An Exit Strategy for Opioids: When, How and Why

Dr. Maureen Allen CCFP-EM(PC) FCFP

Assistant Professor Dalhousie University

Emergency Medicine

December 2018

2015-2016 1

No Disclosure

2015-2016 2

Your in the office…

• Sandra

• 57 yo female

• Re-fill of her medications

• Legacy patient (colleague)

• CNCP: Neck and back (MVC)

2015-2016 3

Medications

• Fentanyl 250 mcg q 48hrs

• Amitriptyline 25 mg at night,

• Clonazepam 2mg at night

• Zopiclone 15 mg at night

• Wellbutrin 150mg in the morning

• Gabapentin 600mg tid

• Synthroid 100mcg daily

• Medical marijuana (~3 gms/day)

• Insulin

Call about Ryan….

• Ryan (31 yo male)

• In-patient (Transfer from Halifax)

• 5 weeks post surgery

• HMC 18mg tid; HM 4mg SC

• Nursing staff: Finding empty pill capsules in garbage, “hear him” sniffing …..ALOT!!

2015-2016 5

Tapering opioids

2015-2016 6

WHERE ARE THOSE TAPERING TEAMS WHEN YOU NEED

THEM?!!

What I hope you learn

1. How to taper opioid using the Canadian Guidelines for Safe and Effective Opioid use.

2. Explore common barriers to tapering opioids including the role of tolerance, dependence, and addiction.

3. Tapering in patient’s with complex pain including “legacy” patient’s, patient’s “not ready” to taper or when concerns of an opioid use disorder are present

2015-2016 7

Why Taper

• Recommendation #13

• For patient’s experiencing unacceptable adverse effects or insufficient opioid effectiveness from one particular opioid, try prescribing a different opioid or discontinue treatment.

• Grade B

2015-2016 8

Evidence to taper

• A. Lack of efficacy

1. Unresponsive pain

2. Incapacitating pain

3. Withdrawal-mediated pain

• B. Adverse events

1. Hyperalgesia

2. Addiction

• C. Tapering leads to improvement in mood, function and pain

2015-2016 9

Opioid Tapering: How confident are you?

• “Physicians admit that they are not confident about how to prescribeopioids safely, how to detect abuse or emerging addiction, or even how to discuss these issues with their patients.”

2015-2016 10

Volkow N, McLellan AT. Opioid Abuse in Chronic Pain-Misconceptions and Mitigation Strategies.NEJM. 2016; 374: 1253-1263.

Why are opioids so challenging to stop in some patient’s?

• Effective in producing analgesiaand euphoria (energy)

• Brain learns benefit early which is reinforced with repetitive use (Pavlovian conditioning)

• Tolerance and dependence contribute to increase use and aberrancy

2015-2016 11

Opioid Crisis

2015-2016 12

RECREATIONAL CHRONIC PAIN

Addiction Diagnosis

Cravings

Talking points(Benefit/Motivation to use)

DSM-V ASAM-APS

Drug/Substance Increasing Pain

“Euphoria”(Avoid withdrawal)

“Pain/Energy”(Avoid withdrawal)

Savage S, Kirsh K, Passik S. Challenges in Using Opioids to Treat Pain in Person’s With Substance Use Disorders. Addiction Science & Clinical PracticeJune 2008. Pages 4-25.

American Society of Addiction Medicine (ASAM), American Pain Society (APS), American Academy of Pain Medicine (AAPM)

Talking with patients about pain can be challenging

13

Universal

Majority(Pain experiences)

OK

Some(Pain experiences)

“Disruptive pain experience”

Persistent (chronic) pain

• 1:5 (1:4 elderly)• ~200,000 NS• ~30,000 PEI• ~190,000 NB

Survival

Pain circuitryre-wired

(neuroplasticity)

Chronic pain can co-exists with MANY medical condition

• Diabetes

• “Arthritis”

• Migraines

• Degenerative Disc Disease

• Osteoarthritis

• Fibromyalgia

• Ehler-Danlos Syndrome

• Previous broken bones

• Spinal stenosis

• And many others

Chronic pain is a unique illness that requires a unique approach

Drivers of Pain

Crohn’s

DiseaseOpioids

Degenerative arthritis

Chronic pain

5 Factors that drive the “Chronicity” of Chronic pain

(Protection and Survival)

1. Central sensitization (neuroplasticity)

2. Muscle memory

3. Movement memory (Pain protective stance)

4. Brain memory (protective)

5. Amygdala’s (Neighbourhood watch)

What does sensitization look like?

CHAOS

Pain Self-Management Programs

-http://www.nshealth.ca/service-details/Chronic%20Pain%20Services -PSMPs (Halifax, Windsor, Berwick and South Shore). http://www.nshealth.ca/servicedetails/Chronic%20Pain%20Self%20Management%20Program

Approach to Tapering Opioids

• Step 1: Signal a shift in your prescribing practice

• Step 2: Develop an EXIT STRATGEY that does NOT ABANDON the patient

• Step 3: Is the patient taking what your prescribing?

• Step 4: What is the patient “readiness” to change?

• Step 5: Get good at talking about and managing opioid addiction (or know where to reach out for help).

2015-2016 19

Step 1: Signal a shift

• Make prescribing safelyyour priority

• Should not be about moral or ethical reasoning

• Letter to patient

• Get other prescribers to sign on

• Video “Brainman stops his opioids”

2015-2016 20

Step 2: Develop an exit strategy that does not abandon the patient

• Unable to taper

• Legacy patient >90mg MEDD

• Problematic substance use

• Addiction

• Develop strategy before you begin taper

2015-2016 21

Step 3: Is the patient taking what you’ve prescribed?

• Diversion (poverty, abuse, addiction)

• Stock piling

• Don’t take it personal

• Non-judgemental

2015-2016 22

Approach

• Monitor use (MAPing)

• Admit the patient to hospital

• 10-day supply, call them back for pill and solution count (Day 7)

• Or get the pharmacist to call them back

• When in doubt, daily dispensing

2015-2016 23

MAPing

• MONITOR opioid use for aberrancy (UDT, PMP)

• ADJUST immediately if aberrancy (Bi-weekly; daily)

• PRESCRIBE using principles of HARM REDUCTION

Step 4: What is the patient’s “readiness” to change?

• If “ready” then TAPER (Compassionate)

• Remember, the patient DID NOT prescribe opioids to themselves

• Opioids are HABITS and BEHAVIOUR’s we give our patient’s

• Someone told them that they would NEED this medication possible FOR LIFE

• Consider sending patient to a *PSMP before tapering

2015-2016 25

*Pain Self Management Program

“Our life experiences shape the habits and behaviours we choose. They are not who we are, they are what we do to find calm and connection”. (Allen, 2018)

2015-2016 26

How to taper

• It depends…

• Do you use short acting or long-acting opioids?

2015-2016 27

Short-acting opioid versus long-acting

SHORT-ACTING

• Preferred on the streets (diversion)

• Can keep patient pain focused

• Reinforce relief due to rapid onset (Pavlovian conditioning)

• Tolerance develops more quickly

• Withdrawal mediated pain and anxiety

• Poor sleep (withdrawal=pain)

LONG-ACTING

• Higher risk of poisoning (OD) in chemical coper

• In theory better control of pain

• Not covered by insurance

• Often patient’s don’t like this especially if they’ve been using short-acting opioids only

Tapering opioids

• Consider an opioid rotation to controlled-release (Morphine)

• Decrease by 5%-10% of total daily dose (ranging from every day to every 1-2 weeks)

• Once 1/3 of original dose is reached, decrease by 5% every 2-4 weeks

• Hold the dose or increase when appropriate. (severe withdrawal, significant worsening of pain and mood, or reduced function during the taper or sedative-hypnotic use, or alcohol use).

• Taper can usually be completed between 2 weeks to 4 months.

29

http//nationalpaincentre.mcmaster.ca/opioid

Switching to Morphine

• Fentanyl Patch 250mcg = 940mg MEDD

• Take 25 mcg of the patch

• MEDD of 25 mcg=100mg

• Drop by ~30%=70mg Kadian

• Decrease Kadian by 5-10%

• HM 8mg qid=160mg MEDD

• Drop by ~30%=110mg Kadian

• Decrease by 5-10%

2015-2016 30

25-30% in palliative

care world

• Work with the patient to find the lowest possible dose (<200mg MEDD) without decompensation

• Continue to monitor use

• Review functional goals

• Are there consequences of use? (martial discord, falls, work etc.)

• Is there hypnotic-sedative use or concerns of ETOH?

• Are they getting back to a life of purpose and connection?

2015-2016 32

Legacy patient

Hypnotic-sedatives

“Talking points”

• This is where you take back your power as a prescriber (Compassion and non-judgemental)

• “Pick your fights” and “roll with resistance”

• “Ask-tell-ask”

• “Your right….”

• “I care enough….”

2015-2016 34

Addiction talking points..“I care enough...”

1. Use the “Ask-tell-ask” approach.

Ask permission to discuss something with them.

Tell them your concerns.

Ask what they thought about what you said

2. Remember your role as a health care provider. Explain that you need to

discuss drug use because you are concerned about their health and explain

why you are recommending a referral to addiction services or psychologist.

3. You want to give them the best treatment possible so you’re referring them

to a specialist much like you would any other chronic illness that requires

focused care.

4. Point out the direct relationship between drug use and any health or social

consequences they may have experienced due to their drug use.

5. Point out that addiction is a treatable chronic disease.

Boxer H, Synder S. Five Communication Strategies to Promote Self-Management of Chronic Illness. Family Pract Manag. 2009 Sept-Oct; 16(5): 12-16.

Step 4: Not Ready “Failed Opioid Trial”

2015-2016 37

Is this opioid induced pain?

Is this problematic substance use?

Is this Addiction?

Opioid induced Hyperalgesia

• Etiology controversial

• Paradoxical effect of opioid use

• Increasing pain

• “Wind-up” effect CNS

• Opioid rotation or taper

• Pharmacist or palliative care clinician can help you with the math

2015-2016 38

“Unstable angina of addiction medicine”

2015-2016 39

Is This Problematic Use?

Problematic use

ADDICTION

• Selling drugs

• Forging prescriptions

• Stealing prescriptions pads

• Altering a delivery route

• Buying from an illicit source

• Abusing illicit drug

• Multiple dose escalations

• Multiple lost prescriptions

PROBLEMATIC USE• Request more or stronger opioids

• Hoarding drugs when symptoms improve

• Request specific drugs

• Acquiring analgesics from more than one source

• Unapproved dose escalation once or twice

• Unapproved use of analgesia to treat other symptoms

• Porteroy RK. Opioid prescriptions for chronic non-cancer pain: Clinical perspectives. J Law Med Ethics. 1996;24:301

PROBLEMATIC USE IS NOT ADDICTION

Addiction is the AMI

2015-2016 41

If Problematic use is the Unstable angina of addiction medicine then….

*ASAM-APS-AAPM BEHAVIORAL CRITERIA EXAMPLES

Impaired control over use, compulsive use Frequent loss/theft reported, calls for early renewals, withdrawal noted at appointments

Continued use despite harm due to use (consequences) Declining function, intoxication, persistent over sedation

Preoccupation with use, cravings Recurrent requests for opioid increase/complaints of increasing pain in absence of disease progression

Criteria Suggestive of Misuse or Addiction in Patient’s With Pain (4 C’s)

Savage S, Kirsh K, Passik S. Challenges in Using Opioids to Treat Pain in Person’s With Substance Use Disorders. Addiction Science & Clinical PracticeJune 2008. Pages 4-25.

*American Society of Addiction Medicine (ASAM), American Pain Society (APS), American Academy of Pain Medicine (AAPM)

Opioid Addiction

• Is a Life-threatening complication of opioid use

• Pain will never be controlled if opioid addiction exists REGARDLESS of how many buckets of opioids you give your patient !!!

• They need Opioid agonist therapy in an addiction framework (Methadone/Suboxone)

• If not ready…

2015-2016 43

Tapering when Concerns of Addiction?(Meta:Phi 2015. Dr. Mel Kahan)

• Be clear and non-judgemental

• Inform patient that their opioid use is harming them, and that treatment will improve their pain, mood, and functioning

• If they do not engage in Rx tell them you will perform an involuntary taper or rotate them to another LA opioid (daily dispensing)

• DO NOT abruptly stop Rx

• Taper dose with frequent (i.e., daily, bi-weekly) dispensing

2015-2016 45

Framing Difficult Conversations

• The journey is ultimately the patients.

• Frame the conversation around SAFETY and HEALTH BENIFITS

• Recognize that we taper and change many medications based on failed treatment goals (BP, anti-clotting etc.)

• Acknowledge that it will be difficult but not dangerous to their health to taper

• They need to know that you “care enough” to set boundaries.

2015-2016 46

Your in the office…

• Sandra

• 57 yo female

• Re-fill of her medications

• Legacy patient (colleague)

• CNCP: Neck and back (MVC)

2015-2016 47

Is this an opioid use disorder? (Addiction)

Possible strategies

• Fentanyl Patch 250mcg = 940mg MEDD

• 25 mcg=100mg MEDD

• Drop by 30%=70mg Kadian

• Decrease by 5%-10% every third day

• Manage withdrawal symptoms

• Dose changes on patch day

In-patient rounds….

• Ryan (31 yo male)

• In-patient (Transfer from Halifax)

• 5 weeks post surgery

• HMC 18mg tid; HM 4mg SC

• Nursing staff: Finding empty pill capsules in garbage, “hear him” sniffing …..ALOT!!

2015-2016 50

Follow-up

• Became very emotional, remorseful but “Not Ready” for ORT

• Rotation to Kadian

• Daily witnessed

• Relapsed in community

• ORP “Doing well”

• Now on Suboxone 24mg

2015-2016 51

Summary

• What you do matters

• Take back your power as a prescriber

• Pull together a group of colleagues in your community for support

• Reach out if complicated

• Never let a patient tell you how to prescribe a dangerous drug

“Habit and Behaviour’s”Thrive on repetition

2015-2016 53

Opioids

Pain(Suffering)

Pain reduction

(calm)

Addiction and opioid

induced pain(Chaos)

Here’s the problem

REWARD(Pain reduction)

HARM(ADDICTION)

9-11%

100% will develop:• Tolerance• Dependency (Phys/Psyc)• Withdrawal

PROBLEMATIC USE

Habit’s and Behaviours

• What habits and behaviours do we promote as health care providers ?

• What habits and behaviours do our patient’s choose?

• Are they habits and behaviours that just “get them through” the moment or do they promote calm and connection in the long term?

2015-2016 55

Pain Management

2015-2016 56

Is about CHANGING Pain Chemistry!!

AMYGDALA’S“Survival mode”

(Left) PREFRONTAL CORTEX“Mindful mode”

5 Tools that change pain chemistry

• “Talking Points” (acute, chronic and SUD)

• Interventions

• Alternative therapies

• Medications

• Opioid risk tool (Risk stratify)

2015-2016 57

The Amygdala’s are driven by….

2015-2016 58

FEAR (ANGER) UNCERTAINTY UNPREDICTABILITY

As a Health care provider you can…

•Make them feel safe and cared for

•Prepare them for what to expect

•Reassure them

2015-2016 59

Talking points

• How we engage with patient’s

• Dignity intact (ours and theirs)

• Remember: The journey is the patient’s

• “What is their Readiness to listen and change ?”

• “Pick your fights” and Roll with resistance”

2015-2016 60