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13 Articles in Volume 18, Issue #6
Advice for the Advanced Practice Provider
Authorities’ Use of Big Data May Harm—or Help—Your Chances of Investigation
Considering Comorbidities When Selecting Medications (Part 2)
Gaps in the Pharmacist’s Pain Management Role
How can cyproheptadine manage complicated chronic pain cases?
Letters to the Editor: Trackable Pills; Buprenorphine; CRPS Diagnosis
Managing Opioid Use Disorder
Mobile Trackers and Digital Therapeutics
New Insights in Understanding Chronic, Central Pain
Nocebo Effects: How to Prevent them in Patients
Polarizing Topics in Chronic Pain
The Fight to End Peripheral Neuropathy
Urine Drug Monitoring

Managing Opioid Use Disorder

A clinical action plan for assessment, referral, and medication-assisted treatment.
Page 1 of 2

Hypothetical Case

A 55-year-old woman presents with rheumatoid arthritis and destructive arthropathy from past disease activity. Among her treatments, she is prescribed 10 mg of short-acting oxycodone four times a day. She exceeds this dose frequently. The prescribing physician believes she does this to self-medicate her untreated depression: she lives alone and has not coped well with her disability. Despite repeated reminders of her pain agreement, she runs out of her prescribed dose early every month, experiencing withdrawal. She visits emergency rooms, makes appointments with other community practitioners, and pleads for more opioids.

A recent urine drug screen revealed an opioid not prescribed to her. The patient insisted that the test result was inaccurate, however, her actions bring into question the advisability of continuing opioids. At the same time, her chronic condition warrants strong analgesic treatment. The physician-patient relationship is becoming contentious, and the physician begins to dread seeing her name on the schedule.

The prescribing physician, in this case, may think, “Has the patient developed an addiction to the opioids prescribed? If so, does her addiction preclude opioid treatment for her arthritis?” Pain care providers face similar questions every day and, increasingly, managing pain requires the recognition and treatment of opioid use disorder (OUD). Incorporating OUD screening, diagnosis, and treatment into the opioid therapy regimen for a patient with pain has been strongly recommended and reinforced in recent guidelines, with evidence showing that timely intervention may improve mortality rates.1-4 The following sections offer recommendations for integrating this practice while addressing growing challenges in addiction, not to be confused, in this case, with physical dependence to opioids.

Educate

Educating a patient about OUD before initiating opioid therapy should be standard practice, even among patients with little to no identifiable risk factors (eg, a mental health disorder or history of substance abuse),5 as it is impossible to predict who may develop an addiction. More than half of the opioids prescribed for pain in the United States go to patients with serious mental illness (who represent one-sixth of the population).6 Patients on high-dose opioids are more likely to have an addictive disorder.7 OUD has a strong genetic component as well.8 But even low-risk patients may develop OUD. Providers should engage all patients about their relationship with opioids throughout the course of treatment. Inviting patients to share whether they are struggling to control how they take their medication may be more effective than simply warning them of the consequences if they break the pain agreement.

Screen & Query

Most screening tools used in pain management are validated to predict the misuse of opioids rather than an addiction to them.9,10 Unlike opioid misuse, which signifies a worrisome behavior, OUD is a chronic medical disease that carries a grave prognosis and has life-saving treatments. Pain providers should not mistake misuse for addiction. No currently available screening tool functions adequately to identify OUD in pain patients. However, the recently released TAPS tool for substance use screening in primary care patients may be completed in the waiting room; it offers reasonable sensitivity and specificity for OUD.11 In addition, the National Institute for Drug Abuse has a one-question screening tool that may serve to start a conversation with a paitent. That question is: "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?"12

Ultimately, a diagnosis of OUD requires the provider to be familiar with the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5) of Mental Disorders’ OUD criteria.13 In practice, many pain providers monitor patients through urine drug screens and prescription drug monitoring program (PDMP) queries, and respond to “red flags” with a diagnostic interview for addiction. This approach is reasonable, but providers are also encouraged to regularly review their monitoring procedures, their list of red flags, and their knowledge of the DSM-5 OUD criteria to ensure consistency and accuracy with current best practice.

Pursue an Accurate Diagnosis

A common outcome of a diagnostic interview for OUD is an indeterminate diagnosis. Patients are often reticent to disclose their pill-taking behaviors and sometimes lack the insight about how their relationship with opioids has become unhealthy. Also, OUD itself may not develop all at once, but rather, evolve over the course of many months, leaving a patient in a diagnostic grey zone.

Like many things in medicine, an accurate OUD diagnosis can only be reached after extensive patient counseling and careful monitoring, which may take multiple visits. For patients with an indeterminate diagnosis of OUD, frequent follow-up, increased urine drug monitoring and PDMP queries, repeated patient education, and interventions, such as providing the patient with a naloxone rescue kit for opioid overdose, to improve patient safety may be beneficial.14,15 In addition, a review of the indication for opioids is warranted. For example, physicians often realize that the initial pain generator has resolved after a period of opioid therapy, making continued benefit of the prescribed medication questionable. While gathering this information, pain providers may prepare the patient for receiving a possible diagnosis of OUD, including possible next steps.

Refer & Reassure

When concern of OUD arises, pain providers may refer the patient to an addiction specialist for diagnostic evaluation and, if appropriate, medication-assisted treatment (MAT) with behavioral counseling.16

I would like to offer some additional perspective to the article titled “Managing Opioid Use Disorder” by Charles Reznikoff, MD, FACP, published in the September 2018 issue. As someone who is certified in both addiction medicine and pain management, I found this article very interesting. However, it also raised some concerns.

In the hypothetical case presented of a patient who frequently exceeds her prescribed dose of 10 mg short-acting oxycodone four times a day, Dr. Reznikoff wrote: “The prescribing physician believes she does this to self-medicate her untreated depression.” This could well be true, yet the article does not address the importance of evaluating or treating the patient for depression, nor does the author discuss getting to know the patient, such as through dialogue or psychological assessment. I believe that this is an important part of treating addiction before turning directly to medication-assisted treatment, or MAT. Moreover, this hypothetical patient might be not an addict but rather a “chemical coper,” using oxycodone IR, the most popular and effective opioid for anxiety and depression, to treat her psychological symptoms.

Later in the article, Dr. Reznikoff hypothesizes that buprenorphine may be more effective at controlling pain than methadone “due to its long half-life, which prevents daily withdrawal episodes, or because the full agonist was causing opioid-induced hyperalgesia, or a result of the somaticized pain.” With regard to hyperalgesia, I believe he is introducing a very controversial matter that does not particularly help in addressing Opioid Use Disorder. According to the literature, the concept of opioid-induced hyperalgesia has never been shown to be clinically relevant in a chronic pain setting. The author also states that for patients with pain and opioid use disorder (OUD) on methadone maintenance, the methadone may be the best choice for treating their pain. I agree with this, but it is important to note for prescribers that methadone is not a long-acting analgesic; thus, when it is used for treating chronic pain, it must be given in divided doses, 3 to 4 doses a day, whereas 1 daily dose will suffice in preventing withdrawal symptoms. Dr. Reznikoff was right to point out that physicians working in pain management should consider obtaining certification in addiction care, and thus, avoid off-site referrals. However, the existing 8-hour buprenorphine courses focus on the technical aspects of buprenorphine, and do little in the way of explaining the psychological parts of treating addiction. In my live, national 21-CME remedial/proactive opioid prescribing course (see https://professionalboundaries.com/prescribing_course/1), I have met dozens of clinicians who have taken the buprenorphine course and now have a stable of patients on the medication, but few of these doctors have attended a 12-step meeting (such Alcoholics Anonymous or Narcotics Anonymous) or recommended group therapy/support 12-step groups to their patients. This additional training would go a long way toward improving addiction treatment and best serve the patient’s long-term interests.

Last updated on: October 11, 2018
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Managing Opioid Use Disorders and Chronic Pain
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