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Managing Acute Pain for Hospitalized Patients with Substance Use Disorder
Jane Liebschutz MD MPH @Liebschutz
Update in Internal MedicineOctober 10, 20191
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Patient: SS 47 yo female
Consult: Help with pain management
HPI:Presented after accidental heroin OD with compartment syndrome, rhabdomyolysis s/p fasciotomies
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Patient: JB 29 year old male
HPI:Admitted for AVR, MVR for fungal endocarditis to native valves dx’d in April 2019 Treated oral fluconazole; Worsening CV function CHF
Consult: Pain management and transition to buprenorphine
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Patient: LR 39 year old male
HPI:Admitted for R shoulder pain. Blood cultures + for MSSALeft AMA b/c pain not controlled at OSHPresented to Presby ED
Consult: Help with addiction
Learning Objectives
• Describe a framework for acute pain management in the context of opioid use disorder
• Institute best practices for managing acute pain in patients maintained on buprenorphine
• Learn a novel method to switch from full opioid agonists to buprenorphine
Addiction Is a Brain Disease
• Drugs hijack brain reward circuits
• Develop tolerance and withdrawal
• Learned behavior “Habit”
THE OPIOID EPIDEMICVolkow, N Engl J Med 2016; 374:363-371 Lewis, N Engl J Med 2018; 379:1551-1560
77https://smhsgwu.hosted.panopto.com/Panopto/Pages/Viewer.aspx?tid=88dcb04f-b129-4b94-9baf-5e34e8683f65
Opioid Use Disorder
(OUD) Symptoms
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Strong desire for opioids
Inability to control or reduce use
Continued use despite harm
Tolerance/Use of larger amounts over time
Spending a great deal of time to obtain & use opioids
Withdrawal symptoms
Increased vulnerabilities
impact experience of
pain
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Experience of Pain
Pain threshold
Social Stress
Depression-Anxiety
Financial Strain
Coping Skills
Liebschutz,2014, Current Treatment Options in Psychiatry
Pain impacts recovery from
SUD
Pain
Distress
Craving
Use
Withdrawal
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Goals of care
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Humane care
Standard medical treatmentPrevention of withdrawal
Alleviate acute painSubstance use –discussion/referral
Initiate MOUD
Linkage to Treatment
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Humane care
Non-stigmatizing language
Person who uses drugs PWUDPerson who injects drugs PWID
Impacts clinical care and treatment
decisions
Erodes confidence that addiction is a valid and treatable
health condition
Stigma
Van Boekel 2013 DAD
Patient: SS 47 yo female
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HPI:Presented after accidental heroin OD with compartment syndrome, rhabdomyolysis s/p fasciotomies
Past Medical HistoryDepressionHep C (treated)Past Substance Use HistoryHeroin- return to drug use after OD death of daughterCocaine- crack, intermittentInjection Drug use
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Case: Fasciotomies, Untreated OUD, Depression
Clinical question: Pain control and OUD
Multiple surgeries on RLE
Pt c/o pain post-op
PCA Pump:
No Basal; Hydromorphone 1 mg bolus 4x/hr 4x12= 48 mg
Hydromorphine 3 mg IVP q 6 hours 3 x4=12 mg
Humane
Medical Rx
Withdrawal
Acute pain
What option would you choose next for her treatment?
1. Methadone for both opioid withdrawal and pain2. Buprenorphine for both opioid withdrawal and pain3. Start to taper the medications so she won’t be
dependent at discharge4. Add basal dose hydromorphone
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Methadone
Mechanism of actionqAgonist at the mu
receptor. qActs in the CNS and
smooth muscleqForms: Oral, Injectable
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PharmacokineticsqLong and variable half-life for sedation,
withdrawalqOpioid-naive half life: 55+ hoursqOpioid-tolerant half-life 24 hours
qMethadone analgesia 4-8 hours
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Grissinger 2011 P & T
Cardiac risksqQT prolongation >500 ms:
q2-16% of patients on methadoneqMortality rate for cardiac arrhythmia attributable
to methadone 0.06 per 100 patient-years
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Pani 2013 Cochrane review
Long term methadoneqFederally licensed programsqDaily dosingqBarriers: transportation, time, stigma
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Pani 2013 Cochrane review
BuprenorphineqMechanism of action
qPartial agonistic effect at the mu-opioid receptors
qBinds 16x more tightly than morphine
qHalf-life 24-42 hoursq Forms
qSublingualq InjectionqTransdermalq Implant
May Precipitate Withdrawal
Office Based Buprenorphine
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First Office Based MOUD treatment
The Drug Addiction Treatment Act of 2000 • 8 hour training to qualify physicians for a waiver
to prescribe and dispense buprenorphine (24 hrs for NP/PA)
American Society of Addiction Medicine (ASAM)• Free courses- online and live
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Kosten, O’Connor. NEJM. 2003.
Withdrawal Symptom Severity
Inpatient Prescribing
Rules
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If opioid use disorder is complicating inpatient medical treatment, no need for special
waiver to prescribe:
• Methadone 20-40 mg/day• Buprenorphine 2-16 mg/day
• Needs to be in withdrawal or opioid free
What option would you
choose next for her treatment?
1. Methadone for both opioid withdrawal and pain
2. Buprenorphine for both opioid withdrawal and pain
3. Start to taper the medications so she won’t be dependent at discharge
4. Add basal dose hydromorphone
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Theoretical Concern with IR/SA Opioids
With
draw
al Pain Pain Pain Pain
Opioid Opioid Opioid Opioid
Incre
ased
Side e
ffects
Com
fort
Opi
oid
Conc
entr
atio
n
Opioid Withdrawal-Mediated Pain
What’s a MME?
• Morphine Milligram Equivalent– Tested on normal controls in laboratory conditions
• Caution when calculatingHydromorphone: 48 + 18 = 60 mg/dayConversion to Morphine = 1200 MME/day
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What we did
Basal Hydromorphone 0.5 mg/hour = 12 mg/day
Bolus: 0.5 mg every 20 minutes = 36 mg/day
Start LA Oral Morphine 15 mg bid
Stop IV Push
Motivational Interviewing for MOUD
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Markedly improved painStarting point for tapering
Patient: JB 29 year old male
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HPI:Admitted for AVR, MVR for fungal endocarditis to native valves dx’d in April 2019 Treated oral fluconazole; Worsening CV function CHF
Past Substance Use History
Heroin, stopped ~7 years ago when started on bupe;
Failed tapering à Injection drug use in December- March 2019 àendocarditis
Stable on bupe/naltrexone 16 mg/day
Buprenorphine & Surgery Option 1
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Continue bupe throughout perioperative period
Add non-opioid pain treatments
Add IV opioids as needed
Buprenorphine & Surgery Option 2
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Hold bupe morning of procedure
LA/ER opioid for basal dose (Morphine 15 bid)
PCA for breakthrough
Transition to bupe post-discharge
Buprenorphine & Major
Surgery Option 3
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Stop bupe >5 days prior to surgery
LA/ER opioid for withdrawal (Morphine 15 bid)
PCA for breakthrough perioperatively
Transition to bupe post-discharge
NOTE- RISK FOR RELAPSE HIGH OFF BUPE
Patient: AVR/MVR
post-op pain
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Hydromorphone 3 mg IV q 4 hours prn
Significant pain
Pharmacodynamics-IV Hydromorphone
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ONSET- 5 MIN PEAK- 10-20 MIN
HALF-LIFE ~3 HOURS
What we did
initially
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Start LA Oral Morphine 15 mg bid (standing)
Oral oxycodone 20 mg every 4 hours (standing)
Hydromorphone 0.5 mg IV Push q3 hours for severe pain x 48 hours
Non-Opioid Pain Options: NSAIDS
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Does Multimodal Analgesia with Acetaminophen, Nonsteroidal Antiinflammatory Drugs, or Selective Cyclooxygenase-2 Inhibitors and Patient-controlled Analgesia Morphine Offer Advantages over Morphine Alone?:Meta-analyses of Randomized Trials Anesthes. 2005;103(6):1296-1304. doi:0000542-200512000-00025
24 hr morphine consumption, weighted mean difference
Ketamine (Off label
use for pain)Non competitive reversible
inhibitor of NMDA receptor, acts on mu opioid receptor.
Impact on pain at rest over 24 hrs
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Ketamine (Off-label
use for pain)
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Impact on weighted mean difference in morphine use over
24 hrs
Gabapentinoids
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Limited evidence shows some benefit
High rates of sedation and dizziness
Potential drug of abuse with street value
DO NOT START LONG TERM TREATMENT FOR ACUTE PAIN
Transition to bupeAt initiation Continue short acting opioid regimenDay 1 Add ButransTM 20 mcg/hr patch (10 mcg/hr patch if MME 30-80/day)
Day 2 Start buprenorphine 1 mg sl, observe 2 hrs
If pain or withdrawal, administer 1-2 mg sl, observe 2 hrs
Repeat above up to buprenorphine 8 mg
Discontinue ButransTM patch
Day 3 Administer Day #2 buprenorphine dose
If pain or withdrawal, can titrate up to buprenorphine 16 mg/day
Day 4 Administer Day #3 buprenorphine dose
If pain or withdrawal, can titrate up to 24 mg/day
Consider split dosing of buprenorphine for pain management
Day 5 Continue established daily bupe dose. Taper/Discontinue other opioids
as appropriate39
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Patient: LR 39 year old male
HPI:
Admitted for R shoulder pain. Blood cultures + for MSSA
Left AMA b/c pain not controlled at OSH
Presented to Presby ED
Past Substance Use History
Heroin, since age 20
Crack cocaine
Periods of sobriety without any meds, +12-step meetings
XR-naltrexone (Vivitrol)
Case: Septic Shoulder,
Endocarditis, Untreated Addiction
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Behavioral- leaving AMA
Pain
Interested in naltrexone treatment
Plan
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Behavioral: • Build trust• Make alliance with patient
Pain:• Standing pain regimen,
including long acting
Conversion to naltrexone• Opioid antagonist• Need 7 days off all opioids
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XR-NTX vs. Buprenorphine
44 Lee 2018 The Lancet
USA n=570XR-NTX 72% inductionBup-NX 94% induction
XR naltrexone vs. buprenorphine/naltrexone
Management
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SUPPORTIVE CARE ALLIANCE WITH PATIENT
RESIDENTIAL OR CLOSE FOLLOW UP
Learning Objectives
• Describe a framework for acute pain management in the context of opioid use disorder
• Institute best practices for managing acute pain in patients maintained on buprenorphine
• Learn a novel method to switch from full opioid agonists to buprenorphine
