Transitioning a Pain Program Away From Chronic Opioid Prescribing

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Transitioning a Pain ProgramAway From Chronic
Opioid Prescribing
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Steve(Stephen Z. Hull, M.D.)HullS_at_MercyME.com
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Transitioning a Pain ProgramAway From Chronic
Opioid Prescribing
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WHY
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(No Transcript)
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Addiction
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January 4, 2011 Maine plagued by painkiller
habit A growing epidemic of abuse is behind an
addiction treatment rate that is eight times the
national average. By John Richardson
jrichardson_at_mainetoday.com?State House Bureau
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Misuse

• 26 for purposeful oversedation
• 39 for increasing dose without prescription
• 8 for obtaining extra opioids from other doctors
• 18 for use for purposes other than pain
• 20 for drinking alcohol to relieve pain
• 12 for hoarding pain medications

Michael Von Korff, ScD, Annals of Internal
Medicine, 6 September 2011
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Perspective A Flood of Opioids a Rising Tide of
Deaths Susan Okie, M.D. N Engl J Med 2010
3631981-1985 November 18, 2010
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National Center for Injury Prevention and Control
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National Center for Injury Prevention and Control
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Crime
Federal Criminal Law
Chief Judge John A. Woodcock, Jr. U.S. District
Court, District of Maine
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Adverse effects

• No end organ toxicity
• No ceiling dose
• Safer and more effective than OTCs
• Addiction
• Respiratory depression and overdose death
• Endocrinologic dysfunction
• Immune dysfunction
• Opioid induced hyperalgesia

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EFFECTIVE?
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EFFECTIVE?

• There is no evidence from randomized controlled
  trials to support the popular assertion that the
  benefits of long term opioid therapy outweigh the
  risks.
• Major Study Limitations
• Used placebo comparators
• Invariably excluded patients at high risk of
  serious adverse events
• Trials that have been completed were generally
  short term (lt16 weeks)

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EFFECTIVE?

• There is no evidence from randomized controlled
  trials to support the popular assertion that the
  benefits of long term opioid therapy outweigh the
  risks.
• The findings of this systematic review suggest
  that proper management of a type of strong
  painkiller (opioids) in well-selected patients
  with no history of substance addiction or abuse
  can lead to long-term pain relief for some
  patients.

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EFFECTIVE?

• Ten-year follow-up of chronic non-malignant pain
  patients Opioid use, health related quality of
  life and health care utilization
• Opioid Users had
• Higher pain levels
• Poorer self-rated health
• Higher unemployment
• Greater use of the healthcare system
• More maladaptive coping skills
• Lower health-related quality of life (SF-36)

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EFFECTIVE?

• Ten-year follow-up of chronic non-malignant pain
  patients Opioid use, health related quality of
  life and health care utilization
• Study Limitations
• Denmark has the highest use of opioids in the
  world
• Cross-sectional epidemiological research, cannot
  be established a causal relationships

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EFFECTIVE?
Ten-year follow-up of chronic non-malignant pain
patients Opioid use, health related quality of
life and health care utilization It is
remarkable that opioid treatment of
long-term/chronic noncancer pain does not seem to
fulfill any of the key outcome opioid treatment
goals"
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EFFECTIVE?
Ten-year follow-up of chronic non-malignant pain
patients Opioid use, health related quality of
life and health care utilization It is
remarkable that opioid treatment of
long-term/chronic noncancer pain does not seem to
fulfill any of the key outcome opioid treatment
goals pain relief, improved quality of life, and
improved functional capacity."
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EFFECTIVE?

• A longitudinal study of the efficacy of a
  comprehensive pain rehabilitation program with
  opioid withdrawal Comparison of treatment
  outcomes based on opioid use status at admission
• At admission patients using opioids reported
  significantly greater pain severity and
  depression.
• Significant improvement was found on all outcome
  variables following treatment and six-month
  posttreatment regardless of opioid status at
  admission.

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EFFECTIVE?

• Outcome Variable Non Showing Differences
• Depression
• Pain catastrophizing
• Pain interference
• Perceived control over pain/life
• General activity
• Health perception
• Physical functioning
• Social functioning
• Role limitations related to physical problems
• Role limitations from emotional factors

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EFFECTIVE?

• A longitudinal study of the efficacy of a
  comprehensive pain rehabilitation program with
  opioid withdrawal Comparison of treatment
  outcomes based on opioid use status at admission
• At discharge, patients taking higher doses
  continued to report significantly greater pain
  severity than the non-opioid group.
• Patients in the opioid cohort who completed
  rehabilitation and opioid withdrawal maintained
  treatment gains comparable to those in the
  non-opioid cohort.

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EFFECTIVE?

• A longitudinal study of the efficacy of a
  comprehensive pain rehabilitation program with
  opioid withdrawal Comparison of treatment
  outcomes based on opioid use status at admission
• Study Limitations
• Self-selection bias
• Methodology of this study precluding causal
  inferences suggesting patients functioning
  improved because of the opioid withdrawal

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EFFECTIVE?

• Chronic Noncancer Pain Rehabilitation With Opioid
  Withdrawal Comparison of Treatment Outcomes
  Based on Opioid Use Status at Admission
• No significant pretreatment differences were
  found between the opioid and nonopioid group
  regarding demographics, pain duration, treatment
  completion.
• No significant differences were found regarding
  all outcome variables, including pain severity,
  between the opioid and nonopioid group.

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EFFECTIVE?

• Multidisciplinary rehabilitation for chronic low
  back pain systematic review
• Twelve randomized comparisons of
  multidisciplinary treatment and a control
  condition.
• Strong evidence that intensive multidisciplinary
  biopsychosocial rehabilitation with functional
  restoration improves function when compared with
  inpatient or outpatient non-multidisciplinary
  treatments.
• Moderate evidence that intensive
  multidisciplinary biopsychosocial rehabilitation
  with functional restoration reduces pain.

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Mercy pain center
History Interventional Pain Management and Medi
cal Pain Management
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Mercy pain center

• Confirm diagnosis
• Exhaust interventional options
• Functional rehabilitation
• Physical therapy/exercise
• Cognitive behavioral therapy
• Adaptive equipment
• Lifestyle change
• Medication management

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Mercy pain center
Evolution Interdisciplinary Biopsychosocial Rehab
ilitation and Medically Managed Opioid
Withdrawal
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Mercy pain rehabilitation

• Patient selection evaluations
• Physiatry/pain medicine evaluation
• Psychiatry/psychology evaluation
• Addiction medicine evaluation

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Mercy pain rehabilitation

• Patient selection evaluations
• Treatment program
• 2 ½ hour treatment days
• 1 hour of cognitive behavioral therapy
• (Health and Behavior codes)
• ¼ hour mindfulness exercise
• 1 hour of physical exercise
• (Group Medical Visit coding)
• ¼ hour homework assignment

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Mercy pain rehabilitation

• Patient selection evaluations
• Treatment program
• 2 ½ hour treatment days
• 12 week program
• Orientation/foundational training week
• Treatment weeks
• 5-week opioid taper
• 5-week opioid free
• Discharge planning week
• Open ended aftercare program

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Mercy pain rehabilitation

• Treatment Team
• Patient
• Family
• Physiatrist/pain physician
• Psychiatrist
• Psychologist
• Addiction medicine provider
• Nurse Practitioner
• Registered nurse
• Physical therapy assistant/exercise instructor
• Medical assistant
• Support staff

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Mercy pain rehabilitation

• Medically Managed Opioid Withdrawal
• Pretreatment detox
• Supported progressive taper (5-weeks)
• Adjuvant medication management
• Suboxone induction and rapid taper
• Suboxone induction and maintenance

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The lost generation
MJ Christie, Cellular neuroadaptations to chronic
opioids tolerance, withdrawal and addiction.
British Journal of Pharmacology (2008) 154,
384396
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Thanks