RENEW OR SUBSCRIBE TO PPM
Subscription is FREE for qualified healthcare professionals in the US.
13 Articles in Volume 18, Issue #6
Authorities’ Use of Big Data May Harm—or Help—Your Chances of Investigation
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 a New High-Dose Opioid Patient
Managing Opioid Use Disorder
Medication Selection for Comorbid Pain Management (Part 2)
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.

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

Share MAT Expectations

Medication-assisted treatment consists of methadone maintenance therapy, buprenorphine maintenance therapy, or intramuscular (IM) naltrexone. Methadone should only be prescribed for OUD from a federally licensed addiction clinic (except when an enrolled patient is hospitalized).1,2,17 Methadone clinics allow for daily observed dosing and on-site addiction counselors and nurses. Buprenorphine, a partial opioid agonist, has a much wider margin of safety, and may be prescribed in an outpatient setting with less monitoring, including from a pain provider. Both buprenorphine and methadone substantially lower mortality in OUD, as well as improve other medical and social outcomes.16,18,19 IM naltrexone is an opioid antagonist delivered once a month by injection to lower opioid use and cravings, but definitive evidence of improved mortality is not available.20 Despite solid evidence for their benefit, MAT treatments are not currently made available to the vast majority of patients with OUD.21 Every effort should be made to de-stigmatize this treatment and make it available to patients in need.


Despite solid evidence for their benefit, MAT treatments are not currently made available to the vast majority of patients.

 


Anecdotally, many patients with chronic pain report that their pain is better controlled with buprenorphine than with full agonist opioids. This may be 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.

Patients with OUD are expected to have nociceptive pain flares, such as that which arises from rheumatoid arthritis, chronic pancreatitis, or Sickle Cell Disease. In these cases, methadone maintenance may be the best choice. In a pain flare, the dose of methadone remains constant to stabilize the addiction and additional opioids treat the acute pain. For patients wishing to try IM naltrexone, additional analgesic opioids are not possible. In any case, patients with OUD may successfully treat both their pain and their addiction; it is not feasible or safe to treat only one of the two diseases.

Maintain the Provider-Patient Relationship

In many cases, an addiction referral is to an off-site location, with an unknown provider, with a waiting period of a month or more. Meanwhile, the patient may worry about his or her standing with the pain clinic and the unknown. A best practice in this regard may be to facilitate the addiction referral while making reassurances to the patient. The more diagnostic work and counseling completed prior to the referral, the less uncertainty the patient may have going into the addiction evaluation. Most important, an addiction evaluation or treatment referral should not represent the end of the pain provider’s relationship with the patient. The patient may fear pain, withdrawal, stigma, and abandonment. A practitioner must make every effort to ensure that the referral process does not lead to a loss of follow-up; for example, the patient may miss the referred appointment and becoming estranged from the pain care team.

A recent meta-analysis estimated that 11% of patients treated for chronic pain with opioids have OUD22 and the eight-year mortality rate of OUD was measured at 20%.23 Therefore, when possible, a more desirable option for both the patient and the provider is for the pain physician to obtain certification in addiction care, and thus, avoid off-site referrals. Licensure to provide buprenorphine requires an 8-hour training.24 For providers interested in incorporating buprenorphine treatment of OUD into their clinic, models of support have emerged.25,26

Use All Available Tools

In demanding clinical scenarios such as that presented herein, the worst possible outcome is the loss of follow-up with the patient. Given the alarming rise of opioid-related deaths, and the underuse of life-saving medication-assisted treatment, it is the responsibility of pain physicians to ensure that patients are taken care of, which is not always easy. Patients incorrectly believe that acknowledging their addiction may invalidate their pain. In addition to patient and public education on opioid addiction, a strong screening tool for OUD is needed, as are MAT referrals when appropriate

While the process of diagnosing and treating opioid use disorder in a patient living with a chronic pain condition may be challenging emotionally and intellectually, there are tools available to successfully treat opioid addiction and pain together. With these treatments, patients may emerge happier, healthier, and more functional.

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
Continue Reading:
Managing Opioid Use Disorders and Chronic Pain
close X
SHOW MAIN MENU
SHOW SUB MENU