PTSD, Chronic Pain, and Opioid Use Disorder: A Case Discussion

Hosted by John A. Renner, Jr., MD, DLFAPA

Professor of Psychiatry Boston University School of Medicine

Director, Addiction Psychiatry Residency Training Boston University Medical Center and

VA Boston Healthcare System

August 22, 2017

Presented By: Providers’ Clinical Support System for Opioid Therapies Funding: Substance Abuse and Mental Health Services Administration PCSSMAT Partner Organizations:

American Academy of Addiction Psychiatry (lead) American Psychiatric Association 11 other national medical specialty organizations

Website: www.pcss-o.org

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

PCSS-O Webinar Series

Prescription Pain Medications and Heroin: A Changing Picture

August 22, 2017

PTSD, Chronic Pain, and Opioid Use Disorder: A Case Discussion

Jonathan Buchholz, MD Medical Director Inpatient Psychiatry VA Puget Sound Seattle, WA

At the end of the session, participants will be able to:

State challenges and opportunities associated with transitions in care for both patients and health care providers generally and those specifically related to the use of opioids chronically

Discuss non-pharmacologic and pharmacologic treatments for the management of chronic, non-malignant pain

Discuss criteria for diagnosing opioid use disorder

Discuss the experiencing transitions middle-range theory as a framework for understanding transitions between patients and their health care providers

Learning Objectives

PCSS-MAT Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid addiction.

PCSS-MAT Mentors comprise a national network of trained providers with expertise in medication-assisted

treatment, addictions, and clinical education. A 3-tiered mentoring approach allows every mentor/mentee relationship to be unique and catered to the

specific needs of both parties. The mentoring program is available at no cost.

For more information on requesting or becoming a mentor, visit

www.pcssmat.org/mentoring

PCSS-MAT Mentoring

Instructions will be provided in an email sent to participants an hour after the live session

Certificates are available to those who complete an evaluation

Recordings of all PCSS-O webinars can be accessed at

www.pcss-o.org and http://education.psychiatry.org

Session Evaluation and Certificates

Please direct your comments,

questions, and suggestions

regarding future webinars to

pcsso@psych.org

Thank You!

PTSD, Chronic Pain and Opioid Use Disorder: A Case Discussion

Jonathan Buchholz, MD

VA Puget Sound Health Care System

University of Washington Department of Psychiatry

Disclosures

• No financial disclosures

Goals and Objectives

• Understand the clinical complexity and overlapping symptoms for patients experiencing co-occurring disorders of chronic pain, opioid use disorder, and PTSD including how to assess these conditions and set expectations for care

• Describe evidence based approaches to the treatment of co-occurring PTSD, chronic pain, and opioid use disorders

• Observe strategies for supervision of trainees working with patients experiencing co-occurring PTSD, chronic pain, and opioid use disorders

Overview and Scope

• Lifetime Prevalence of PTSD • 6.8 - 12.3% in the United States (US) and Canada, higher in Veterans1

• 21.8% prevalence in Veterans2

• More than 100 million Americans suffer chronic pain3

• Lifetime prevalence of severe opioid use disorder is estimated to occur in 8-13% of patients on chronic opioid therapy4,5

• During the past decade, the number of patients seeking substance use treatment for the primary opioid use disorder has increased six-fold

• Chronic pain prevalence of 66% among veterans suffering from PTSD6

Overview and Scope Continued

• Patients with PTSD have more risk factors for pain • Higher rates of other psychiatric conditions

• Higher rates of substance use disorders

• Number of general medical conditions

• Patients with PTSD and Chronic Depression • Greater pain severity

• Greater pain related impairment

• More likely to be prescribed opioid medications for chronic pain

• More likely to have opioid use disorders

Morasco et al7

The Case of Ms. L

• You are supervising the addiction psychiatry fellow on the addiction treatment consult service who presents the case history prior to seeing the patient in person.

• Ms. L is a 48 y.o. Navy veteran • Military Sexual Trauma • PTSD • Depression • Chronic low back pain • Newly diagnosed severe opioid use disorder

• Presents to the inpatient psychiatry service following suicide attempt

Pain History

• Radiculopathy for more than 10 years

• Worsening symptoms in the last 6 years

• Reduced functioning in the last 2 years

• Multiple orthopedic surgeons have recommended against fusion or other procedures

• Subjective pain inconsistent with imaging

Pain History Continued

• Tried various combinations of pain regimens including various opioids

• 12-month history of overusing her opioids

• Broken her pain contract on several occasions during that time

• ER visit 3 weeks ago asking for more opioids, physician declined

• 2 days after the ER visit: suicide attempt via overdose of alcohol, alprazolam, and oxycodone

Recent History

• On inpatient psychiatry • Detoxified from opioids

• Started on venlafaxine and prazosin

• Suicidal ideation reduced

• Complaints of pain, anxiety and depression remain

• Chronic pain service consulted and recommended that non-narcotic treatment options be considered – patient declined

• PCP won’t prescribe opioids

• Referred to addiction treatment

• The patient reluctantly agrees - “If being in a methadone clinic is my only option, then I’ll do it.”

“Honestly, I don’t know where to begin?”

• The fellow appropriately asks for some guidance prior to assessing the patient.

• What are the clinical considerations that you would advise the fellow to assess during this consultation?

Assessment of symptoms and proper diagnosis: Top Down vs Bottom Up • Typical history obtained: Top Down

• CC, HPI, ROS, PMH/PPH/Substance history, Social, FH

• “What brings you to the hospital today?”

• Challenges to this approach with pts experiencing multiple co-occurring disorders • Current symptoms for Ms. L

Insomnia Physical pain – low back, legs and feet Anxiety Dysphoria Irritability Feeling detached/wanting to detached Feelings of guilt Numbness physically and emotionally

Anger Poor energy Constipation, nausea, low appetite Using opioids most all day (for various reasons: sleep, pain, anxiety, avoid withdrawal) Giving up on activities she once enjoyed

Assessment of symptoms and proper diagnosis: Top Down vs Bottom Up – cont. • Bottom Up

• Longitudinal life history • Childhood development – family history • Educational history • Relationship history – social history over time • Employment history • Psychiatric, medical history chronologically

• Current presentation

• Tell me what you life looked like the last time you were feeling well both emotionally and physically

Fellow: “I don’t want to sound like a pessimist but…isn’t that going to take hours?”

Establishing Diagnosis of Opioid Use Disorder

• Goals for treatment of opioid use disorders • ↓ Craving

• ↓ Withdrawal

• ↓ Illicit Use of Opioids

• ↓ Side effects

• Goals for treatment of pain • ↑ Physical Comfort

• ↑ Emotional wellbeing

• ↑ Quality of life

Setting Expectations and Engaging in Treatment

•Shared therapeutic starting point

• Fellow: “I want to help her but I’m a psychiatrist, not a pain specialist”

Working Together in Treatment

• What are the patient’s goals?

• Is there a shared starting point?

• Explicit description of what the treatment setting will look like • Negotiating this may take more than one visit

• Understand your resources, capabilities, and limitations

• Determine your own boundaries and be up front about those

Case Continued

• The Fellow assesses the patient on the psychiatry ward and has two good clinical encounters

• Diagnoses: Severe opioid use disorder, PTSD, MDD & chronic pain

• Patient wants comprehensive treatment

• Doctors give me mixed messages: “My psychiatrist says I should see primary care for pain, my primary care doc says I should see psychiatry and go to addiction care. It feels like everyone is passing the buck.”

• Interested in opioid replacement therapy but terrified about what will happen without some form of opioid

• Worried about relapse without replacement therapy

• Willing to consider alternative treatments for pain

Creating a plan

• Opioid use disorder • Medication options

• Therapy options

• Pain • Medication options

• Therapy options

• Alternative options

• PTSD • Therapy options

• Medication options

Opioid Use Disorder

Chronic Pain

PTSD

Creating a plan

• Opioid use disorder • Medication options

• Therapy options

• Pain • Medication options

• Therapy options

• Alternative options

• PTSD • Therapy options

• Medication options

Opioid Use Disorder

Chronic Pain

PTSD

Buprenorphine

CBT

Creating a plan

• Opioid use disorder • Medication options

• Therapy options

• Pain • Medication options

• Therapy options

• Alternative options

• PTSD • Therapy options

• Medication options

Opioid Use Disorder

Chronic Pain

PTSD

Creating a plan

• Opioid use disorder • Medication options

• Therapy options

• Pain • Medication options

• Therapy options

• Alternative options

• PTSD • Therapy options

• Medication options

Opioid Use Disorder

Chronic Pain

PTSD

Case Continued

• Patient agrees to treatment in Addiction Treatment Center • Fellow – medications for opioid use disorder and PTSD

• Psychologist – therapy for pain, PTSD, OUD

• ARNP - chronic pain management, coordination of care with PCP

• Question for the fellow: “What are your medication options for treatment of OUD and PTSD?”

Opioid use disorder and Chronic Pain

Benefits Drawbacks

Buprenorphine

- Flexibility in dosing (office based) - Safer - Easier to switch to methadone if bup. fails than other way around

- Patient misconceptions about pain management with bup.

- More complicated to add full mu agonists for pain relief

Methadone

- Potentially more robust engagement from OUD perspective

- More dangerous - Cannot split doses as easily up

front - Longer period of titration - Less flexibility (clinic dosing)

IM Naltrexone

- Generally Safe - Limited evidence for opioid use disorder

- Will likely not address pain

PTSD and Chronic Pain

Benefits Drawbacks

SSRIs - Best evidence for treatment of PTSD

- If PTSD improves, pain is likely to improve

- Limited evidence for treatment of pain

SNRIs - Evidence for treatment of PTSD and some pain symptoms

- Potential side effects (HTN, withdrawal)

Anticonvulsants (Gabapentin, pregabalin)

- May help both anxiety and neuropathic pain

- Limited evidence in treatment of PTSD

Prazosin - Potentially helpful with nightmares related to PTSD

- Improvement in sleep can significantly improve pain

- Lack of evidence for co-occurring PTSD and chronic pain

Structure of Treatment

• Integrated care approaches • Substance use disorders and chronic pain

• Pade 20128

• PTSD and chronic pain

• Otis 20099

• PTSD and substance use disorders

• Mills 201210

Substance use disorders and chronic pain

• Pade et al 2012 – integrated care models • Retrospective review 143 pts engaged in care at the co-occurring disorder

clinic embedded within the Primary Care Service at the Albuquerque VA.

• 65% retention rates for >6 months

• Mean pain score reduction after induction onto buprenorphine/naloxone • Mean daily dose 16mg BID/TID

• Pain treated with adjunctive measures such as non-opioid pain medications and physical therapy

PTSD and Chronic Pain

• Otis 2012 – Pilot no control group, RCT currently underway • 12 sessions

• Session 1 - Education on chronic pain and PTSD, goal setting • Session 2 - Making meaning of pain and PTSD • Session 3 - Thoughts/feelings related to pain and PTSD, cognitive errors • Session 4 - Cognitive restructuring • Session 5 – Diaphragmatic breathing and progressive muscle relaxation • Session 6 – Avoidance and interoceptive exposure • Session 7 – Pacing and pleasant activities • Session 8 – Sleep hygiene • Session 9 – Safety/trust (related to pain and PTSD) • Session 10 – Power/control/anger (related to pain and PTSD) • Session 11 – Esteem/intimacy (related to pain and PTSD) • Session 12 – Relapse prevention and flare-up planning

PTSD and Substance Use Disorders

• Mills 2012 – RCT 103 pts • Intervention group > control: ↓PTSD symptoms at 9 months

• SUD outcomes equal

• Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) • 13 individual 90-minute sessions

• Sessions 1-4 (and throughout) - Motivational enhancement and CBT for substance use + psychoeducation relating to both disorders and their interaction

• Sessions 5-12 - In vivo exposure

• Sessions 6-12 - Imaginal exposure and cognitive therapy for PTSD

• Session 13 – Summary

Case Continued

• Fellow begins office based buprenorphine • Safety profile, ability to split dosing, chronic pain and relapse prevention

• Venlafaxine and prazosin for PTSD

• Addition history of “numbness, tingling, shooting pains in my legs/feet”

• Gabapentin started for neuropathic pain and anxiety symptoms

Case Continued

• Patient stable for 2 months from OUD perspective

• CBT oriented treatment for OUD and pain

• Patient reluctant to engage in trauma focused therapy

• Still in good deal of pain

• Avoidant of leaving house

• Insomnia/nightmares

• Feels guilty that she avoids son’s soccer matches

• Talks about “letting son down” regularly

Case Continued

• Current medication list: • Gabapentin 400mg po TID

• Buprenorphine/naloxone 6mg sublingual TID

• Venlafaxine 150mg po qday

• Prazosin 4mg po qhs

• Desipramine 50mg po qhs

• Lidocaine patch 5%

• Ideas for next steps?

• Fellow: “I feel like she really needs to engage in trauma focused therapy. Is it too soon?”

Next steps – Case continued

• No studies for treatment of PTSD, chronic pain, substance use disorder simultaneously occurring

• Case • She engages in hybrid of CBT and PE over next 12 weeks

• Patient’s pain increases subjectively

• She remains engaged well with ARNP for treatment of pain

• She is attending her son’s soccer games, objectively functioning better

Current Medications

• Gabapentin 600mg po TID

• Buprenorphine/naloxone 6mg sublingual TID

• Venlafaxine 225mg po qday

• Prazosin 12 mg po qhs

• Desipramine 50mg po qhs

• Lidocaine patch 5%

• Fellow: “Patient is asking for an increase in buprenorphine for pain, what do you think?”

References

1. Resnick HS, et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol. 1993;61(6):984.

2. Seal K, et al. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. Am J Public Health. 2009 Sep;99(9):1651-8. Epub 2009 Jul 16.

3. Dzau VJ, Pizzo PA. JAMA. Relieving pain in America: insights from an Institute of Medicine committee. 2014 Oct;312(15):1507-8.

4. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: Comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis 2011;30:185–94.

5. Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain 2015; 156:569–76.

6. Shipherd et al. Veterans seeking treatment for posttraumatic stress disorder: what about comorbid chronic pain? J Rehabil Res Dev. 2007;44(2):153-66.

7. Morasco et al. The Relationship between PTSD and Chronic Pain: mediating Role of Coping Strategies and Depression. Pain 2013; 154(4): 609-616

8. Pade PA, et al. Prescription opioid abuse, chronic pain, and primary care: a Co-occurring Disorders Clinic in the chronic disease model. J Subst Abuse Treat. 2012 Dec;43(4):446-50

9. Otis JD, et al. The development of an integrated treatment for Veterans with comorbid chronic pain and post-traumatic stress disorder. Pain Medicine. 2009; 10 (7): 1300-1311