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12 Articles in Volume 17, Issue #2
Chronic Pain and Bipolar Disorders: A Bridge Between Depression and Schizophrenia Spectrum
Differences in Pain Management of Peripheral Vascular Disease and Peripheral Artery Disease
Duloxetine and Liver Function Tests
How Well Do You Know Your Patient?
Insurers End Policies Requiring Prior Authorization for Opioid Use Disorder
Letters to the Editor: Initiating Hormones
Managing Opioid Use Disorders and Chronic Pain
Opportunities and Challenges of Pain Management: The Family Physician’s Perspective
Pathways to Recovery From Co-Occurring Chronic Pain and Addiction
Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain
Treating Multiple Pain Syndromes: A Case Series Using a Functional Medicine Model
Treatment of Chronic Exhaustion and Chronic Fatigue Syndrome

Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain

Interview with Jordan L. Newmark, MD, clinical assistant professor in the Division of Pain Medicine and, by courtesy, Addiction Medicine, and associate division chief of education at Stanford University School of Medicine.

In a patient with chronic pain who develops an opioid use disorder (OUD), what factors go into the decision of whether or not to wean the patient off opioids?

Dr. Newmark offers strategies for weaning patients off opioids.Jordan L. Newmark, MD

Dr. Newmark: In patients with an OUD, overdose or toxicity as the most major concern, a number of monitoring tools exist to help reduce the risk for these serious consequences. Keep in mind that none of these tools are flawless, therefore sound clinical judgment, combined with the principle of “safety first,” is essential in caring for these patients. Also, having a low threshold for seeking consultation from an addiction medicine specialist for comanagement is important to consider.  

The first tools are state prescription drug monitoring programs (PDMPs). Checking the PDMP every time you see a patient while on opioid therapy is essential. If the patient simultaneously received an opioid prescription from another physician without clear and reasonable purposes (for example, after a surgical procedure), this may signal aberrancy, and the need to either wean or stop prescribing.

The second tool is the 4 A’s screening tool (analgesia, activities of daily living, adverse effects, and aberrant drug-related behaviors),1 which helps determine whether the benefit of continued opioid use outweighs the risk in the chronic pain population. If a patient is determined to be at higher risk for adverse effects, consideration should be made to reduce the opioid dose or wean treatment. Also, if a patient is not showing improved function, but is showing side effects—such as sedation or aberrant drug taking—consideration should be given to lower the dose or wean treatment.

In contrast, if the patient is treatment adherent and functioning well, this may suggest that opioid treatment is effective, and consideration should be given to continue treatment as long as that benefit outweighs any potential risks found.

A third tool is called the 4 C’s (see Managing Opioid Use Disorders and Chronic Pain), which can be used to screen for a substance use disorder.2 If the patient has an OUD, presumably, he or she will answer yes to 1 of the 4 C’s.

Finally, in-office pill counts and urine drug testing help ensure the patient is taking prescribed opioids on time and as scheduled, and is not taking any other unexpected substances. These safety checks help protect the patient from harm, and protect the physician as well. However, none of these tools are perfect. Recognizing both their benefits and potential weaknesses will allow you to make the best clinical decisions for your patient.

Optimally, patient expectations should be set up-front, before opioid therapy is initiated. I tell patients, “You are going be monitored while you are on the medication. We will ask you about your function and want to make sure you meet certain goals, such as increasing physical activity. If you are not meeting those goals, then the dose needs to be adjusted such that your goals are met, because we do not want to expose you to the potential risks of chronic opioid therapy for no benefit to yourself.”

If this conversation has not occurred, or you are seeing a new patient who comes to you already taking chronic opioid therapy, risk management is a little more challenging. However, at the end of the day, try to align the patient’s goals with your goals, which should be to improve function and quality of life.

What do you do if the patient is unhappy with your decision to reduce the dose or wean from opioids?

Dr. Newmark: When delivering the message, you need to take a moment to breathe, and put on your “breaking-bad-news hat,” which was taught to you in medical school. This reminds you to be empathetic with the patient. Preliminary, unpublished simulation-based research I conducted with my colleagues indicates that if you exhibit empathy and communicate clearly with the patient about your concerns and why you are making a treatment change, usually, the patients will align with your goal and be satisfied with that treatment alteration.

This was a surprising research finding. I would have thought that giving the patient what he or she asked for (ie, more opioids) at least in a simulated environment, would have led to higher patient satisfactions scores as well as higher prescribing rates. Instead, I found the exact opposite, with clinicians in a simulated environment who were more restrictive with opioid prescribing and did the most monitoring actually ending up communicating better, having safer prescribing patterns, and the simulated patients thought that those were the most satisfying interactions.

While these conversations can be anxiety-provoking, with practice, the patient is not likely to get upset. Again, the bottom line is that you have to keep yourself and the patient safe, no matter what.

Another strategy is to align the patient’s family members and friends with the goals of treatment, so that they can secondarily sell the patient on the idea of reducing or stopping the opioid dose down the road, should that be warranted. Often patients need time to think over and process your conversation, and then may agree with the treatment change.

What is the optimal weaning strategy for those patients for whom weaning is considered the best choice?

Dr. Newmark: The optimal strategy depends on the degree of aberrancy. If the patient is engaging in high-risk behaviors that put him or her at risk for overdose, the patient should be weaned aggressively. And what do I mean by that? This is more of an art than a science. In general, I would probably wean over a less than 2- or 3-week time frame, and give patients adjuvant treatments, such as gabapentin for pain, clonidine for pain and withdrawal symptoms, ondansetron for withdrawal symptoms, and loperamide for diarrhea.

For these higher risk situations, other things to consider include making an extra effort to educate the patient and family on the signs and management of toxicity or overdose, discussing the use of a locked box system to keep medications secure, having family or friends dispense the opioid medication to the patient to ensure compliance with proper dosing schedules, and having naloxone available in the patient’s home as a rescue in case of overdose.

I explain to the patient that the process will be challenging and to align your family and friends with your treatment to have as much social support as possible. Make it clear that you are not abandoning their care, and that ultimately this change will lead to a safer, better outcome.

Another important consideration, as I mentioned earlier, is to have an addictionologist or addiction-related clinician involved during the weaning process because pain management specialists are not always well-trained in the addiction space. If the patient’s behavior is less concerning, or if you are more focused on side effects rather than aberrancy, weaning can be done more slowly, such as over a several-month period. It comes down to safety first and what the goals of weaning are.

One of my pain medicine colleagues at Stanford, Dr. Ming Kao, has developed an opioid taper tool, which he presented at the American Academy of Pain Medicine annual meeting in 2016. That information should be accessible through the academy.

How do you treat pain flares in a patient being tapered or weaned from opioids?

Dr. Newmark: This is where patient education, as well as pain psychology, can play a key role. It is important for patients to understand that pain flares often do not represent harm to the body, and that the use of pain coping skills, such as deep breathing exercises, biofeedback, relaxation, and strategies targeted to combat pain catastrophizing, can help reduce their pain experience. The problem is that access to pain psychology may be limited, especially in remote areas.

In terms of pharmacotherapy for pain flares, I typically dose gabapentin 3 times per day, and tell patients that they can take a fourth or a fifth dose during a flare, if they do not have kidney disease. However the patient’s active engagement in coping strategies, rather than relying on a passive, biomedical modality (eg, opioids) is the ideal.

How do you choose between buprenorphine/naloxone (Suboxone) and methadone for OUD treatment?

Dr. Newmark: For the highest-risk patients, I think buprenorphine is a much better choice given its higher safety profile. Methadone is better for patients who have physical dependency issues, rather than aberrancy, and are having a lot of problems weaning from opioids. However, methadone has a lot of drug-drug interactions with other medications that can lead to overdose events, and thus, is not a great choice for patients with a high degree of aberrancy or general medical complexity.

How long should patients stay on treatments for OUD such as methadone, buprenorphine, or naltrexone?

Dr. Newmark: These treatments often need to be taken long term, because addiction is a chronic disease much like asthma or diabetes. It may need to be managed for much of a patient’s life.

Ultimately, the length of opioid treatment depends on whether the pain condition resolves. Patients whose chronic pain conditions do resolve can consider stopping opioid therapy. Patients whose pain conditions do not resolve and who are getting good benefit with buprenorphine can remain on treatment long term. This high-risk population should remain in addiction-related treatment to ensure that they are safe. Note with buprenorphine that if the patient has elective surgery planned, he or she should be seen in a preoperative anesthesia or pain clinic to have his or her dose reduced or tailored for the upcoming perioperative journey.

Any other advice on managing OUD in chronic pain for our readers?

Dr. Newmark: Pain management is a team sport. When you are treating a patient with chronic pain and a coexisting OUD, you will need to incorporate additional resources than you otherwise would for your general pain population. This includes collaborating with colleagues who specialize in addictionology, pain psychology, and mental health.

Preventing relapse can be a challenge, and the patient should be actively involved in addiction-related care to help prevent relapse. Make sure that the team is collaborating with one another and reminding the patient to be consistent with these treatment modalities.

If you do all of these different steps—use the monitoring tools, clearly explain to the patient why you are making certain decisions, and align your goals and with patient’s goals, and collaborate with other specialists, you and the patient will be set up for success. All of these steps take time and effort, but practicing in this way will lead to elevated outcomes, a rewarding group of patients, and a rewarding practice.

Last updated on: March 17, 2017
Continue Reading:
Opportunities and Challenges of Pain Management: The Family Physician’s Perspective

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