Chronic Pain Management in Individuals with Substance Use Issues

Chronic Pain Management in
Individuals with Substance Use Issues
Lisa Lefebvre, MDCM, MPH, CCFP, Dip. ABAM
Centre for Addiction and Mental Health
Laura Murphy, PharmD, ACPR, BScPhm
University Health Network
Faculty Disclosure
 Program Name: OMA Physician Health Program
“Train The Treater” Education Day
Faculty:
Lisa Lefebvre and Laura Murphy
 Relationships with commercial interests:
 We do NOT have an affiliation with pharmaceutical, medical
device or communications organizations
Disclosure of Commercial
Support
 Dr. Lefebvre and Dr. Murphy have both received an honorarium from
the OMA PHP for this presentation
 This program has received NO in-kind support in any form
 Potential for conflict(s) of interest:
 None
Mitigating Potential Bias
 We have NO potential sources of bias in the presentation.
Acknowledgements
 Thank you to Dr. Andrew Smith for his contribution of
slides for this presentation
Chronic Pain Management in
Individuals with Substance Use Issues
 Learning Objectives:
 Identify the risks inherent in managing chronic
pain in individuals with substance use disorders
 Apply strategies drawn from the NOUGG
guidelines to mitigate these risks and improve
individual outcomes
Question
What percentage of North Americans are currently
experiencing pain which has gone on for more than
6 months?
1. 2%
2. 5%
3. 10%
4. 20%
Question
What percentage of Ontario middle and high school
students (Grades 7-12) used opioids for nonmedical purposes in the past year?
1. 5%
2. 7%
3. 10%
4. 15%
Question
Opioid therapy can increase pain.
1. TRUE
2. FALSE
What to do when the drug is
both a solution and a problem?
Opioid Use & Misuse
Prevalence
nd
Sp
a
Au in
st
ra
li a
Ir e
lan
No d
Lu r w a
y
xe
m
bo
ur
g
Fi
nl
an
Ne
d
th
er
la
nd
s
Sl
ov
en
ia
G
ibr
alt
a
Sw r
ed
en
Fr
an
Ne
ce
w
Ze
al
an
d
ela
tr i
a
Ic
nd
Au
s
rl a
giu
tze
Sw
i
Be
l
da
nm
De
y
Ca
na
s
an
te
er
m
G
St
a
d
i te
Un
ar
k
42230
22210
20990
17790
17660
17250
14950
11170
10830
10360
9777
9646
8732
8515
8358
8306
8088
7720
7496
7003
Average D DD's Per Million Inhabitants
United States
Germany
45000
Canada
Denmark 40000
Belgium
Switzerland
35000
Austria
Iceland 30000
Spain
Australia 25000
Ireland
Norway 20000
Luxembourg
15000
Finland
Netherlands
10000
Slovenia
Gibraltar 5000
Sweden
France
0
New Zealand
m
Prescription Opioid
Consumption
Top 20 Countries (2006‐2008)
DDDs = ‘defined daily doses’
(INCB 2009)
(www.camh.ca)
Past-Year Initiates of Illicit Drug Use: 2006
Number (in millions)
Persons aged ≥12 yrs
SAMHSA. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series: H‐32, DHHS Publication No. SMA 07‐4293). Rockville, MD.`
Prescription Opioid Source
By Age Group
70
60
% Clien ts
50
Street
40
Rx
30
Street & Rx
20
OTC
10
0
25 &
under
26-35
36-45
46-55
over 55
Age Categories (years)
(Sproule et.al., 2009)
# Admissions
CAMH Opioid Detoxification
Admissions
100
90
80
70
60
50
40
30
20
10
0
CR-Oxycodone
Other oxycodone
Other Rx opioids
Heroin
2000
n=78
2001
2002
2003
2004
n=96
n=120
n=111
n=166
(Sproule et.al., 2009)
Opioid-Related Deaths in
Ontario
800
30
700
# deaths 1991-2004
# deaths per m illion
25
20
15
10
5
600
500
400
300
200
100
0
Year 1991
Year 2004
0
morphine/heroin
codeine
methadone
oxycodone
Increase in deaths
Opioids
Oxycodone‐related deaths:
1999 → 1.39 deaths / million
416% ↑
2004 → 7.17 deaths / million
CR‐oxycodone introduced to formulary Jan 2000
(Dhalla et.al. 2009)
Opioid-Related Deaths in
Ontario
 Increase in deaths due to inadvertent toxicity  Most deaths also involved another CNS depressant
 Oxycodone‐related deaths:
1999 → 1.39 deaths / million
2004 → 7.17 deaths / million
CR‐oxycodone introduced to formulary Jan 2000
 Physician visits prior to death
 66% had at least one within 4 weeks
 reasons for visit ‐ mental health problems and pain
(Dhalla et.al. 2009)
Health Professionals
 55 physicians monitored due to substance-related impairment
 Focus groups; 94.5% male
 RESULTS:
 All participants were diagnosed with substance dependence
 69.1% had a history of misusing prescription drugs
 5 primary reasons:





(1) to manage physical pain
(2) to manage emotional/psychiatric distress
(3) to manage stressful situations
(4) to serve recreational purposes
(5) to avoid withdrawal symptoms.
Merlo LJ, Singhakant S, Cummings SM, Cottler LB. Reasons for misuse of prescription medication among physicians undergoing monitoring by a
physician health program. J Addict Med. 2013 Sep-Oct;7(5):349-53.
Principle of Balance
1. Ensure medical
availability of
opioids to treat pain
2. Enforce controls to
prevent abuse,
diversion and
trafficking
Analgesia
Abuse
Pain & Policy Studies Group. Achieving Balance in State Pain Policy: A Progress Report Card. 3rd ed. 2007.
Addictions Terminology
Aberrant Drug-related Behaviour
A behavior outside the boundaries of the
agreed upon treatment plan, which is
established as early as possible in the
doctor-patient relationship
Consensus Document. The American Academy of Pain Medicine. The American Pain Society. The American Society of Addiction Medicine. 2001.
Misuse
Use of a medication (for a medical purpose) other
than as directed or as indicated, whether willful or
unintentional, and whether harm results or not
Consensus Document. The American Academy of Pain Medicine. The American Pain Society. The American Society of Addiction Medicine. 2001.
Tolerance
“A state of adaptation in which exposure to a drug
induces changes that result in a diminution of one
or more of the drug’s effects over time.”
Key: All other conditions being constant
Consensus Document. The American Academy of Pain Medicine. The American Pain Society. The American Society of Addiction Medicine. 2001.
Physical Dependence
A state of adaptation manifested by a drug classspecific withdrawal syndrome that can be
produced by:
Abrupt cessation
Rapid dose reduction
Decreasing blood level of the drug, and/or
administration of an antagonist
Consensus Document. The American Academy of Pain Medicine. The American Pain Society. The American Society of Addiction Medicine. 2001.
Physical Dependence
vs. Addiction
Physical dependence and addiction can coincide but are not the
same:
 Physical dependence is a neuropharmacological phenomenon
 Addiction is both a neuropharmacological and behavioral
phenomenon
Addiction (5Cs)
A primary, chronic, neurobiological disease, with
genetic, psychosocial, and environmental factors
influencing its development and manifestations
characterized by :
• Compulsive use
• Continued use despite harm
• Cravings
• Control impaired over drug use
Consensus Document. The American Academy of Pain Medicine. The American Pain Society. The American Society of Addiction Medicine. 2001.
DSM-5 Diagnostic Criteria for
Substance Use Disorder
Tolerance*
Withdrawal*
More use than intended
Craving
Unsuccessful efforts to cut-down
Spends excessive time in acqusition
Activities given up because of use
Use despite negative effects
Failure to fulfill major role obligations
Recurrent use in hazardous situations
Continued use despite social or interpersonal problems
*not counted if prescribed*











2-3 = MILD
4-6 = MODERATE
7-11 = SEVERE
ASAM Definition of Addiction
 Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social
and spiritual manifestations. This is reflected in an individual
pathologically pursuing reward and/or relief by substance use
and other behaviors.
 Addiction is characterized by inability to consistently abstain,
impairment in behavioral control, craving, diminished
recognition of significant problems with one’s behaviors and
interpersonal relationships, and a dysfunctional emotional
response. Like other chronic diseases, addiction often involves
cycles of relapse and remission. Without treatment or
engagement in recovery activities, addiction is progressive
and can result in disability or premature death.
Addiction Changes Brain Circuits
Non-Addicted Brain
Addicted Brain
Control
Control
Saliency
Drive
NOT
GO
Saliency
Memory
Source: Adapted from Volkow et al., Neuropharmacology, 2004.
Drive
Memory
GO
Recovery From Addiction
 The chances of recovery may be improved with:





pharmacological treatment and/or behavioural support
social and spiritual support
a change in social or physical environment
a change in important aspects of identity
a positive coping style
 and if:
 the degree of addiction was lower
 there were fewer other psychological or social problems
 capacity for self-regulation was higher
 there were stronger motives for attempting recovery
West R (2006) Theory of Addiction. Oxford: Wiley‐Blackwell
Spectrum of Medication Use
Therapeutic
Domain
Recreational
Domain
Use
Benefits
Risks
Side‐Effects
Tolerance
Hyperalgesia
Misuse
Abuse
Disorder
Dependence
Disorder
A Pain Primer
 Types of pain
 Nociceptive vs Neuropathic
 Acute vs Chronic
 Cancer vs Non-Cancer
Nociceptive vs. Neuropathic
Pain
Nociceptive
Normal stimulation of nociceptors
Somatic
Nicholson BD (2003)
Visceral
Neuropathic
Abnormal nervous system activation
Central
Peripheral
Hyperalgesia
“Opioid-induced pain”
tolerance
hyperalgesia
resistance to opioid
hyperesthesia +/- allodynia
 anatomically distinct
 qualitatively different
 long- and short-term therapy
desensitization
downregulation
NMDA
Dynorphin
μ-opioidRc
 dose
cAMP
 dose
Chronic Pain
 Acute pain is a vital, protective mechanism that
permits us to live in an environment fraught with
potential dangers
 In contrast, chronic pain serves no such
physiologic role and is itself not a symptom, but
a disease state
 Chronic = pain which lasts beyond the ordinary
duration of time that an insult or injury to the
body needs to heal
 Beyond 3-6 months in duration
Chronic Non-Cancer Pain (CNCP)
 Low Back Pain
 Arthritis
 Headache
 Vulvodynia
 Trigeminal neuralgia
 Pudendal neuralgia
 Post‐herpetic neuralgia
 Carpal tunnel syndrome
 Fibromyalgia
 Endometriosis
 Post traumatic or post‐
 Irritable bowel
surgical pain
 Post‐herpetic neuralgia
 Whiplash
 Diabetic Neuropathy
 Inflammatory bowel
 Interstitial cystitis
 Alcohol neuropathy
Burden of Chronic Pain
 Prevalence in the adult population may be 30% (Moulin et
al 2001)
 18% of Canadian adults suffer from moderate-to-severe
chronic pain daily or most days of the week (Nanos
Survey 2007-2008)
 Associated with an increase in the use of health services
(Tarride, Gordon et al 2005)
 Massive economic burden: Cost of pain in US workplace
is $95B annually (US CDC, 2007)
 2x that of depression
 Mostly due to decreased productivity, not absenteeism
Opioid Use Disorders in CNCP




Prevalence of opioid use disorders 3.3%
Aberrant drug-related behaviors 11.5%
UDS with illicit drugs present 14.5%
UDS with non-prescribed opioids present 20.4%
 Based on review of 67 studies (Fishbain 2008)
 Many limitations
 No breakdown of the clinics studied or dates of study (opioid
dependence increasing)
 Dx of addiction depends on clinician’s judgement
 ADRBs and positive UDTs are only proxy measures of addiction
 eg: pseudoaddiction
Fishbain DA et al. Pain Medicine 2008 May;9(4):444‐59.
Universal Precautions in Pain
Diagnosis with appropriate differential
2. Psychological assessment including risk of addictive disorders
3. Informed consent (verbal vs written/signed)
4. Treatment agreement (verbal vs written/signed)
5. Pre/post intervention assessment of pain level and function
6. Appropriate trial of opioid therapy +/- adjunctive medication
7. Reassessment of pain score and level of function
8. Regularly assess the “Four A’s” of pain medicine

Analgesia, Activity, Adverse effects, & Aberrant behavior*
9. Periodically review pain diagnosis and comorbid conditions,
including addictive disorders
10. Documentation
1.
D Gourlay, HA Heit, A Almahrezi. Universal Precautions in Pain Medicine: A Rational Approach
to the Treatment of Chronic Pain. Pain Medicine. 2005;6(2):107-12
5 Pillars of Chronic Pain
 Assess: Symptoms and Risk
 Define the problem: Where
and what is it?
 Diagnose and treat it
 Other issues: Mood, anxiety,
sleep, addiction, sex
 Personal management, selfmanagement
Risk Assessment
 Current and previous pain treatment
 Aberrant use of medications
 Previous drug and alcohol use
 Family history of drug or alcohol use
 History of other addictions
 History of physical, sexual or
emotional trauma
 Depression, anxiety, and other mental
health issues
 Urine drug screen
A Canadian Approach to Opioids
 Developed by the National Opioid Use Guideline Group (NOUGG)
NOUGG: Guiding Principle
Patients deserve to have their chronic pain treated. Opioids
can be a useful and appropriate treatment option.
Harms associated with opioid use can be reduced
when:
1. Drugs are prescribed and monitored with
knowledge of the patient’s history and risks
2. Patients understand potential benefits and harms
and participate in reducing harms
3. Clinicians assess outcomes for both
effectiveness and risk
Overview of NOUGG Guidelines
1. Deciding to initiate opioid therapy
2. Conducting an opioid trial
3. Monitoring long-term opioid therapy
4. Opioids in specific populations
5. Managing opioid misuse and addiction in
CNCP patients
CLUSTER 1: Deciding to Initiate
Opioid Efficacy
Opioid Efficacy – NOUGG Review
 Updated systematic review of opioids for CNCP
included 62 randomized trials
 Opioids were compared to placebos in 47 trials
 Effect size for improvement in pain was medium
 Effect size for improvement in functional outcomes
was small
Cluster 2: Conducting an Opioid Trial
Principles of An Opioid Trial
 Important to emphasize it is a trial of therapy
 It can help to determine:
 Effectiveness of opioids as part of the treatment plan
 Presence of opioid-related adverse effects
 Compliance
 Presence of aberrant drug-related behaviours
 Whether the initial assessment of opioid-risk
approximates that observed during the trial
WHO Analgesic Ladder
Dose Titration
“When conducting a trial of opioid therapy, start with a low dosage, increase dosage gradually and monitor opioid effectiveness until optimal dose is attained.”
 On average, a reduction of approximately two points in the numerical rating scale (0‐10 scale) or a reduction of approximately 30% represents a clinically important difference
Risk Management
 Periodic monitoring is an important FOR ALL
PATIENTS
 Urine drug screens
 Pill counts
 Prescription drug monitoring programs
 Tools to screen for abuse/misuse behavior
during therapy (e.g. Current Opioid Misuse
Measure (COMM®))
 Consider expert consultation
Assess Risk at Each Visit
 Risks and benefits are dynamic, not static
 Therapeutic response
 Adverse effects
 New or worsening medical or psychiatric
comorbidities
NOUGG Guidelines
CLUSTER 5: Managing Opioid Misuse and
Addiction
For patients with chronic non‐cancer pain who are addicted to opioids, three treatment options should be considered:
1. Methadone or buprenorphine treatment (Grade A),
2. Structured opioid therapy (Grade B), or
3. Abstinence‐based treatment (Grade C)
Consultation or shared care, where available, can assist in selecting and implementing the best treatment option (Grade C)
Case: AA
 47 year old male Pharmacist with chronic low back and
sciatic pain
 Working in the community (long hours, majority standing)
 History of osteoarthritis (spine, bilateral knees)
 MRI demonstrated L5/S1 disc herniation, multilevel DDD,
mild compression of S1 nerve root, mild foraminal
stenosis
Mr. AA
 Current Issues:
 dull, burning and electrical shock pain in lumbosacral area,
radiating down his left leg to lateral aspect of his calf
 difficulty sleeping
 low mood
 Current Medications (no known allergies)
Medication
Start Date
Comments
Tylenol #3, 2 tabs po
QID
2011
Minimal efficacy, “takes the edge
off”, causes constipation
Celecoxib 200mg po
BID
2005
Reports as effective, no adverse
effects
Zopiclone 15mg po
QHS
2012
Minimal efficacy, 2 hours to initiate
sleep, 2-3 hrs of uninterrupted
sleep, feels tired in AM
Mr. AA
 At the initial assessment, Mr. AA is requesting switch to
oxycodone Controlled Release (prefers generic, does not
want OxyNeo), and reports that he has used it in the past
and was the only thing that was helpful
 His pain has escalated recently, he relates this to
increased pressures at work, stress at home with his wife
and kids
 Physical exam:
 Hyperesthesia and allodynia over lateral aspect of left foot,
restricted lumbar-spine range of motion, flexion worsens pain,
positive straight leg raise on R side
Mr. AA
 Small Group Discussion:
 Is he an appropriate candidate for opioid
therapy?
 What do you think of his request for
oxycodone generic?
 Is there other information you would like to
know before prescribing?
Mr. AA – Further History
 Past Medications
Comments
Morphine CR
Discontinued in 2001, not effective
Oxycodone CR
Used 2001-2004, discontinued because of
tolerance, misuse, “lost control”
Gabapentin
Max dose reached was 400mg, unable to tolerate
further dose increases
Nabilone
Not effective, discontinued after 2 weeks
Mr. AA –Substance Use History
 Cocaine use x 1-2 in his teens
 Smoked marijuana as a teen and through University, quit upon
graduation
 Does not drink alcohol or smoke cigarettes
 In 2004, after being prescribed oxycocet and oxycodone Controlled
Release to manage his pain, he developed a “problem”.
 He often ran out early, and had to increase his dose several times
because tolerance developed.
 He said it was the only thing that helped his pain, however he lost
control, and after several requests for dose escalations and early refills,
his doctor cut him off and he went through withdrawal “cold turkey”
 He continued to borrow from friends an occasional tablet to get by when
his pain was very bad, however, has not had any oxycodone in 5 years
Mr. AA –
Opioid Risk Assessment
 Using the Opioid Risk Tool, you determine that his
risk is High (score >8) because he reports
 family history (father) of alcohol use disorder
 personal history of prescription drug abuse “problem”
with oxycocet and oxycodone CR
 personal history (teenager) of cocaine & marijuana
use
Mr. AA
 Small Group Discussion:
 Should he continue on opioid therapy?
 What additional information might be helpful?
 If he does stay on opioid therapy, how could
you minimize his risk?
Mr. AA
 You decide to prescribe Mr. AA hydromorphone CR,
4.5mg po Q12H, dispensed weekly. (d/c Tylenol #3)
 He signs an Opioid Agreement, and complies with
UDS weekly
 Two appointments from now, his urine drug screen is
negative for HM, and positive for oxycodone
 He reports he is trading his HM for oxycodone, since
HM was not effective
Mr. AA
 Small Group discussion:
 How might the information Mr. AA has shared
change treatment recommendations
regarding opioids?
 What additional therapies might you suggest
for Mr. AA’s pain?
Stepwise Management of
Neuropathic Pain
TCAs
SNRI
Gabapentin or
g
Pregabalin
Topical Lidocaine
Tramadol or CR Opioids
Fourth Line
(cannabinoids, methadone, lamotrigine, topiramate, valproic
acid))
Pain Res Manage 2007;12(1):13-21
Medication
NNT
(Number needed‐to‐treat to improve pain by 50%)
Tricyclic Antidepressants
2‐3
Morphine and oxycodone
2.5
Tramadol
3.9
Pregabalin
4.2‐5
Venlafaxine 4.6 Duloxetine (60mg )
5‐5.2
Topical capsaicin
5.8
SSRIs
6.7
Gabapentin
6.8
Carbamazepine
1.7 (trigeminal neuralgia)
Antidepressant- TCAs
TCAs (amitriptyline, nortriptyline, desipramine)
 First line agent
 Painful diabetic neuropathy, mixed neuropathic pain, post‐herpetic neuralgia, and central neuropathic pain (post stroke, spinal cord), neuropathic cancer pain
 Analgesic properties independent of antidepressant properties
 High likelihood of adverse effects: anticholinergic effects (blurred vision, dry mouth, constipation, weight gain, sedation, tachycardia)
 Less side effects with secondary amines
 Caution use in patients with serious CVD (ischemic cardiac disease or ventricular conduction abnormalities)
 Adequate trial of treatment: at least 6 to 8 weeks, including 2 weeks at the highest dosage tolerated
Antidepressant-SNRIs
Duloxetine (Cymbalta)
 First line for painful diabetic peripheral neuropathy (DPN)
 Nausea most concerning side effect‐ slow dose titration
 Start dose at 60mg with upward titration to 120mg/day
 Onset of analgesia is at approximately 1 week, with maximum effect at about 4 weeks
Antidepressant-SNRIs
Venlafaxine (Effexor XR)
 Efficacy for painful diabetic peripheral neuropathy (DPN) and polyneuropathies
 Well tolerated

Blood pressure elevation can occur at higher doses
 Low doses predominantly serotonergic, at higher doses inhibition of both monoamines (+noradrenergic effects) is more balanced.  150–225mg/day may have mild to moderate analgesic effect (30%–50% reduction in pain)
Calcium Channel α2-δ ligand:
Gabapentin
 Evidence for PHN, PDN
 Modest benefits for pain reduction
 Reduces mean pain score <1 point on a 0‐10 point (NNT 6‐8)
 Similar proportion of people suffer harm (NNH=8)
 Common dose‐dependent side effects: dizziness and drowsiness
 Less common side effects: peripheral edema, unsteadiness
 Requires slow dose titration (3‐8 weeks)
 Maximum dose 3600mg/day (in three divided doses)
 Adequate therapeutic trial: 2 months of at least 900‐1200mg/day
Calcium Channel α2-δ ligand:
Pregabalin
Pregabalin
 Efficacy in PHN, DPN, spinal cord injury
 Pregabalin may provide slightly better pain relief ( of pain 30% ‐50%) compared to gabapentin, similar tolerability
 May have greater potency at the alpha‐2‐delta subunit protein of voltage‐gated calcium channels than GBP
 Linear pharmacokinetics, more rapid dose titration, faster onset of effect
 Anti‐anxiolytic properties
 Maximum dose 600mg/day (in two divided doses), adequate therapeutic trial: 4 weeks
Topical Therapies
 Useful in well-localized peripheral neuropathies
 Capsaicin cream (Zostrix)
• Alkaloid derived from chilli peppers
• Apply 3-5 times/day for up to 6–8 weeks before full effect
 Lidocaine 5% gel patch
 (not available in Canadian market) – gel can be compounded
• Na2+ channel blocker
 Investigational topical compounding
 antidepressants, anticonvulsants, ketamine, alpha-2 agonists,
vasodilators
• Limitations
• patient adherence, procurement
Cannabinoids
Turcotte et al. 2010
Cannabinoids
 Risks associated with cannabinoids
• Concerns regarding risks of abuse and addiction
• Potential to precipitate psychosis especially in highrisk individuals
• May worsen underlying anxiety and depression
• Cognitive side effects, negative effects on learning,
amotivation
Case BB: Fibromyalgia
•29 yo woman •Endometriosis diagnosed at 14
•Multiple laparoscopic procedures
•Escalating doses of hydromorphone
•Running out of meds early
Case BB: Medication History
 Pain regular, daily since age 19…T3 nauseous
 Between age 19‐23: Rx meperidine 50mg po TID (client took 6/day)
 Transitioned to fentanyl 2550mcg/hr + morphine for “breakthrough”
 Short trials of gabapentin (up to 400mg BID) and pregabalin ineffective
Case BB: Currently
 Recently transitioned from fentanyl to hydromorphone CR 32mg TID  Pain: lower back, abdomen (dull), sharp radiation to legs; cramps worsened with menses.  Worse in morning (9/10), + diaphoresis, abdominal pain, back pain
 Poor sleep  Often using hydromorphone IR overnight
 No longer able to work
 Can walk only about 1 block
Case BB
 Small Group Discussion:
 Is this therapy appropriate?
 What changes could be made?
Case BB: Further History
 Medical History
 Fibromyalgia
 Interstitial cystitis
 Irritable bowel syndrome
 Psych history
 Depression treated with SSRIs in the past
 Self‐harm attempt...cutting
 Denies trauma or abuse, though states "while I was never abused, I did have a lot of stress at home.”
 Family History
 No substance abuse/dependence history
 No history of mental health issues
Case BB: Substance Use History
 First drink @16 yo; first drunk @ 16
 Maximum alcohol consumption: 6 units/24 hours
 No alcohol since starting opioids
 CAGE ¼
 Multiple blackouts in during college (patient thought it was a normal experience for college students)
 Marijuana age 21...last use 22 y.o.
 2‐3 cigarettes periodically, usually with alcohol
Case BB
 Small group discussion:
 Does this change your recommendations?
Case BB: Outcome




Hydromorphone tapered
Re‐trial of pregabalin for 3 months
Graded exercise program initiated
Assessment of concurrent disorder – dx depression, duloxetine started
 Cognitive and behavioural therapy group for pain
 Assertiveness group
 Pain scores and function improved
Adjunctive Therapies
 Exercise
 Nerve stimulation or block
 Spinal manipulation
 Acupuncture
 TENS
 Meditation
 Mindfulness techniques
 Physical therapy
 Botox
 Cognitive and Behavioural Therapy (CBT)
 Biofeedback
Exercise
Exercise can decrease pain and improve function
 <30% reduction in pain
 <20% improvement in function
 Hastens return to work
 Patient adherence problematic
 Extremely variable treatments  difficult to measure outcomes
 NB: quota-based reactivation
 Important to reverse secondary deconditioning, abnormal
postures and dysfunctional movement patterns
vanTulder M et al. Spine 2007
Exercise and Fibromyalgia
Aerobic exercise (20 mins per day, 2-3 days per week, x 2-24 weeks) –
moderate quality evidence
 Improve overall well-being by 7/100
 Increase the amount of pressure that can be applied to a tender point by
0.23 kgs/cm2 before the onset of pain.
 Reduce pain by 1.3/10
 Unknown effects on fatigue, depression or stiffness
Strength training (2-3 x per week, 8-12 reps per exercise) – poor quality
evidence
 Reduce pain by 49 fewer points on scale of 0 to 100.
 Improve overall well-being by 41 points on a scale of 0 to 100.
 Lead to 2 fewer active tender points on a scale of 0-18.
Cochrane Review 2009, DOI: 10.1002/14651858.CD003786.pub2
Nerve Blocks
 Epidural steroid injections most commonly




performed pain management procedure
No consensus, re: technical aspects
No guidelines for optimum diagnostic criteria for
patient selection. Frequency, number or timing of
injections
DIFFICULT MEASURING OUTCOMES
Evidence for efficacy – in reducing pain and
improving function
 Radiculopathy with prolapsed lumbar disc (fair)
 No evidence for efficacy
 Non-specific low back pain
 Failed back surgery syndrome
Trigger Point Injections
 Used when specific “trigger points” or tender




areas are present in muscles in widespread
or regional myofascial pain syndromes
Local anesthetics +/- steroids
Same efficacy as therapeutic u/s
Conflicting evidence for efficacy in short-term
relief of back pain
No evidence for long-lasting benefit in
chronic back pain  can’t be recommended
Spinal Manipulation
 Most commonly used CAM
therapy for low back pain
 More effective than sham
manipulations, bed rest and
traction
 Not more effective than other
recommended treatments for
low-back pain
 Evidence for efficacy in other
CNCP disorders is lacking
Tan G et al. J Rehab Res Devel. 2007. 44;2. 195-222
Transcutaneous Electric
Nerve Stimulation (TENS)
 Applied to diverse pain states since introduction in
early 1970s
 Few large RCTs to evaluate efficacy in pain
management
 Meta-analyses and recent systematic reviews draw
mixed conclusions
Massage
 Wide variations in technique
make generalization from studies
difficult
 Effective in low back and
shoulder pain
 Possible benefit in fibromyalgia
and neck pain
Tan G et al. J Rehab Res Devel. 2007. 44;2. 195-222
Acupuncture
 No scientific proof for efficacy
 Several theories
 Endorphin, serotonin and noradrenaline release in CNS
 May reduce vasodilation caused by histamine release
 May close pain “gate” in spinal cord
 Effective in dental, chemo-related and chronic low back
pain
 Probably effective in PMS-related pain, fibromyalgia and
neck pain
 Otherwise data too sparse to evaluate efficacy in other
chronic pain conditions
 Little study of functional outcomes
Mindfulness
To pay deliberate attention to our experience from moment to moment,
to what is going on in our mind, body and day to day life and doing this
without judgment.
Mindfulness  ability to recognize and disengage from patterns of
self-perpetuating, ruminative, negative thought.
1. Realization that most sensations, thoughts, and emotions fluctuate
or are transient
2. Recognition of deteriorating mood
3. Preventing the ruminative thought-affect cycle
4. Providing tools to stay connected with body and reality
95
CBT
CBT: Yes, ‘A’, Cochrane
 CBT had moderate effects in improving pain.
 CBT has minimal effects on disability associated with




chronic pain.
CBT is effective in altering mood outcomes
These changes are maintained at six months
There is insufficient evidence to recommend any one
therapeutic approach or modality over another.
Patients with different characteristics might derive
benefits from treatments with different foci and
targets
Patient Ambivalence
Ambivalence Regarding…
 Staying on opioid therapy despite
 Side effects (constipation, sexual dysfunction, sedation)
 Limited function
 Limited or zero pain relief
 Structured opioid therapy
 Changes to opioid medication
 Schedule
 Polypharmacy
 Dose
 Methadone as a treatment option
 Concurrent alcohol, benzodiazepine or cannabis use
Stages of Change:
Where is the Patient?
 Meet them where they are
 Continuum of ambivalence
 Explore readiness to change,
importance and confidence
Evidence for MI
• Research in pain management
• Cancer Pain
• Fibromyalgia
• Chronic pain in elderly patients
• Low back pain
 Research in Methadone Maintenance Treatment (MMT)
 Treatment retention, time to relapse
 Smoking cessation
 Reduction of concurrent drug/alcohol use
 Adherence to HIV medications
 Improved knowledge of HBV and HCV
Pain Recovery
 Reimagining pain from uncontrollable to manageable
 Fostering optimism and combating despair
 Promotion of patient feelings of success, self-control and
efficacy
 Patients attribute success to their own role
 Education in specific skills: pacing, relaxation, problemsolving
 Emphasis on active patient participation and
responsibility
Take-home Points
 Risks are inherent in managing chronic pain in individuals
with substance use disorders
 NOUGG Guidelines
 Harms associated with opioid use can be reduced

risk assessment, structured prescribing, monitoring, patient
participation, outcome assessment
 Beyond the Opioids
 Optimize other pharmacotherapy
 Optimize adjunctive /non-pharmacological/ psychological therapy
 Motivational interviewing to help patients with behavioural
changes
Questions?