relationship Best odds whatever course needs to be taken will occur
Integrative treatment
Patients understanding the biopsychosocial model
The ability to support autonomy while also conforming to opioid prescribing guidelines Goal: increase probability patient will make an adaptive choice
Ability to accurately diagnose and treat OUD in pain settings
AN INTEGRATIVE SYSTEMS APPROACH TO
HIGH DOSE OPIOIDS
Opioid Safety Program (OSP)
joint venture between…
Pain Service
Addictions Treatment Center
Mental Health
Primary Care
Goal…
to achieve the objectives of the OSI and provide
comprehensive treatment for patients engaging in the
opioid tapering process
Increase the use of MAT for patients with OUD who present
to pain clinic, mental health, or primary care (CARA;
SCOUTT)
OSP FOUNDING PRINCIPLES
High dose opioids is a systems problem Calls for a coordinated systems approach if the problem is to be
adequately addressed
Use a model equal to the task Biopsychosocial
Problem is complex, multifactorial
Build a system reflective of the model Programs exist, but integration is lacking
Complexity of the solution needs to reflect complexity of the problem Pain
Addiction
Mental Health
OPIOID SAFETY PROGRAM
OPIOID TAPERING:
HOW YOU DO IT IS AS IMPORTANT AS WHY
Some patients are
abruptly getting cut
off
Why? Pressure + Lack
of…
Time
Resources
Support
Skill
The pendulum keeps
swinging
OPIOID TAPERING PROBLEMS
Rarely is the problem knowing the formula for
strategically reducing the dose.
What is the primary difficulty?
Managing the interpersonal process surrounding
opioid tapers
Hint: this is where you come in
PAIN PATIENTS REACTION TO
PSYCHOLOGISTS
“Why am I seeing you? I have real pain. My pain
is not in my head”.
“Of course I’m depressed. You would be too if you
had my pain”.
“If they would just give me what I need I will be
fine”.
“If someone doesn’t do something about my pain
my life is not worth living”.
CO-DISCIPLINARY CARE
Efficient: one interview, no need to meet separately to discuss case
Effective: legitimizes role of psychologist and expands scope of inquiry
Give ‘em what they want and slip ‘em what they need
Embodies biopsychosocial model
Medical provider = bio
Mental health provider = psycho/social
Gives psychologists a chance to intervene where the core problems occur
THE MISSING INGREDIENT IN OPIOID
TAPERS
Always Start with Relationship, never lead with
an opioid lecture
Patients often initiate with an argument to maintain
or increase opioids
Validate concerns and postpone opioids until end of
appointment
“I want to give you feedback that treats you like a person,
not a statistic”
Do an exhaustive psycho/social history
What scares them most?
What problems other than pain contribute?
What is the function of opioids (e.g. PTSD)
BEFORE PATIENTS HEAR A NO, THEY NEED
TO HEAR A YES
Validate Patient as a person
covey understanding of who they are
That they have a real pain problem
That their fears around tapering are valid
Then Educate…
Why opioids are not recommended
How you plan to address their fears
Biopsychosocial rehab alternatives to opioids
Positive outcomes
Their influence on the taper process Compliance gives us luxury of going slow
SAFETY TRUMPS PAIN RELIEF
Primary Goal = Safety
Construct that unifies specialty services
Disagree whether pain or addiction
But can all agree safety is in question
Clarifies rationale and priorities
Safety always trumps pain relief
Communicates goals to the patient
Avoids stigma surrounding addiction
Opioid Safety Evaluation
A SYSTEM APPROACH TO ASSIST WITH
PATIENT ALIGNMENT
Decision to taper opioids determined by Opioid Safety Review Board (OSRB)
Reduces conflict
Shifts focus from should
we taper to how we taper
Allows providers to
align with the patient
Increases confidence in decision to taper Difficult to follow through if you don’t believe in what you
are doing
WHO NEEDS TO TAPER AND WHO NEEDS
OUD TREATMENT?
Pain and SUD
Overall prevalence 3 to 48% (Morasco, 2010)
Life time prevalence 16 to 74% (Morasco, 2010)
78% of patients with chronic pain report 1 or more
past‐year indicator of misuse (Morasco & Dobscha, 2008)
Borrow pain medications from others – 8%
Take more medication than prescribed – 53%
Multiple requests for opioid dose increase – 56%
Ran out of pain meds and requested early refill – 30%
Doctor shopping – 3%
WHERE WE GET STUCK WITH OPIOID
MISUSE
The way you define a problem, dictates the
solutions you look for
What is causing the problem?
Is this…
A medication problem
A pain problem
A mental health problem
An addiction problem
Because the cause is invisible it can be endlessly
debated
CUTTING THROUGH THE CONFUSION
• Avoid tendency to devolve to simplistic explanations
• Is this “real pain”
• Or is this patient simply an “addict”
• Pain and OUD are complex problems
• Tolerate ambiguity that can dominate initial evaluation
• With observation and time, more information will
become available to inform treatment
• How do I keep them engaged?
• What data should I gather?
UNDER REPORTING OF SYMPTOMS
“Pain is my only problem”
“only opioids work”
Need to rely on more than patient self-report
Chart review
Consult with past providers
Prescription Monitoring Program (PMP)
UDAS
Prescription patterns
Early refills
Family members, friends
WHERE PATIENTS PRESENT IS INDICATIVE
OF WHAT THEY THINK THE PROBLEM IS
Identify with pain
Get opioids by…
minimizing OUD
symptoms
Pain only problem
Opioids only solution
Identify with OUD
Get opioids by…
endorsing OUD
symptoms
Endorse psycho/social
problems
Pain Clinic Addictions Treatment
DIAGNOSING OUD IN PAIN CLINICS
Pain Clinic
Addictions Treatment Center
COLLABORATIVE RELATIONSHIP
Never Argue: Pushing hard for an
admission of OUD will almost always result in patients arguing against it
Emphasis patient autonomy and choice Your job = help patients
make adaptive choices Within the context of a
supportive relationship, inform them…
What choices exist
What the likely outcomes are
Patients job = make the choice and learn from consequences
Patient = pilot
Provider = navigator
Air traffic control = OSRB
44
CUTTING THROUGH THE CONFUSION:EFFECTIVE FOCUS
Separate the motive from the behavior
More effective to focus on the problematic behavior
(overusing) rather then debating the motive behind it (e.g. pain,
addiction, chemical coping)
BehaviorOpioid Misuse
MotiveAddiction?Pain?Chemical coping?
DSM-5 CERIAFORPRESCRIPTIONOUD
DSM-5 Criteria Example behaviors
Craving or strong desire to use
opioids
Describes constantly thinking about
opioids
Recurrent use in hazardous
situations
Repeatedly driving under the influence
Using more opioids than intended Repeated requests for early refills
Persistent desire/unable to cut
down or control opioid use
Unable to taper opioids despite safety
concern or family’s concern
Great deal of time spent obtaining,
using or recovering from the effects
Spending time going to different
doctor’s offices and pharmacies to
obtain opioids
Continued opioid use despite
persistent opioid-related social
problems
Marital/family problems or divorce due
to concern about opioid use
Continued opioid use despite opioid-
related medical/psychological
problem
Insistence on continuing opioids
despite significant sedation
Failure to fulfill role obligations Poor job/school performance; declining
home/social function
Important activities given up No longer active in sports/leisure
activities
DIAGNOSING OUD IN PAIN CLINICS
Complex Persistent Dependence?
Patients who are unable to taper or exhibit addictive
behaviors in the context of an opioid taper
Buprenorphine
Approved for OUD
Off label for pain?
Chronic pain Complex Persistent Dependence OUD
PSYCHOLOGISTS ROLE IN OSI
Help patients challenge the idea that pain is their primary problem and that short-term relief via opioids is their only solution
Primary problem for our most “difficult” patients is the self-defeating, short-term solutions for pain and other life problems
• Do what you do best
– Improve mental health = improve chronic pain
– Patients who are overwhelmed by chronic pain are always overwhelmed by problems independent of pain
PSYCHOLOGISTS ROLE IN OSI
Put opioids on trial, not the patient
Opioids tend to be a big part of the problem because they are
such a small part of the solution
Once therapeutic rapport is gone, so is our ability to
effectively help the patient
QUESTIONS
