Transitioning a Pain Program
Away From
Chronic Opioid Prescribing
Steve
(Stephen Z. Hull, M.D.)
HullS@MercyME.com
Transitioning a Pain Program
Away From
Chronic Opioid Prescribing
• 30% of patients prescribed
opioids chronically become
addicted.
• 0.19-3.7% demonstrating
observed signs of addiction
(Fishbain DA, et.al. Pain Medicine 2008;9(4):444–459.)
January 4, 2011
Maine plagued by painkiller habit
A growing epidemic of abuse is behind
an addiction treatment rate that is
eight times the national average.
By John Richardson
jrichardson@mainetoday.com State House Bureau
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26% for purposeful oversedation
39% for increasing dose without prescription
8% for obtaining extra opioids from other doctors
18% for use for purposes other than pain
20% for drinking alcohol to relieve pain
12% for hoarding pain medications
Michael Von Korff, ScD, Annals of Internal Medicine, 6 September 2011
Perspective
A Flood of Opioids
a Rising Tide of Deaths
Susan Okie, M.D.
N Engl J Med 2010; 363:1981-1985 November 18, 2010
National Center for Injury Prevention and Control
National Center for Injury Prevention and Control
Federal Criminal Law
Chief Judge John A. Woodcock, Jr. – U.S. District Court, District of Maine
• No end organ toxicity
• No ceiling dose
• Safer and more effective than OTCs
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Addiction
Respiratory depression and overdose death
Endocrinologic dysfunction
Immune dysfunction
Opioid induced hyperalgesia
• There is no evidence from randomized controlled
trials to support the popular assertion that the
benefits of long term opioid therapy outweigh the
risks.
Major Study Limitations
• Used placebo comparators
• Invariably excluded patients at high risk of serious
adverse events
• Trials that have been completed were generally short
term (<16 weeks)
• There is no evidence from randomized controlled
trials to support the popular assertion that the
benefits of long term opioid therapy outweigh the
risks.
• The findings of this systematic review suggest
that proper management of a type of strong
painkiller (opioids) in well-selected patients with
no history of substance addiction or abuse can
lead to long-term pain relief for some patients.
Ten-year follow-up of chronic non-malignant pain
patients: Opioid use, health related quality of life
and health care utilization
Opioid Users had:
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Higher pain levels
Poorer self-rated health
Higher unemployment
Greater use of the healthcare system
More maladaptive coping skills
Lower health-related quality of life (SF-36)
Ten-year follow-up of chronic non-malignant pain
patients: Opioid use, health related quality of life
and health care utilization
Study Limitations
• Denmark has the highest use of opioids in the world
• Cross-sectional epidemiological research, cannot be
established a causal relationships
Ten-year follow-up of chronic non-malignant pain
patients: Opioid use, health related quality of life
and health care utilization
“It is remarkable that opioid treatment of longterm/chronic noncancer pain does not seem to
fulfill any of the key outcome opioid treatment
goals…"
Ten-year follow-up of chronic non-malignant pain
patients: Opioid use, health related quality of life
and health care utilization
“It is remarkable that opioid treatment of longterm/chronic noncancer pain does not seem to
fulfill any of the key outcome opioid treatment
goals: pain relief, improved quality of life, and
improved functional capacity."
A longitudinal study of the efficacy of a
comprehensive pain rehabilitation program with
opioid withdrawal: Comparison of treatment
outcomes based on opioid use status at admission
• At admission patients using opioids reported significantly
greater pain severity and depression.
• Significant improvement was found on all outcome
variables following treatment and six-month
posttreatment regardless of opioid status at admission.
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Outcome Variable Non Showing Differences
Depression
Pain catastrophizing
Pain interference
Perceived control over pain/life
General activity
Health perception
Physical functioning
Social functioning
Role limitations related to physical problems
Role limitations from emotional factors
A longitudinal study of the efficacy of a
comprehensive pain rehabilitation program with
opioid withdrawal: Comparison of treatment
outcomes based on opioid use status at admission
• At discharge, patients taking higher doses continued to
report significantly greater pain severity than the nonopioid group.
• Patients in the opioid cohort who completed
rehabilitation and opioid withdrawal maintained treatment
gains comparable to those in the non-opioid cohort.
A longitudinal study of the efficacy of a
comprehensive pain rehabilitation program with
opioid withdrawal: Comparison of treatment
outcomes based on opioid use status at admission
Study Limitations
• Self-selection bias
• Methodology of this study precluding causal inferences
suggesting patients’ functioning improved because of the
opioid withdrawal
Chronic Noncancer Pain Rehabilitation With
Opioid Withdrawal: Comparison of Treatment
Outcomes Based on Opioid Use Status at
Admission
• No significant pretreatment differences were found
between the opioid and nonopioid group regarding
demographics, pain duration, treatment completion.
• No significant differences were found regarding all
outcome variables, including pain severity, between the
opioid and nonopioid group.
Multidisciplinary rehabilitation for chronic low
back pain: systematic review
• Twelve randomized comparisons of multidisciplinary
treatment and a control condition.
• Strong evidence that intensive multidisciplinary
biopsychosocial rehabilitation with functional restoration
improves function when compared with inpatient or
outpatient non-multidisciplinary treatments.
• Moderate evidence that intensive multidisciplinary
biopsychosocial rehabilitation with functional restoration
reduces pain.
History
Interventional Pain Management
and
Medical Pain Management
1. Confirm diagnosis
2. Exhaust interventional options
3. Functional rehabilitation
a. Physical therapy/exercise
b. Cognitive behavioral therapy
c. Adaptive equipment
d. Lifestyle change
e. Medication management
Evolution
Interdisciplinary Biopsychosocial
Rehabilitation
and
Medically Managed Opioid Withdrawal
1. Patient selection evaluations
a. Physiatry/pain medicine evaluation
b. Psychiatry/psychology evaluation
c. Addiction medicine evaluation
1. Patient selection evaluations
2. Treatment program
a. 2 ½ hour treatment days
I. 1 hour of cognitive behavioral therapy
(Health and Behavior codes)
II. ¼ hour mindfulness exercise
III. 1 hour of physical exercise
(Group Medical Visit coding)
IV. ¼ hour homework assignment
1. Patient selection evaluations
2. Treatment program
a. 2 ½ hour treatment days
b. 12 week program
I. Orientation/foundational training week
II. Treatment weeks
i. 5-week opioid taper
ii. 5-week opioid free
III. Discharge planning week
c. Open ended aftercare program
Treatment Team:
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Patient
Family
Physiatrist/pain physician
Psychiatrist
Psychologist
Addiction medicine provider
Nurse Practitioner
Registered nurse
Physical therapy assistant/exercise instructor
Medical assistant
Support staff
Medically Managed Opioid Withdrawal
• Pretreatment detox
• Supported progressive taper (5-weeks)
• Adjuvant medication management
• Suboxone induction and rapid taper
• Suboxone induction and maintenance
MJ Christie, Cellular neuroadaptations to chronic opioids: tolerance, withdrawal and addiction. British Journal of Pharmacology (2008) 154, 384–396
Thanks