Treating Acute Pain in Patients with Opioid Use Disorder ......•Stigma (Chronic pain, addiction)...

Treating Acute Pain in Patients with Opioid Use Disorder in the Emergency

Department

Dr. Maureen Allen CCFP-EM(PC) FCFP

Assistant Professor Emergency Medicine

Dalhousie university

March 7-8, 2019

No Disclosure

2015-2016 2

What I Hope You Learn:

• Approach to acute pain in patients receiving opioid agonist therapy. (Methadone/Suboxone)

• Risk management strategies to minimize harm.

• Common barriers to effective pain management in the emergency department.

Rick

• 47 yo male

• Dx: FOOSH: Colle’s fracture

• Hx: IVDU, HCV +, OUD (Beganwith non-medical use)

• Rx: Methadone 125mg (Daily witnessed)

• UDT: +EDDP, +BZD

Shelly

• 32 yo mother of 3

• Dx: Appendicitis

• Hx: Opioid use disorder (Began with medical use), CNCP (Fibromyalgia)

• Rx: Suboxone 24mg SL

• UDT: + Bup

How we MANAGE PAIN MATTERS!!!

• Undertreatment can contribute to significant morbidity

• Overuse of high risk medications can also contribute to morbidity and death (opioids, BZD, sedative-hypnotics)

• It’s also about the “tools” or “habits and behaviours” we give patient’s to manage their suffering

Managing safety Managing

suffering

Oyler DR, et al. Non Opioid Management of Acute Pain Associated with Trauma: Focus on Pharmacological Options. J Trauma Acute Care Surg.

79(3):475, September 2015

Barriers to effective Pain Management in the Emergency Department

• Tools (Pain scales)

• Stigma (Chronic pain, addiction)

• Language, vocabulary (“addict”, “drug seeking”)

Mendiola CK, et al. An Exploration Of Emergency Physicians’ Attitudes Toward Patients With Substance Use Disorder. J Addict Med 12(2):132, March/April 2018

2010: Framework

STEP 1 View pain scales as SUFFERING scales

STEP 2 What TYPE of pain

ACUTE PAINAcute Pain Protocol

CHRONIC PAIN CHRONIC PAIN

FLARE-UP

CANCER PAIN OR PAIN AT EOL

PALLIATIVE CARE SERVICES

STEP 3Any interventions

indicated?

STEP 4Any alternative

therapies indicated?

STEP 5 What medication is available?

STEP 6Are there concerns of

problematic use, addiction or diversion?

Allen MA. A Community based-approach to the treatment of Pain and Addiction. Canadian Journal of Rural Medicine. 2014. 19(1)Allen MA, Jewers MH, McDonald JS. A Framework for the Treatment of Pain and addiction in the Emergency Department. Journal of Emerg Nursing. November. 2014.

What is the RISK of Opioid use disorder when opioids are used to manage Acute Pain ?

NNH1:7864

ADDICTION needs:1. Time

2. Repetition3. Vulnerable brain DIVERSION more of a

concern

Heins SE, et al, EARLY OPIOID PRESCRIPTION AND RISK OF LONG-TERM OPIOID USE AMONG US WORKERS WITH BACK AND SHOULDER INJURIES: A RETROSPECTIVE COHORT Injury Prev 22(3):211, June 2016

BIOLOGY/GENES ENVIRONMENT

DRUG/SUBSTANCE

BRAINMECHANISM

ADDICTION

Risk Factors Contributing To SUD• Chaotic home• Parent’s use and

attitudes• Academic• Role models

• Early use• Availability• Cost

• Genetics• Gender

• Route of administration• Effect of drug• “Clinical inertia”

• Mental health disorders• Brain memory

Individuals with a Lived Experience of ADDICTION FEAR

WITHDRAWAL

WORSENING PAIN

The Pain-Addiction-Anxiety Pathway: Alarm state

The Brain Decides“Amygdala” (Neighbour hood watch)

Fight, flight, freeze

The Amygdala is driven by….

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FEAR (ANGER) UNCERTAINTY UNPREDICTABILITY

As a Health care provider you can…

•Make them feel safe and cared for• Prepare them for what to

expect•Reassure them (manage pain

and prevent withdrawal)• But also..manage expectations

2015-2016 14

Acute Pain

• More about tissue damage or potentialdamage

• Has the acute warning function of physiological nociception

• 0-3 months

• Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003. • Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.

Time

PainIntensity

10

00/10

3 monthsInjury

Illness

Surgery

Unknown

Chronic “persistent” pain

• More about CNS

• Pain that persists beyondthe expected time of healing that lacks the acute warning function of physiological nociception

• > 3 months

Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003. Treede RD, Rief W, Barke A et al. A classification of chronic pain for ICD-11. Pain. 2015 Jun; 156(6): 1003-1007.Treede RD, Jensen TS, Campbell JN et al. Neuropathic pain: redefinition and a grading systems for clinical and research purposes. Neurology 2008:70: 1630-5.

PainIntensity

TimeInjury

Illness

Surgery

Unknown

10

0

>3 months

5/10

Chronic Pain “Flare-up”

• NOT caused by a new condition or progression of a pre-existing condition

• Investigations unchanged

• Often confused with ACUTE pain

PainIntensity

Time

0InjuryIllnessSurgeryUnknown

Daily baseline pain5/10

Flare-up Pain15/10

• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.

• Belgrade M, St. Marie B. Understanding and Managing Flares in Chronic Pain. Fairview Pain Management Centre.

PHARMACOLOGY TREATMENT GOALS

ACUTE PAIN

80-90% Pain reduction

Minimize Sedation

Improve Function

CHRONIC PAIN AND

CHRONIC PAIN FLARE-UP

30-40% Pain reduction

Avoid Sedation

Improve Function

CANCER PAIN OR PAIN AT THE END OF

LIFE

80-100% Pain reduction

May Cause Sedation

May Compromise Function

Treatment goals

Managing Pain in Patients Receiving Medical Assisted Therapies for OUD

• Opioid agonist(Methadone, Suboxone)

METHADONE

• Synthetic mu agonist

• Developed by the German’s in WW 2

• Potency misunderstood

• 1960’s resurfaced (opioid/heroin addiction)

• Inexpensive Analgesic

Antitussive (Prolong QTc)

Properties

• Mu and delta receptor agonist

• NMDA receptor Antagonist

• Inhibits re-uptake of norepinephrine and serotonin (SNRI)

Lynch ME. Pain Res Manag 2005: 10(3):133-44

X

Confusion regarding clinical use

Methadone

Addiction

Cravings and withdrawal

90-120mg

Chronic pain

Function

45mg

EOL

Pain

30-35mg

Pharmacokinetics

• Oral bioavailability 80%

• Lipophilic (PO; SL; PR; Buccal)

• Rapid absorption (Analgesic effect 30-60 minutes)

• 60-90% protein bound

• Steady state ~10 days

• Metabolized in liver to INACTIVE metabolites

• Excreted thru gut and kidneys unchanged

Challenges and controversy’s

• Prolonged QTc (marker for TdP)

• Central sleep apnea

• Low testosterone

• Stigma

QTc in MMT: Cochrane Review: 2013

• To evaluate the efficacy and acceptability of QTc screening to prevent cardiac-related morbidity and mortality in Methadone Maintenance Therapy (MMT).

• 872 pertinent records.

• Their finding:

• “No evidence has been found to support the use of the electrocardiogram (ECG) for preventing cardiac arrhythmias in methadone-treated opioid dependents.”

The Cochrane study, at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008939.pub2/abstract

Cochrane Review cont’d

• QTc prolongation is “not a safety concern per se,” but a “sharply imperfect” surrogate marker for the risk of TdP.

• A QTc longer than 500 milliseconds—considered the threshold of increased danger—is found in about 2 percent to 16 percent of MMT patients.

• But the prolongation isn’t necessarily due to methadone; liver disease, low potassium levels, and therapy with a variety of drugs also prolong QTc.

The Cochrane study, at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008939.pub2/abstract

Buprenorphine-Naloxone (Suboxone)

• Partial mu-opioid agonist

• High affinity (prevent binding of other mu agonist making them less effective)

• To over ride this you need strong conventional opioid at higher than normal dosing

• Naloxone (tamper resistant)

Buprenorphine-Naloxone

• Ceiling effect to both it’s euphoriant potential and it’s toxicity

• Safe-er in overdose

Managing Pain: Important principles for Patient’s on OAT

• CONTINUE opioid agonist therapy

• Establish realistic Goals of care

• Consider “split-dosing” OAT (stable, close oversite)

• What if they can’t swallow?

• Retrospective case series

• 2013-2015

• 30 patients

• Palliative care program

• Rural community, hospital and nursing home

• Oral to atomized dosing the same

• 10mg/ml; 50mg/ml

Interventions

• Clinical actions that have the ability to modify the pain experience

Alternative therapies

• Therapeutic practices that have the healing effects of medicine but are not based on a scientific model

ACUPUNCTURE VS INTRAVENOUS MORPHINE IN THE MANAGEMENT OF ACUTE PAIN IN THE ED Grissa, M.H., et al, Am J Emerg Med 34(11):2112, November 2016

Medications

• Elia N, Lysakowski C, Tramer MR. Does multimodal analgesia with acetaminophen, nonsteroidal anti-inflammatory drugs, or selective cyclooxygenase-2inhibitors and patient-controlledanalgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296-304.

• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.• Belgrade M, St. Marie B. Understanding and Managing Flares in Chronic Pain. Fairview Pain Management Centre.

How Complicated can it be?

Pharmacological choices• Acetaminophen (Tylenol)

• NSAID’s (Advil, Aleve etc)

• TCA (Elavil)

• Anticonvulsants (Lyrica, Gabepentin)

• Broad spectrum antidepressants

(Duloxetine, Effexor)

• Calcitonin

• Topicals

• Opioids

• Cannabinoids

• Lidocaine, Ketamine etc...

• Low dose naltrexone

• Gamma hydroxybutyrate (GHB)

• Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.• CALCITONIN FOR TREATING ACUTE PAIN OF OSTEOPOROTIC VERTEBRAL COMPRESSION FRACTURES: A SYSTEMATIC REVIEW OF RANDOMIZED, CONTROLLED TRIALS Knopp, J.A., et al, Osteoporosis

Int 16:1281, October 2005• *CHOICES BEFORE OPIOIDS for CNCP: DALHOUSIE CPD Academic detailing service, April 2018. http://www.medicine.dal.ca/departments/core-units/cpd/programs/academic-detailing-service.html

Multi-modal Analgesia: Acetaminophen and NSAID’s

• Cochrane data base• Moore, (2015)• Pain reduction at 6 hours• Several analgesia (OTC)• Most effective was a combination

(SA) (Acetaminophen 500mg/Ibuprofen 200mg) NNT: 1:6 (Success rate 67%)

• If you double the dose NNT 1:5 (Success rate 70%)

• Single dose medication (Ibuprofenbetter than Acetaminophen)

• Moore RA, et al. Non-prescription analgesic(OTC) oral analgesic for acute pain-an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015 Nov 4;1(11): CD010794 PMID: 26544675.• Chang AK, et al. Effect Of A Single Dose Of Oral Opioid And Nonopioid Analgesics On Acute Extremity Pain In The Emergency Department. JAMA 318(17):1661, November 7, 2017

Multi-modal Analgesia: Low dose Ketamine (LDK)

• Gottlieb, (2018)• Meta-analysis• 8 articles. Total 609 patients. (6 RTCTs

and 2 observational)• Dose range LDK was 0.1-0.5mg/kg IV.

Comparative group was IV Morphine 0.05-0.1 mg/kg)

• Results: No significant difference in pain scores at 30min

• Increase adverse events LDK group (15.4% vs 4.4%) agitation, hallucination that were self-limited

• Gottlieb M, et al. Is Low-Dose Ketamine An Effective Alternative To Opioids For The Treatment Of Acute Pain In The Emergency Department? Ann Emerg Med 72(2):133, August 2018

Multi-modal analgesia: Calcitonin for compression fractures

• Knopp, (2012)

• Systematic review and meta-analysis

• Acute and Chronic pain

• 5 RTCs

• 246 patients

• IM/IN/PR (Salmon calcitonin)

• Effective analgesia acute pain not chronic

• Few side-effects

• Cost and optimized dosing not evaluated

• IN spray: 50-100mcg daily

• Knopp JA, et al. Calcitonin for treating acute and chronic pain of osteoporotic vertebral compression fractures: A Systematic Review of Randomized Controlled Trials.Osteoporosis. Int 16:1281, October 2012

If Discharged: How much opioid and for how long?

• It depends

• Chai et al (2017)

• Acute fracture in 15 opioid-naïve patients (mean age 45 years; 60% male)

• As few as six pills (5mg oxycodone) may be sufficient for acutely painful conditions

Chai PR, et al. Oxycodone Ingestion Patterns In Acute Fracture Pain With Digital Pills. Anesth Analg 125(6):2105, December 2017

If Opioids used: How much and for how long?

• Duration (3 days)

• Quantity (<10)

• Non-euphoriant

• Non-combination

• Oxycodone; Hydromorphone (More euphoriant)

• Recommended: IR Morphine

• Daily witnessed dispensing

How much SA opioid is enough for BTP?

• It depends….

• What else is in the mix?

• Hypnotic-sedatives?

• Liver or Renal Disease?

• Elderly?

• 1-1.5 times normal dosing

Managing safety Managing

suffering

Oyler DR, et al. Non Opioid Management of Acute Pain Associated with Trauma: Focus on Pharmacological Options. J Trauma Acute Care Surg.

79(3):475, September 2015

Rick

• 47 yo male

• Dx: FOOSH: Stable Colle’s Hx: IVDU, HCV +, OUD (Began with non-medical use)

• Rx: Methadone 135mg (UDT +EDDP +BZD)

• Pain intensity 6/10

Talking Points (Pain Specific)

Interventions: Splinting early

Alternative Therapies: Breath, acupuncture

Medications: Procedural sedation (Fentanyl, propofol)

Risk Management (Safety) Morphine IR, Tylenol, NSAID, Bowel regieme

ACUPUNCTURE VS INTRAVENOUS MORPHINE IN THE MANAGEMENT OF ACUTE PAIN IN THE ED Grissa, M.H., et al, Am J Emerg Med 34(11):2112, November 2016

Shelly

• 32 yo mother of 3

• Dx: Appendicitis

• Hx: Opioid use disorder (Began with medical use), CNCP (Fibromyalgia)

• Rx: Suboxone 24mg SL (UDT + cocaine)

• Pain intensity 12/10

Talking Points (Pain Specific)

Interventions: Anesthesia (blocks)

Alternative Therapies: Breath, distraction

Medications: (Fentanyl, IV Morphine)

Risk Management (Safety) Morphine IR, Tylenol, NSAID, Bowel regime

Summary

• How we talk with patient’s about pain matters

• Develop a systematic approach to pain

• Communicate, communicate, communicate!!

• Be open, curious and non-judgemental

• Manage risk with the patient to keep them and the community safe

Managing safety Managing

suffering

• Dr. Maureen Allen

• jimandmoe@eastlink.ca

• (902) 870-0853

The complexity of pain andsuffering

PHYSICAL

SOCIAL SPIRITUAL

TOTAL PAIN

Kross E, Berman M, Mischel W, et al. (2011) Social rejection shares somatosensory representations with physical pain. Proceedings ofthe National Academy of Sciences, 108, 15: 6270-6275.

EMOTIONAL

VIEW PAIN SCALES as

SUFFERING SCALES

Talking Points

• Listening

• Acknowledging suffering

• Re-framing role of pain

• Reassuring (cared for)

• Recognizing that the pain experience is Influenced by many factors

Pain scales..

• CTAS: “Sets the tone”• Can lead to stigma and over

medicating• Accurately reflects the

intensity of pain the patient is experiencing (subjective)

• Don’t always tell us what’s going on in the patient’s tissue

• Why is this?

Opioid Use Disorder: Extent of the problem

TOTAL # OF CANADIAN DEATHS

FROM SARS

44

CANADIAN DEATHS PER WEEK FROM OPIOID

OVERDOSE

49

Reality Check

• Fatalities are on the rise

• ¾ Fentanyl or Fentanyl analogues (2013: <300 deaths/year, 2018: ~1000 )

• Increase in male 30-39 years

• 94% accidental (unintentional)

Mortality trends

• Increase shift toward 1st time users

• Those with CNCP (Historically LT drug users

• Canadian seniors: 30% of all deaths in 2017 >50 yo

• >65yo had highest rate of hospitalizations (stay longer >8d)

Talking to patients about Pain

52

Universal

Majority(Pain experiences)

OK

Some(Pain experiences)

“Disruptive pain experience”

Persistent (chronic) pain

• 1:5 (1:4 elderly)• ~200,000 NS• ~30,000 PEI• ~190,000 NB

Survival

Pain circuitryre-wired

(neuroplasticity)

What Tools do we have to manage pain?

• “Talking Points”

• Interventions

• Alternative therapies

• Medication

• Breath

• Safety: Risk stratification

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