Hi, my name is Christy Gively. I am the medical director at Retreat Behavioral Health in Lancaster, Pennsylvania, in Ephrata, Pennsylvania. And today we're gonna talk about managing non-cancer pain in your clinic. So there's four sections to this. The first one is gonna be your initial assessment of somebody with pain and what kind of treatment approaches that you would have take. And then these are the learning objectives for today for the first section. We'll take a deeper look at characterizing the ongoing public health challenges due to the opioid epidemic and its effect on patient care. We're gonna evaluate the fundamental concepts of pain management, including definitions and sources of pain. We're gonna perform an effective assessment of patients with pain to determine the most appropriate treatment options and create an effective pain treatment plan customized to the needs of the individual patient. So in America, we're facing two important public health challenges even before COVID started. There's at least 50 million Americans who report chronic pain. And this result comes from a national survey that went out to about 30,000 Americans. There is an estimated 20 million Americans who report high impact chronic pain, which is pain that limits their life or their work on most days over the past six months. This 20 million reflects those people that are more likely to go to a hospital or to receive medical care for their pain. So one in 10 or 11 Americans are actually reporting high impact chronic pain. From the last count, which was in 2016, 2 million Americans suffer from opioid use disorder. Many argue that opioid use disorder diagnosis is significantly underestimated. So chronic pain, high impact chronic pain and opioid use disorder all present significant problems. We're gonna talk about biological significance of pain. So in the most simplistic terms, pain is a biological function and it offers survival value. But it's important to realize that patients are not having just the pain they're telling you about, but also the compensatory issues, whether it's a physical component like guarding or psychological issues related to dealing with pain becomes a much greater issue than just the pain. It also encompasses biopsychosocial issues with compensatory and other indirect factors which increase the pain experience. Okay, so there's a relationship between acute and chronic pain. Classically, we describe pain as acute, subacute or chronic. Acute pain is usually pain that lasts less than six weeks and usually within that timeframe, normal healing should occur in most people. Subacute pain is pain anywhere from six weeks to three months. There has been more emphasis on the subacute period lately. The thought is to look more closely at patients during this time period to prevent the pain from becoming chronic. And then chronic pain is pain that's been there for more than three months. Most of the time when we're seeing patients, they've already developed chronic pain. So there's three types of chronic pain. There's three types of pain to talk about. Nociceptive pain is that pain which arises from the stimulation of specific pain receptors. And those are the receptors that can respond to cold, to heat, to stretching, to vibration, to chemical stimuli that are released when tissues are irritated or injured. Neuropathic pain is the result of structural damage or dysfunction in the nervous system. Nociplastic pain is pain which arises from the altered nociception no clear evidence of actual or threatened tissue damage causing the activation of the peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain. It's not entirely understood, but it's thought that augmented CNS pain and sensory processing and altered pain modulation all play prominent roles. Nociplastic pain is typically multifocal. So it could be more widespread, it could be more intense, or it could be both than would be expected given the identifiable tissue or nerve damage. And it may be associated with other CNS derived symptoms such as fatigue, sleep, memory, and mood problems. It's important to recognize nociplastic pain because the treatment is gonna be different from those experiencing nociceptive or neuropathic pain. So nociceptive pain is a stimulation of specific pain receptors. So these are the ones that can respond to cold, heat, stretching, vibration, and chemical stimuli released when tissues are irritated or injured. This includes osteoarthritis, rheumatoid arthritis, tendinitis or bursitis, ankylosing spondylitis, gout, neck and back pain with structural pathology, tumor-related nociceptive pain, sickle cell disease or inflammatory bowel disease. Neuropathic pain is the result of structural damage or dysfunction in the nervous system either centrally or peripherally. So these are your postherpetic neuralgia, painful diabetic peripheral neuropathy, lumbar or cervical radiculopathy, stenosis, tumor-related neuropathy, chemotherapy-induced neuropathy, small fiber neuropathy, persistent postoperative pain, multiple sclerosis pain, post-stroke pain or pain associated with spinal cord injuries. And then nosoplastic pain is pain which arises from the altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system. So this is your fibromyalgia, irritable bowel syndrome, tension-type pain, interstitial cystitis or pelvic pain syndrome, TMJ disorder, chronic fatigue syndrome, restless leg syndrome, neck and back pain without structural pathology. All right, so now we're gonna turn to opioids and their effects on the brain. So by understanding the risks of opioid misuse and abuse, physicians can create opportunities for patient counseling and other strategies to reduce these risks. This complex pathophysiology of opioid use of pain plays an important role in pain treatment. Opioids can add to the complexity of treating pain because they often have rewarding effects in addition to pain alleviation and this contributes to the potential for misuse. Remember that the opioid itself is not just an analgesic, it has other positive and negative effects on the nervous system. This comes into play when we start talking about patients developing opioid use disorder or other aberrant behaviors. This image here is from the NIDID, National Institutes of Drug Abuse and it shows a revolving mechanism between addiction, reward mechanisms and pain. We've recently developed a better appreciation for the underlying causes of addiction but also how the underlying causes of addiction so closely interact with the pain pathways. So these are some of the effects that you can see when people are using opioids. You get analgesic effects, you get analgesia, altered mood, decreased anxiety, respiratory depression, inhibition of the central reflexes, GI motility, cough suppression, meiosis, pruritus and nausea or vomiting. Reinforcing effects are what contribute to addiction. They reduce anxiety, they decrease boredom, they decrease aggression and they increase self-esteem. So we're gonna talk about a couple of patients as we go through the next sections. And first one we're gonna talk about is Emily. Emily is a 25 year old woman who has a history of pelvic pain. She developed her pelvic pain when she was a teenager and it was associated with dysmenorrhea and menorrhagia. It was initially managed with oral contraceptives and had little impact on her day-to-day life. At the age of 23, she developed a pulmonary embolism that was thought to be related to the oral contraceptives and she needed to stop those. She then developed a continued cyclical pelvic pain, nausea, bloating and diarrhea. She underwent a diagnostic laparoscopy three months ago and had a biopsy confirmed endometriosis during that exam. There were no lesions noted on the rectum, the abdominal wall, the ovaries and the utero sacral ligaments. But physical exam revealed no lesions. Sorry, that should have been lesions were noted on all of those areas. Physical exam revealed tenderness with nodules along the thickened utero sacral ligaments. So how do we assess pain in Emily? So you wanna do all of these different, you can use all of these different techniques to assess their pain. So you wanna ask the patient about their pain, the intensity or severity. This is typically done by a doctor This is typically done verbally through self-report from the patients. Sometimes we can't do that because they may be older age or they may have a cognitive deficit or impairment or they might be very young children. In that case, you can use a proxy for the verbal assessment, which would be a behavioral assessment. Behavioral assessment can be helpful seeing patients use behaviors that would indicate stress or if a family member or a friend is present and the patient is unable to verbalize their pain, you can ask and assess the pain indirectly by obtaining some history from the family member or friend. And then there's also pain assessment scales that we can use. There's multiple ones out there. You can use these for both verbal and nonverbal patients. The most common scale is numeric rating pain from zero to 10. The visual analog scale is probably more used in research than in practice. You draw a line on the left, which indicates no pain. You draw a line on the right, which is the worst pain possible. And you have the patient who draw a line perpendicularly where their pain falls. And then there's also the FACES scale, which is useful in children who are as young as three or those who aren't able to read or write and those who don't speak your language. FACES is a rating scale that has different faces with the different levels of distress. Assessment scales can be used for multidimensional factors, such as a brief pain inventory or the short form McGill pain questionnaire. These scales take into account pain intensity and the impact of pain on that person's life activities, their daily function, their mood. It's important to ask patients where they feel their pain. Is it radiating? Are they having other symptoms? Patients with visceral pain will often have other effects, such as diaphoresis or GI distress. It's important to obtain all the information that you can from the patient to help determine their diagnosis. When we're thinking about using an opioid, whether it's a short-term or a long-term, it's important to screen the patient for the risk of opiate use disorder. Personal or family history of drug or alcohol use is one of the prime factors that's predictive of opioid misuse or abuse, but there's other factors to take into account too, such as do they have an underlying untreated psychiatric disorder like anxiety or depression? Do they have bipolar disorder? Do they have personality disorders? All of these can increase the risk of opioid misuse or abuse. There's the Opioid Risk Tool and the SOAP-R, which are multidimensional tools that you can use online and administer to your patients to determine their risk of opioid abuse or misuse. The Prescription Drug Monitoring Program is a great tool to use. It's important to access your state PDMP. Each state has specific requirements, but it's a good idea to get in the habit of checking the PDMP of many of your patients, if not all of them. You should definitely check it anytime you're gonna prescribe or refill an opioid to ensure patients aren't obtaining opioids from multiple sources. You wanna document in your notes that you check the PDMP and document any red flags. Are there multiple prescribers? Do they have other controlled substances? It's also important when prescribing opioids to discuss safe storage of opioids with patients. For example, use a lockbox to store the medication to ensure others don't have access. It seems obvious, but discuss with patients that they should not be sharing their opioids with others and discuss proper disposal of the opioids once they are no longer needed. So if somebody comes in with pain like Emily, you're gonna get to the physical exam. You wanna do, the physical exam is very, very important. A neurological exam is also important, especially in patients who have neuropathic pain to help document the subjective complaints of pain. The physical and the neurological exam can help verify the preliminary impression that you might've had based on their history, and it helps guide you in what testing to order next. Obviously, testing will be dictated by the symptoms. An x-ray would be important if you suspect a fracture of a finger or an MRI of the lumbar spine might be indicated if they have radicular pain in their right leg. EMG and nerve conduction tests might be important to determine why a patient might have pain that's below the knee when there's no MRI evidence of the lumbar spine or disc disease. And certainly, if you feel like patients would benefit from injection therapies of nerves or joints, it's important to refer those patients to pain specialists for those particular injections because they can be both diagnostic and therapeutic. You also wanna be doing psychosocial and social evaluations. Pain changes a person, so it's natural for a patient to feel depressed or anxious. Patients can also develop a substance use disorder as a result of pain, or they may have had one in the past that's now reactivated. This is all important information to ask patients about and to document in your note. It's also important to refer patients as appropriate when you discover that they have an untreated mental health problem and get them the help they need. It's also important to discuss family planning with the patient. Is she considering a pregnancy? It's important to discuss the risks of opioid use if she would become pregnant, the risks of physical dependence, the risk of neonatal opiate withdrawal syndrome in the infant. It's also important to discuss in breastfeeding women because opioids can pass into the breast milk and neonates would need to be monitored. So you've done your thorough history, you've done your thorough assessment, and now you are reaching your comprehensive management plan. These plans are often, there's often going to be multiple elements to a pain treatment plan, and the components can vary significantly between patients depending on their needs. So you're gonna take into account their history, their factors contributing to pain, their physical exam, and the diagnostic testing, and what results you've got. HHS had an interagency task force that was established to put together a comprehensive plan based on legislation from 2016. It helped us better understand some of the gaps in our current understanding of pain, how we treat pain, and how we study pain. So they defined five different areas of pain management and outline a good basic treatment approach for any clinician. The first area is medication, we're gonna touch on that later. The second area is restorative therapies such as physical and occupational therapy and exercise. The third group included interventional procedures like epidurals, facet injections, spinal cord simulators, and the like. The fourth area includes behavioral health approaches. This could be cognitive therapies, behavioral therapies, meditation, mindfulness training. And the fifth group is complementary and integrative medicine, which encompasses acupuncture or chiropractic care. In some cases, patients may only need one or two of the categories, but keeping this list in your mind when developing their care plan can be beneficial. It's also important to consider their biopsychosocial issues and evaluate their risk for the development of chronic pain after an acute injury or disease. There's screening tools you can use to assess for the risk of chronic pain. You also have to think about the underlying stigma affecting all five of the domains and consider your patient's access to the care you're recommending and the background and needs of the individual patient. Each patient is going to require an individualized treatment plan. There's not going to be a one size fits all. You want to take into consideration all the biopsychosocial aspects. One patient may only need NSAIDs and yoga therapy, while another patient may require Tai Chi, gabapentinoids, epidural injections, and other treatments. Determining how their pain affects them socially and affects their mood may also help determine the treatment plan. It's critical to talk to the patient about the difficulty that we have in terms of eliminating pain control completely. This isn't always a realistic goal. The elimination of pain is not realistic. It's important for both the patient and the physician to have the same goals in mind for the treatment plan for it to be considered effective. The goal is typically going to be to make the pain more manageable and more controlled and to improve their quality of life and improve their function. What are the patient's goals for pain management and function? It's important to know if a patient wants to be able to walk a block and they're not able to do so because of pain. This is a measurable functional goal that the patient could achieve. Pharmacologic options, they may need one or more multiple pharmacologic modalities. Patients should be involved in the decision-making and the options for the treatment of their pain should be the same. If that's out of the scope of your practice, then it's time to consider referral to a pain specialist. And then there should be ongoing discussion about the treatment plan with the patient and it should be reviewed at every visit. If you detect signs of opioid misuse or abuse, you need to address it with the patient and you need to address the steps to take in response to the abuse or misuse. If that's not something you're comfortable handling, then refer the patient to a pain specialist. It's also important to address the responsibilities of both you as the provider and the patient. You should discuss with the patient that their part of the agreement is to adhere to the treatment plan and not overuse medications, while as the provider, you are responsible to do the best you can in managing your patient's pain. If the plan isn't working, you need to reassess the plan and come up with a new plan. It's also important to address the responsibilities of both you as the provider and the patient. If the plan isn't working, you need to reassess the plan and come up with a new plan. It's also important to use patient provider agreements when initiating opioid therapies to help patients understand the risks, benefits, and limitations of opioid therapies and to ensure the safe and appropriate use of opioid medications. Opioids should only be considered when non-opioid options are inadequate and that when the benefits of using an opioid is they've failed non-opioid therapies, the patients really have an impaired quality of life or they have moderate to severe pain. When completing a trial at opioid therapies, you want to assess for their pain levels, you want to assess for the effect the opioid has on their pain level and monitor for adverse effects. There's a lot of barriers to managing patients with pharmacologic or non-pharmacologic treatment options, like they may have no insurance or they may have inadequate availability of certain providers who treat patients with pain. You need to attempt to address these barriers. These barriers exist. We need to do the best we can to facilitate what we feel is the best treatment for each patient. You may have to do those prior offs. You may have to discuss treatment plans with the patient's insurer or you may even have to have the patient get involved if medications or treatments are denied. Document, document, document, document the patient's reports of pain, document your physical findings, document your assessment and plan, document the failures of the treatment plan, document your patient provider agreements. If it's not documented, it didn't happen. The overall treatment approach and plan should also be well-documented in the patient record, including written agreements and informed consent patient provider agreements that reinforce the patient and provider responsibilities and avoid punitive tones. Later in the treatment course, you can always go back to that patient provider agreement to remind them of what they've consented to at that time. For example, if you as the provider feel it's time to discontinue an opioid therapy and the patient disagrees, you can refer back to the agreement and that they agreed to discontinue therapy when the provider felt it was appropriate. When creating the agreement, you wanna avoid punitive tones though. You wanna lay out the terms of, if this happens, then this is the action I will take rather than describing it as a punishment. Okay, so that was section one. Moving on to section two, we're gonna talk about initiating opioid analgesia and other strategies for maintaining effective treatments. The learning objectives for this section are to recognize the clinical applications of non-pharmacologic approaches for pain management, identify the various non-opioid and opioid analgesics and their practical uses, determine which patients are suitable candidates for analgesia and appropriately manage an acute and chronic pain using opioids. Okay, so we're gonna go back to Emily. Emily is a 25-year-old female who has been diagnosed with endometriosis. She cannot take oral contraceptives anymore due to her history of a pulmonary embolism. An acceptable course of treatment at this point would be a trial of non-opioid analgesics such as NSAIDs or acetaminophen and maybe even consider a trial of a progestin IUD with her. So there's a number of non-pharmacologic and self-management treatment options that have been found to be effective either alone or as part of a comprehensive pain management plan, particularly in musculoskeletal pain and chronic pain. Examples include psychological, physical, rehabilitative, surgical approaches, complementary therapies, the use of approved or cleared medical devices for pain management. You wanna inform patients about pain management expectations and managing pain through the different pharmacologic and non-pharmacologic modalities. Emily presents a good case of an average patient you may see in the office. This case offers a lot of different options for treatment and it's important to consider the non-pharmacologic options when managing pain. In the past, opioids may have been the go-to for a patient like Emily, but there's so many more options available and things that should be considered. Non-pharmacologic methods may include physical therapy, occupational therapy. They may include behavioral medicine, interventional therapies or procedures, non-opioid analgesics, complementary therapies, patient education and mind, body and movement-based therapies. It's important for providers to be knowledgeable about the range of options available for the treatment of pain. Every geographic area is gonna have different resources available, but it's important to consider what a patient is willing and able to do. They may be willing to travel a little bit further if you feel this particular therapy would be effective. It's also important to understand the patient's expectations. If you and the patient aren't on the same page, the patient's never gonna feel she's been adequately treated. So education is paramount. How do you use the alternative therapies? Just as you would a medication trial, you and the patient decide on a therapy, you educate the patient about the therapy and you follow up after the therapy has been completed to reassess the patient and make plans for the next step if necessary. So if you send a patient to physical therapy, it's important to review the exercises with the patient, discuss the reasoning behind a trial of physical therapy and what goals have been set for physical therapy. Psychological interventions may be very important, especially when dealing with chronic pain. There's multiple psychological interventions that can be tried. There's behavioral approaches, mindfulness-based stress reduction, relaxation training, pain education. And these interventions can be provided by a psychologist, a social worker, or even a non-behavioral health therapist, like a physical therapist. Many non-behavioral health therapists are getting training in cognitive behavioral techniques, which can be used while they're delivering physical therapy. Therapists can also help the patient identify what are their stressors and how can they develop stress management techniques? How can they improve communication? How can they manage their flare-ups? A good psychological intervention is going to focus in these areas and then hopefully be able to individualize a patient's treatment. Non-pharmacologic interventions, like for example, for a low back pain, there's other things you can do. You could do a medial branch block. You can do injection therapies like epidurals. A pain specialist can use these interventions both to diagnose and to treat the pain. Many times the treatments will be used in combination with other treatments for it to be effective. Many times in the office, non-opioid medications and non-pharmacological therapies are going to be your first line for treatment plan. It's important to have a basic understanding of the mechanisms of action for each group of non-opioid analgesics, such as NSAIDs, anticonvulsants, antidepressants. It's important to know what they're approved by the FDA for, what various forms are available. Is it oral? Is it transdermal? What are the potential adverse effects? Are there any labeled warnings? And what are the drug-drug interactions? A good rule of thumb is always going to be to start the dose low and gradually increase. So Emily has been started on non-opioid medications such as NSAIDs, acetaminophen. She had a trial of a progestin IUD put in. And remember when evaluating Emily and developing her treatment plan, remember all the parts of the effective assessment that we already talked about in the last section. What screening tools can you use to evaluate her risk factors for development of chronic pain after acute injury disease? What functional assessment scales, physical exam, all of those things. You also want to talk to her about family planning, especially with endometriosis because family planning goals are gonna really influence your treatment decisions. If she wants to have children, you're not going to do a hysterectomy on her. Okay, before we even think about opioid therapy, let's take a look at how opioids work. So our understanding of opioids has evolved and we can appreciate, we can all appreciate that opioids act as analgesics, but the opioid receptors are a lot more complex than just analgesia. This image comes from Valentino and Volkow at the NIH in NIDA, and it nicely describes opioids. So opioid receptors have three receptors. There's a delta receptor, a mu receptor, and a kappa receptor. Agonists at all three receptors are analgesic, but each receptor has a different effect on mood and hedonic continuums. Mu agonists produce euphoria and promote stress coping. Kappa agonists produce dysphoria and are associated with stress and negative effects. Delta agonists have anxiolytic and antidepressant activity. So these effects are important to remember when you're tapering a patient as they may experience many of these mood problems while coming off of opioids. Most opioid receptors are G-coupled protein receptors and they're primarily inhibitory. We have endogenous opioids in our body with a very complex endogenous opioid system. When we give exogenous opioids to patients, we sometimes will see opioid hyperalgesia. The opioid receptor initially is inhibitory and it inhibits the release of substance B and glutamate to decrease pain signaling. But in some patients, this may be a shift where it becomes excitatory and this may be the underlying mechanism of opioid hyperalgesia. Patients on chronic higher dose opioids may actually develop an increased sensitivity in their body. We're continually understanding more about the complexity of the receptors. Opioids have effects on the endocrine system. They have effects on the hypothalamic pituitary axis. In men, you can see hypogonadism. In women, you can see decreased libido, infertility, osteopenia, osteoporosis. All three of these receptors may be activated in different ways across different patients and that may be responsible for the variability and response in some of the adverse patients developed from opioid pharmacotherapy. It's important to understand the pharmacokinetics and the pharmacodynamics of the different formulations of opioids available. Is it an immediate release? Is it an extended release? Is it a long acting formulation? Most long acting opioids, if you crush them or melt them and then you snort it or inject it, it'll cause an increased effect, right? Many of the extended release and long acting opioids have abuse deterrence built in to attempt to deter the manipulation of these medications. For example, they may be difficult to crush or if you melt them, you can't draw it up into a needle. This all decreases the chance that the formulation will be abused on the street or by a person with an opioid use disorder. It doesn't mean they won't be abused. It just decreases the likelihood of abuse. Although then many patients just overdose with oral ingestion if they can't get it to be get high another way. Methadone requires special precautions and you could have a whole lecture on methadone on its own. Methadone is one of the original extended release long acting opioids, but methadone has very complex pharmacokinetics which can lead to significant variability from patient to patient. It's important to know the FDA has standards for what drugs are allowed to be labeled as abuse deterrence. They require that labeling describing the abuse deterrence be grounded in science and supported by evidence. Now we're gonna talk about the pharmacodynamics and pharmacokinetics of some different type of opioids. All right, there's a lot of formulations out there. You can have oral formulations, but those could be a tablet, a capsule, a liquid. Some opioids are available as transmucosal forms. Those that are more lipophilic like buprenorphine and can be put inside the side of the mouth or under the tongue. Sublingual absorption can get to the serum levels a lot faster or CNS levels, but some opioids like morphine or hydrophilic. And if you put it under your tongue, it's not gonna get absorbed. Different formulations have different absorption patterns. There's also transdermal routes, such as a patch. The common ones are buprenorphine and fentanyl. They're both lipophilic, allowing them to be put into a patch formulation. The medication is absorbed into the skin, into a kind of reservoir, and then released into the nervous system at a constant rate. There's also solutions, subdermal implants and suppositories. About 90% of opioids prescribed today are immediate release or short-acting opioids. Unfortunately, very early in the development of long-acting opioids, these formulations had a lot of medicine in one pill, making them more easily manipulated. And it led to a lot of misuse of those medications, leading to the overdoses and the problems we saw early on. Immediate release formulations have a quick onset of action and a short duration of analgesia. The 2016 CDC guideline recommends the use of short-acting immediate release opioids prior to using any extended release products. So you wanna use short-acting opioids in an opioid-naive patient, because if you're using long-acting and they have an adverse effect, it's in their system longer, it puts them at higher risk. Using a short-acting formulation first allows better control and limits harm over time. The package inserts and the box warnings have changed. All opioids carry the warnings listed on this slide. Remember that long-acting or extended release formulation should primarily be used for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment, and for which alternative treatment options are inadequate. All of these items should be discussed with the patient if you're prescribing an opioid. Even at prescribed doses, opioid analgesics carry the risk of misuse, abuse, and addiction. Life-threatening respiratory depression in opioid use, respiratory depression is the number one way someone dies. There's a risk of accidental exposure, such as the patient taking opioids with the child in the home, and then the child accidentally, or if it's an older child, intentionally ingests the opioids. This can lead to respiratory depression and death, so it's important to discuss safe storage of medication with patients. Neonatal opioid withdrawal syndrome is another known risk of opioid therapy in pregnant women, and all that goes along with that. Withdrawal in the newborn and prolonged hospital care for the neonate. Opioids also interact with alcohol, especially long-acting opioids. The higher concentrations of alcohol can cause a dose-dumping effect, which would cause a quick release of the opioid, leading to dangerous levels and toxicity. So these are the different types of opioids that are available. Some are full opioid agonists, like methamorphine, oxycodone, codeine, and fentanyl. Buprenorphine is a partial opioid agonist. This doesn't mean it only partially works, it just describes how it binds to the receptors. Buprenorphine only binds to the Mu opioid receptor, and it dissociates very slowly. This allows for once or twice daily dosing. There's also less effects on the endocrine system and other organs. Buprenorphine is primarily used for opioid use disorder, but it is also a very effective analgesic. Mixed opioid receptor agonist antagonists include butorphanol, nalbupine, and pentazocine. And then opioid antagonists include naloxone, naltrexone, which blocks the opioid receptor, and can be used to reduce alcohol cravings for opioid abuse, and naloxone, which is the rescue medication for opioid overdose. Contraindications. Obviously, if they're allergic to opioids, don't use opioids. It's really unlikely a person is allergic to opioids. Most of the time, patients are reporting an intolerance rather than a true drug allergy. If the patient's actively diverting controlled substances, obviously you aren't going to prescribe opiates if they have a known opioid use disorder or they have a history of opioid overdose. These are all relative contraindications, though. It's important to obtain a thorough history from the patient and to query your state's PDMP when you consider prescribing an opioid. We want to move towards safe opioid prescriptions. You screen your patients for the risk of addiction, abuse, or misuse. Even if it's short-term opioid use and it's a low-risk patient, it doesn't mean they won't develop a problem. There's multiple tools you can use to screen a patient, including the audit and asking the patient about a personal or family history of drug or alcohol abuse. You want to discuss the potential adverse effects with the patient. Medication errors. Make sure the patient understands how to take the medication and what doses to be taken. You want to discuss the risk of respiratory depression and the periods of greater risk for significant respiratory depression, including when you first start therapy or anytime you increase the dose. You want to talk about serious adverse drug reactions, including overdose death. Driving and work safety. They shouldn't be driving or operating machinery until they know how they react to the medication. And it's also important to discuss how they're feeling on the medication at follow-ups. It's not just about the pain management. Are they driving? Do they feel impaired? Are they having constipation? All of those side effects. So we're going to talk about another case a little bit. Lucy is 47 years old and she began to have left shoulder pain after playing tennis. She initially treated it with ice, physical therapy and NSAIDs, but had minimal improvement. When her treatment was ineffective, she had a further workup and imaging revealed a rotator cuff tear and a labrum tear. She ultimately underwent surgical repair and was started on opioid therapy postoperatively. She was initially treated with oxycodone acetaminophen, but unfortunately her postoperative course was complicated by an infection. She ultimately required the oxycodone acetaminophen regimen for about three months and then she tapered off the opioids. At that time, her pain was controlled and she had regained function in her shoulder. Three months of opioid therapy is a fairly significant amount of time. Most people would still consider this acute pain, but it's not someone who required a brief course of opioids like two weeks. With respect to initiating opioid therapy, it's important to use immediate release opioids, which was what was done for this patient. And you should always use the lowest effective dose for the shortest period of time. That's the key with respect to opioid therapy. Most medications should be started low dose and increased gradually, but this is really important with opioids. The CDC guidelines from 2016 recommend only three to five days of opioid use for acute pain, but this patient had complications and that necessitated longer term therapy. So when you're initiating therapy for acute pain, it's important to discuss and assess all of the above. You should have an opioid agreement in place as we already discussed, outlining a plan of care for this patient. You should have a plan of care for this patient and you should have a plan of care for this patient. You should have an opioid agreement in place as we already discussed, outlining a plan of care, the responsibilities of the physician, the responsibilities of the patient, and what's gonna happen if there's irregularities occurring with the opioid use. Before you prescribe, query your state's PDMP, prescribe naloxone for any patient on opioid therapy. In 2016, the CDC guidelines recommended prescribing naloxone for patients with a history of overdose, patients with a concurrent benzo use and substance use disorder. Today, most are recommending naloxone with any opioid prescription. There's nasal formulations available that are very easy to use. You also wanna discuss with the patient where they put the opioid bottle, discuss safe storage and keeping it out of the hands of others. I know we've harped on this a lot in this presentation, but they're important factors. So what interventions can we take to keep communities safe? Well, many states allow patients to obtain naloxone at a pharmacy without a prescription. In Pennsylvania, there's a standing order written by the state secretary of health, which allows pharmacies to fill naloxone under the secretary's license. They don't even have to go to their own physician. It's also important to discuss the disposal of unused medications. Many hospitals and pharmacies have a take-back program. Local police stations may have a medication disposal box. And as a last resort, you can mix the leftover medication with used kitty litter or coffee grounds and put them in a paper bag and dispose of them. So Emily was our 23-year-old with endometriosis. She couldn't take oral contraceptives anymore because of her pulmonary embolism. And initially her pain was controlled with NSAIDs, acetaminophen and a progestin IUD. Two years later, her pain has now progressed again and it's debilitating five days out of her cycle. She still does want to become pregnant at some point and she plans to be married in the upcoming year. Up until now with Emily, we discussed the assessment patient factors that you need to look at when you're talking about pain management and things like that. But it's been a while since we first saw Emily. So it's important to reassess her plans. Two years ago, she wasn't considering pregnancy, but she is now. So she's now failed the initial non-opioid therapy. She's failed the initial non-pharmacologic therapy. So you wanna look at your pain assessment scales or use other tools to help her quantify her pain a little bit better. You may also want to consider a psychological and a social evaluation at this point because she's now working with chronic pain and it's reaching a point where it's affecting her life and could be affecting her psychological health as well. And debilitating pain five days a month affects your life. So what would be a reasonable next step with Emily? It's reasonable to consider a trial of opioid therapies with her because she's now failed non-opioid treatments. The first thing you might try is Tramadol. As a schedule four medication, it's felt to have a lower potential of abuse relative to the schedule three medications. But with all opioids, the mantra should always be start low and go slow. As we also talked about always, always, always prescribe Naloxone in addition to the opiate in case of an accidental overdose. You should screen for the known risk factors for opioid use disorder or substance use disorder. Query your PDMP to make sure she isn't on other controlled substances that you are unaware of. This is also the point in your care of Emily that you would initiate an opioid agreement, talk about informed consent and start to perform urine drug testing. In this particular patient, when we're going to start the Tramadol, she's opioid naive. We want to start at the lowest dose and if needed, progress very slowly. Keep in mind that you're going to at some point, and keep in mind that at some point, if you're going to initiate an extended release preparation for this patient, the FDA considers patients tolerant to opioids if they have the equivalent of oral morphine at 60 milligrams a day, transdermal fentanyl at 25 micrograms an hour, oral oxycodone at 30 milligrams a day, daily oral hydromorphone eight milligrams a day or oral oxymorphone at 25 milligrams a day, or some type of equal energies like daily dosing of another opioid. Remember too, that when you're considering the use of an extended release or long acting opioid, that the indication is for the management of pain that's severe enough to require basically daily around the day, around the clock dosing. There's conversion tables out there that you can use when you need to convert a patient from one opioid to another, or when you need to convert them from IV to oral. But when starting a patient on oral opioid therapy, you wanna see the patient in a short term interval, and you wanna be sure to reassess the benefits and the harms at every visit. You wanna talk about how's your pain? What's the improvement? Are you having side effects? What are you doing about those side effects? Are they being managed? All right, moving on to the next section, which is much education. Learning objectives for this section. You wanna manage ongoing therapy for patients using opioid analgesic therapy. Evaluate patients with worsening pain for changes in underlying condition and for signs of opioid use disorder. You wanna safely taper opioid analgesics and recognize and manage signs and symptoms of opioid withdrawal, and employ best practices for treatment and caregivers about the safety and risks related to opioid analgesic therapies. So we're coming back to Emily. She, remember, she is the one whose pain is no longer controlled with NSAIDs, acetaminophen, or IUD. She's having constant daily pain, but for five days of her cycle, it is debilitating. She does desire fertility, and she's going to be married in the upcoming year. When you're looking at a patient who's having progressive pain or continuous pain, it's always important to return to those basics and reassess her levels and reassess her risks for opiate use disorder and all of those things we've already done in the past because things are gonna change over time. Her desire for fertility has changed. She's now failed two initial therapies. So it's time to reassess before moving on to the next step. And what are those next steps? You might wanna consider using a pain assessment scale at this time or some other tool to help quantify her pain. You may also wanna consider having her get a psychological evaluation or a social evaluation because she now has chronic pain that could be affecting her psychological health. We're gonna consider a trial of opioids, something like tramadol. And you always wanna, again, start low and go slow. It's important to discuss both potential risk factors for the development of opioid use disorder and discuss expectations about the analgesic effect and what the potential side effects and adverse effects could be. There's a patient counseling guide from the CDC that does a great job of summarizing the risks, benefits and potential harms of opioids. So the FDA considers a patient to be opioid tolerant if they're taking these various formulations. We went through them in a slide a few minutes ago. But these doses for at least a week are gonna be what constitutes opioid tolerance. Extended release or long acting opioids are indicated for patients who already have an opioid tolerance and have pain severe enough to require daily around the clock dosing when alternative treatments have failed. Long-term opioid treatment is generally considered to be more than six weeks of treatment. Similar to the short acting opioids, you wanna start at the lowest effective dose possible and use it for the shortest duration possible. Conversion tables exist if you need to rotate patients from one extended release formulation to another, but the tables aren't 100% accurate, but there are useful guidelines. When converting a patient, you wanna reduce the dose again by 30 to 50% due to incomplete cost tolerance. And if you're converting to methadone, use extra caution and make sure the starting dose is low. You wanna reevaluate the benefits and harms within a month of initiating the opioid therapy, and then at least every three months after that. This is a good practice for both short acting and long acting opioids. You wanna, you could reevaluate patients every three months or even less depending on the risk, if the risk of opioid therapy is higher in a particular patient. Ensure all your compliance measures are in place for these patients. Is there an opioid agreement signed and in the chart? Are you checking the PDMP? You wanna strongly consider doing pill counts or patch counts, and you also wanna be performing urine drug monitoring. Urine drug monitoring is an important component of prescribing opioid therapy. Depending on the patient, you may wanna do urine screening at every visit, or you could even do longer intervals depending on the risk of abuse or diversion. You wanna review the risk of adverse events at each visit, including nausea, vomiting, constipation, sedation, overdose, and even death. In addition to reviewing the adverse events with patients, you wanna consider that certain groups of people are gonna be more likely to experience adverse events. Those people over 60 years old who are significantly more likely to develop respiratory depression. Serious adverse events can be reported to the FDA by calling 1-800-FDA-1088, or you can fill out the reporting form that's available on their website. When you're talking about the efficacy related to an opioid, you wanna talk about each patient individually. You don't expect non-cancer pain patients to have relief of pain, but you do expect to see functional improvement and improvement in their ADLs. In palliative or end-of-life care patients, you don't really expect to see a change in function, but the goals for those patients is geared more towards pain control, relief of pain, and improvement in their quality of life. Certain products are restricted to opioid-tolerant patients, such as transdermal fentanyl patches, and there's abuse-deterrent opioids available, such as OxyContin, HiSlinga ER, and extended-release hydrocodone. Abuse-deterrent forms are not available for all opioids, but you can certainly consider using them in patients that you feel have an increased risk of misusing or abusing their opioids. Methadone is a whole system, a whole other topic. The methadone has a long plasma half-life. The elimination half-life is between eight and 59 hours. The elimination half-life is longer than the duration of analgesic action, which is only four to eight hours. This is why it's often prescribed three times a day for patients with chronic pain. The peak respiratory depressant effect of methadone typically occurs later and can persist longer than the peak analgesic effect. The cross-tolerance between methadone and other opioids is incomplete, and it doesn't eliminate the possibility of methadone overdose, even in patients who are tolerant to other opioids. If you're converting from an extended-release opioid to methadone, the safest way to do that, regardless of what the numbers tell you, based on the conversion table and based on experience and some of the data, is to convert them to something like five milligrams, perhaps three times a day. When you start someone on long-term opioid therapy, it's important to monitor them frequently. You want to be aware of the signs and symptoms of opioid use disorder. You can assess the four A's of pain management at each visit. You want to assess the degree of pain relief they're getting from the opioid, assess whether their activities of daily living are improving, are they having any adverse effects from the medications, and if so, are they controlled, and are they exhibiting any symptoms and are they exhibiting any drug-related behaviors of abuse or misuse. If they do have adverse effects, such as constipation, are you treating them? You should also check the PDMP at every visit and perform urine drug monitoring at least once a year, more if you're concerned there's aberrant behavior. You want to screen and refer for substance use disorder treatment when concerns arise. If there's any evidence of abuse or misuse, it's appropriate to counsel the patient, and then if need be, refer the patient to substance use disorder treatment, a counselor, a therapist, a psychiatrist, whatever resources are available nearby. You should also consider discontinuing their opioids if there's evidence of aberrant behavior, but you want to taper them. You don't just want to abruptly discontinue them. Pregnancy and breastfeeding patients introduce a whole other aspect to the treatment. So if a pregnant patient is using an opioid, it's imperative to discuss the risks of opioid therapy on the fetus with the mother. You want to recommend that the mom have no use or minimal use of opioids during the pregnancy, and you want to discuss the risk of addiction and the risk of neonatal opioid withdrawal syndrome. You should review with mom that neonatal opioid withdrawal may require a longer hospitalization for the baby, and the baby may possibly require treatment with methadone or other opioids. If you have a mom who's unwilling to discontinue her opioids in pregnancy because of their pain and concern that opioids are the only thing controlling their pain, you may want to consider a referral to an addiction specialist. A pregnant woman on opioid therapy for pain management may be a good candidate to transition to buprenorphine, even if they aren't abusing the opioids. Buprenorphine tends to have less withdrawal symptoms in the fetus versus other opioids, and buprenorphine frequently provides adequate pain control. If you have a patient with renal or hepatic impairment, you want to reduce the dose or reduce the frequency of use, or sometimes both. You want to try to select opioids that have no active metabolites, which would also reduce the risk of toxicity, things like fentanyl, oxymorphone, or methadone. And as we age, unfortunately, the prevalence of pain increases. Older patients may require opioid therapy. Older adults will typically require lower doses, and older patients also experience a faster response to the opioid and develop a tolerance more slowly. It's always important to start low and go slow with opioid therapy, but it's even more important in older adults. You want to consider longer dosing intervals as well, especially in those with hepatic or renal disease. Other special groups to consider is that opioids can lead to sleep disorders, so you want to assure, you want to assess the patient's sleep prior to starting an opioid, and reassess it for frequent intervals. If the patient has a psychiatric disorder, you want to consider co-managing the patient with their psychiatrist due to the increased risk of misuse or abuse, and be aware of the genetic and phenotypic variants in respect to the metabolism of opioids. Screening for endocrine function may be recommended. You want to determine, and then how do you determine when an opioid analgesic is necessary or beneficial? Chronic opioid therapy, six months or more, can have an effect on the endocrine system. You may want to consider screening for the endocrine dysfunction by ordering an LH, FSH, estrogen levels, or even testosterone levels. And you would know when you want to consider weaning the patient off the opioid if it's no longer providing pain relief, if they have improvements in their function and activity of daily livings, and certainly if you suspect signs of abuse or addiction. Okay, let's talk about Emily again. Six months after starting her tramadol, her pain is no longer controlled. She reports that she's taking tramadol as prescribed and is not taking more than direct. Emily and her physician decide to trial hydrocodone. Remember to assess the risk again for development of opioid use disorder, check the PDMP, and perform a urine drug screen. Emily initially starts on 10 milligrams of hydrocodone daily, but she quickly titrates up to 40 milligrams daily over a few weeks for adequate pain control. This titration is pretty typical in a patient that has uncontrolled pain. It's also important to screen patients for a history of sexual abuse, especially women with chronic pelvic pain. This can be a very sensitive topic and one that needs to be approached without judgment or bias. You can preface the questioning by telling the patient, I asked all my patients this question, and I just want to know if there's any history of abuse that we should talk about as this may help me figure out what's going on. Especially in adolescence, you'd need to try to get the parents out of the room. Teens are never gonna tell the truth about abuse or sexual matters if their parents are there. Try to get a few moments alone, ask the parents to step into the waiting room for the rest of the exam, tell the patients it's important for them to be truthful because without the truth, you may not be able to find the correct diagnosis. You also want to encourage the patients to be honest with you, but with teenagers, you want to remind them that whatever they say to you is protected information as the patient provider relationship and you're not gonna turn around and tell their parents, unless of course there's evidence of criminal abuse. All right, counseling and management strategies. It's important to discuss many things with your patients when starting opioid therapies and this slide outlines a few of them. Make sure that patients understand they should take their medication as prescribed and not take it any other way. So they shouldn't be taking higher doses or taking it more frequently. If the patient reports their pain is not controlled on the prescribed dosing, then they need to discuss it with you before making changes to their dosing on their own. Again, opioids should be used at the lowest possible dose for the shortest amount of time. And you wanna discuss serious adverse events with opioids, including death, consider prescribing naloxone with the opioid and discuss the risk of addiction even when the opioid is used as recommended. You should discuss the most common side effects with patients, including opioid induced overdose and respiratory depression, constipation, nausea, vomiting, dizziness, the risk of falls. If a patient operates heavy machinery, they may not be able to use an opioid and they certainly should not drive while on opioid therapy until they know how they react. It's important for patients to know that they can call you if they're having side effects or problems and make sure your clinic is set up in such a way that these calls are returned in a timely manner. Discuss with the patient that they should call the office if their pain is not controlled or if they're having significant side effects. You should also discuss how to handle missed doses and make sure they understand that if they miss a dose, they should not double up on their next dose. Discuss with them that if they miss their dose by an hour or two, they can go ahead and take their dose, but if it's only one hour till the next dose, then they shouldn't take the missed dose and then an hour later take the regular dose. You also need to discuss with patients that they should be telling you all the medications and supplements they take. Remind patients they shouldn't be drinking alcohol or using other opioids or benzos when they're on opioid therapy and the patient should be educated that alcohol or benzos in conjunction with opioid therapy can lead to respiratory depression and death. You wanna discuss that they shouldn't crush or chew extended release opioids. They shouldn't tamper with transdermal patches or buccal films. These films should not be cut or torn. If they're damaged before use, the patient shouldn't use it. You may wanna talk about tapering off the medication when starting the medication just so the patient has a clear expectation of a plan. Discuss with the patient that taper will typically be a slow taper to minimize the withdrawal symptoms. Again, you wanna discuss safe storage and disposal, especially if there's children in the home. Opioids should be stored in a lockbox and disposed of properly in the case of transdermal preparations. They should not just be thrown in the trash after use where others may access it. Also, you wanna discuss how to dispose of excess medication when it's no longer needed. Many pharmacies have take-back programs, police stations have a dropbox. If none of these options are available, they can mix the medication with an unpleasant substance like kitty litter and put it in a bag and then in the garbage. You also wanna discuss that patients should never share their opioids with anyone else. It's a good idea to prescribe naloxone and counsel them on how to use it and also counsel their family or friends if possible as they're likely gonna be the ones administering the naloxone. If overdose does occur, make sure the family knows to call 911. Make sure patients know that if adverse effects continue, they should reach out to you. Patients who are on monoamine oxidase inhibitors and antidiuretics should be counseled on their increased risk of side effects. MAOIs can potentiate the depression effect of opioids and antidiuretic hormones can increase the risk of hyponatremia. When starting a patient on an opioid, it's a good idea to make the PCP aware and also ask the patient about any and all supplements that they're taking. The CDC guidelines for prescribing opioids for chronic pain were released in 2016. And these were based on the best practices around safe opioid prescribing and to help decrease the harms related to opioids, as well as trying to decrease the curve on opioid-related and drug-related overdose deaths. The guidelines touch on three main areas with a total of 12 recommendations. The first part included recommendations around determining when to initiate or continue opioids for chronic pain. It also included a discussion on what to do with starting patients for acute pain. The second part of the recommendations include opioid selection, dosage, duration, when to follow up and some tips and tricks you can do or things you can do around discontinuing patients appropriately. The third part of the recommendations included assessing risk and addressing harms of opioid use, such as prescribing naloxone, what to do if a patient develops an opioid use disorder and the like. Unfortunately, there was some misapplication of the guidelines by some local authorities, legislative groups, some medical boards, and as well as payers and pharmacy benefit plans where they took some of the thresholds that were used and misapplied them. For example, when a patient reached 50 morphine equivalents and 90 morphine equivalents, providers were supposed to stop and reconsider before increasing the dose. It was just intended to be a pause and reassess. Some bodies took those as strict cutoffs and said, nope, we're not gonna fill them above those doses. There's supposed to be some new guidelines coming out this year, taking out those thresholds and hopefully allowing the physician the ability to prescribe effectively for each patient and consider the risks and harms and hopefully there's not gonna be as much confusion as there was early on. The updated document also goes into a lot more detail within the document explaining the importance of incorporating non-pharmacologic and pharmacologic interventions, as well as more information on what to do with patients that you inherit or patients that are already on opioids and how to manage those legacy patients. So it's been three months that Emily's been using Hydrocodone. She is saying that her pain is worsening despite this therapy. So the decision is made to transition her to extended release Oxycodone. She gets started on 15 milligrams every 12 hours and that's based on morphine equivalents. It's important to again, assess her risk for the development of opioid use disorder. You wanna check the PDMP, perform the urine drug screens, start low with her dosing and go slow. You may also wanna consider prescribing eight milligrams of Naloxone rather than four milligrams. When you're providing these higher doses or the extended release medications. It's also important to remember that Emily is now opioid tolerant. So she may require higher dosing than you would initially start somebody on. We previously talked about Lucy. Lucy had her complicated shoulder injury that ultimately required opioid therapy and she was on them for three months. She's now completed her surgery, she's completed her physical therapy and her pain has decreased. So it's appropriate to taper her dose. How do you do that? Since she's been on opioids for several months, she's likely going to require tapering and it's appropriate to decrease her dose by 10% per week. Since she's been using the opiate for less than a year, it's important to have psychosocial support because she will have opiate withdrawal symptoms. And if she's not expecting those, if she's someone who never had any issues with substance abuse before, it may concern or frighten her. So you wanna tell her what she's going to have, tell her what to expect. She might have diarrhea, rhinorrhea, sweating, GI cramps, increased heart rate, irritability. It's also important that Lucy's on board with tapering. If she thinks that she still requires pain management, you're going to have a much more difficult time getting her to taper down. When tapering, most patients tolerate a 10% reduction every one to two weeks till you get to about 30% of the original dose. And then you need to change to reduce the dose by 5% every two to four weeks until the taper is completed. For some patients, they may require very slow tapers, such as a 10% reduction every month. This taper will take a long time, but it may be required typically only in a minority of patients. You can also use comfort medications, such as quinidine or cyclobenzaprine to help with withdrawal symptoms. Moving on to the last section, cause for concern. What do you do when treatment doesn't go according to plan? The learning objectives for this section is to use screening tools to identify at-risk patients for signs of opioid dependence or addiction as early as possible. You want to implement strategies to manage opioid misuse, abuse, and addiction, identify the signs and symptoms of opioid use disorder, utilize pharmacologic and non-pharmacologic treatment options for opioid use disorder, and employ best practices for counseling patients and caregivers about the safety and risks related to opioid analgesic therapies. So Emily, Emily's physician has begun to notice that Emily has asked for refills earlier than would be appropriate if she was taking the medication as prescribed. And a search of the PDMP reveals that she's obtaining opioid prescriptions from two other physicians. An office urine drug screen reveals fentanyl and methamphetamines in her urine. And when asked about the findings, Emily reveals that she has been buying oxycodone off the street. She's being told she's buying oxycodone. In reality, she's getting pressed fentanyl pills, which Emily was unaware of. Pressed fentanyl is frequently made to look like other medications, and they're frequently tainted with many other substances. We sometimes see benzodiazepines, methamphetamine, and mostly fentanyl rather than other opioids. This puts them at very high risk for overdose and death. When presented with a patient who has progressed to misuse, abuse, and addiction, education is essential for both the healthcare providers and the patients. When you suspect misuse or you detect misuse, you want to monitor adherence to a treatment plan. One way you can do this is pill counts. Have the patient bring in the bottle and count to see if the expected number of pills is present based on when they filled it and how often they're taking it. Another way you can do this is to do a medication reconciliation, have her bring in all her bottles to make sure she's taking one. Since pain is being treated properly, is she taking more than prescribed because her pain isn't controlled? Providers should also understand urine drug screening to understand what you're looking for and what you may not be looking for depending on which urine drug test you're using. It's important for all of these patients on opioids to screen and refer for substance use disorder treatment. All right, so there's a bunch of different ways you can do urine drug testing. Office-based screening is typically an immunoassay and it's often antibody-based, which means that the synthetic drugs, that synthetic drugs or opioids, are very often missed because the test is based on antibodies. This is usually going to be a cup that has the antibodies right on the sides of it or sometimes it'll be a panel of sticks that you dip in urine. There's a bunch of different ones out there. Confirmatory testing can be done by a laboratory and then the lab would use gas chromatography and that would break down the specific drug being used rather than just being positive for opiates. So the dip in your office may show you opiates but the confirmatory testing would say morphine, oxycodone, etc. It's important to know which company you're using so know both your in-office screening tests and your lab and know the screening tools you're using for drug tests. You want to use the confirmation testing to support unexpected results. You want to know what also is going to show as a false negative and a false positive. For example, some point of care cups, they don't show clonopin positive as a benzo but then when you send it out to the lab you will see clonopin in the urine. So there's on-site urine drug screens or point of care cups and then you can also use the prescription drug monitoring program. There are no point of care testing cups that are cleaved for in-office use. You must test specifically for fentanyl and almost all street opioids are fentanyl these days so it's important to make sure that you have some sort of testing source to screen for fentanyl as well. Know what your cups are testing for. If you're not looking for buprenorphine you're not going to see buprenorphine. If you're not looking for gabapentin you're not going to see gabapentin. So make sure you know what exactly the cup itself tests for and make sure you're testing for it and anytime you're concerned about opioids you need to be doing some sort of fentanyl testing. So if you're testing for opioids most point of care UDS cups are only going to test for naturally occurring opioids things like morphine, codeine, heroin, hydromorphone, or hydrocodone. All other synthetic and semi-synthetic opioids need a separate immunoassay. So things like oxycodone, methadone, buprenorphine, propoxyphene, or tramadol. When the separate immunoassay may be a separate test strip or a separate set that you're dipping into the cup. Many of the standard point of care cups don't test for the synthetic and semi-synthetic opioids. It's important to know what drug screen you're ordering with your lab and to understand what their panels test for. Again, if you're not looking for things like febuprenorphine you're not going to find them. Most labs have multiple urine drug panels. So take the time to find out what's on each panel and make sure you're ordering the panel that includes both synthetics and semi-synthetics. It's also important to know that there are cutoffs. So there's levels below which these patients may have drugs in their system, but they're going to be below where you can see it on the cup or in the lab, especially with some of the point of care cups. You may see a negative reading on the point of care cup, but when you send it to the lab, the lab's cutoff levels are lower and then you do see the positive result. Some would say that the best use of point of care testing in the office is specifically to rule out if the patient is using an illicit substance. In the office, it might be useful if you're considering prescribing an opioid and you want to make sure the patient is not using an illicit substance that day in the office before you prescribe the opioid. Be sure you know what you're testing for with your point of care cups and make sure you're testing for fentanyl. You can also use the cups to monitor compliance with the prescribed regimen. So if a patient is on buprenorphine and the point of care cup is negative for buprenorphine, either the patient gave you a false urine or they're not taking the medication as prescribed. It's also important to make sure that you're performing confirmatory testing. You may not have to send a lab specimen out for every single patient if you're doing a point of care cup, but you do want to make sure that you're periodically sending it out to make sure that your cups are showing the same as what the lab's more extensive gas chromatography tests are showing. So what do you do when the drug test is not what you expect it to be? Firstly, stay calm and consider your reaction to the patient. You don't want to walk into the exam room and accuse the patient. You may want to consider confirmation testing or discuss the results with the toxicologist before discussing with the patient. But if you have a point of care cup and the patient's in front of you in the office, you don't, you're typically going to want to address it right away. You don't want to wait. So you develop an approach with your patient based on say, some of the things you can say are in the gray box on the slide, but you don't want to the patient. A lot of how you approach it depends on your relationship with the patient. My rule to my patients is don't lie to me. I won't be upset if they had a slip and they used an illicit substance, but if they lie to me about it, I can't help them move forward. So this is something that I discuss with everyone at their first visit when reviewing their patient contract. This approach works a lot of the time and my patients will be very upfront with me and say something like my test is going to show X, Y, Z. Remember to temper your gut reaction because point of care cups can show false positives and make yourself familiar with what medications can show false positives. So this slide shows many of the items that can create a false positive. So sertraline is infamous for causing people to have false positive benzos on point of care testing. Guacamole medicines will cause false positive PCP. There's even some medications that can cause a false positive fentanyl, including things as innocuous as diphenhydramine. And which tests you're using can influence when you see this. We had one particular batch of cups that like everybody kept popping for fentanyl and we're like, okay, not all of these people are abusing fentanyl and not telling us. And when I asked further, a few of them had taken diphenhydramine, a few of them were on buspirone and they're both things that can show as false positive. We got a different batch of cups and we're not having that problem anymore. So also pay attention to that. What are you using? Where did it come from? Is it something different? If suddenly you're having results you don't expect. All right. So we talked to Emily and we made Emily and we talked to Emily about how much medication she's using. Point out to her that she's getting prescriptions from all these different people and she's also purchasing opioids off the street. This discussion helps Emily realize that she has developed an opioid use disorder. She agrees to enter inpatient rehabilitation and she's induced on sublingual, eight milligrams of sublingual buprenorphine naloxone. This dose is found to control Emily's pain. Buprenorphine is a partial opiate agonist and it binds only to the mu receptors of the opioids and this decreases its abuse potential. We'll talk about that a little bit more in a few minutes. So you may want to take a different approach with a patient who's misusing an opioid analgesic by taking the product differently than prescribed for the purpose of managing pain in contrast to the patient who abuses an opioid analgesic with the intent of getting high. Whenever you have somebody that you're suspicious for opioid use disorder, you want to monitor and assess for signs of abuse and misuse. It's important to know how and when to intervene and also to understand the difference between tolerance and physiologic dependence versus addiction. As healthcare providers, we need to be knowledgeable about the basic elements of addiction medicine and be familiar with the definition, neurobiology, and pharmacotherapy of opioid use disorders. Our knowledge about addiction has come so far in the past 20 years that it's important to take the time to be educated. I know when I was in medical school and when I was in residency, we had very little training on addiction and we didn't really understand how it came out, we didn't understand it was a disease, and this is all things that I've learned since I've gotten into the field of addiction medicine. So it's important for healthcare providers to know how to screen for substance use disorders. It's important to evaluate for underlying pain changes as the reason for their increased use. They should be knowledgeable about the basic elements of addiction and be familiar with the things we just discussed. And there's few physicians who are trained in addiction medicine, so there's few people that have a true understanding that the addiction is a disease of the brain that results in a chemical change in the brain. People do not choose to become addicted. They may choose to take a substance, but changes in their brain are what turn them into someone who suffers from addiction. Nobody chooses to become an addict. It's important to talk to your patients with compassion when you're discussing these things because there's such a stigma surrounding addiction and mental health disorders. How do you know when to refer a patient out? At what point do you need to consider getting some additional help? You might see that the patient has a change in behavior or her function is not as expected. Family or friends may call you and say, hey, I think this is going on with this patient. When a urine drug screen comes back as unexpected or the pill count is unexpected, you may want to refer them to a substance abuse counselor for an assessment and then see what the recommendation is for the level of treatment. Patients can enter treatment at many different levels. They can be outpatient or inpatient depending on the severity of the disease. If you have addiction medicine providers available in your area, you can refer them to an addictionologist or to a psychiatrist who deals with addictions. They may be able to offer you some guidance with the use of buprenorphine for treatment or for medication-assisted treatment. You could even consider becoming a certified buprenorphine provider yourself. When do you give a patient another chance? This is going to be different for every patient. A patient using methamphetamine and another opioid which you are not prescribing for you. For example, a patient is using the opioid you're prescribing her, also methamphetamine, and also another opioid which you're not prescribing. Would you discharge her from the practice? No. Our job is to help people in discharging her from the practice for substance use disorder in no way helps the patient. You need to meet with the patient. Is she amenable to making changes? Is she amenable to seeing a therapist? Is she willing to go into treatment? What do you do about the opioid you're prescribing the patient? Again, the answer is going to be different for every patient. For some people, the right answer is to taper the opioid and discontinue it. For others, a transition to buprenorphine naloxone may be a warranted step. Especially in those patients who are not in treatment, a buprenorphine naloxone can be an essential part of the treatment plan. Buprenorphine naloxone can manage their pain, manage their withdrawal symptoms, and allow the patient to focus on other aspects of her recovery. Later, you can circle back to the buprenorphine naloxone and consider tapering off of it when the patient is at a much different, much more emotionally and mentally stable place in her recovery. The next few slides deal with the DSM-5 and the criteria for opioid use disorder, as well as abuse, which is taking an opioid to get high versus misuse, which is taking more than prescribed for pain or providing medication to someone else in pain. DSM-5 have very defined criteria to diagnose somebody with opioid use disorder, and a patient needs to meet at least and a patient needs to meet at least two of the criteria over a 12-month period. Number one, opioids are often taken in longer amounts or over a longer period than was intended. There is persistent desire, unsuccessful efforts to cut down or control opioid use. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects. Craving or a strong desire or urge to use opioids, recurrent opioid use resulting in failure to fulfill major role obligations at work, at school, at home. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids, important social, occupational, or recreational activities are given up or reduced because of opioid use, recurrent opioid use in situations in which it's physically hazardous, continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance, if they exhibit tolerance, if they exhibit withdrawal. All right, so let's talk about opioid use disorder versus addiction. There's a lot of debate about the terms. Does opioid use disorder equal addiction? It depends how you define addiction. The general shift is an effort to get away from using stigmatizing words such as addiction or defining a patient as an addict. The preferred non-stigmatizing term for is opioid use disorder. In some patients, this different terminology is going to allow the patient to accept help. Patients may argue with you that I'm not an addict, but you can pull up the criteria and point out which criteria they need for opioid use disorder. Sometimes this allows patients to admit that they have a problem. When performing an assessment for opioid use disorder, how do you identify if a patient has an opioid use disorder? The assessment is very similar to all of the things we've been using all along to screen them for the risk of opioid use disorder. Look at their history, personal history. Is there any history of prior substance abuse? Have they been in treatment before? Are there risk factors present? Are there any co-occurring psychiatric disorders such as depression, anxiety, PTSD, history of trauma? Are they using other substances such as alcohol, nicotine, marijuana? Is there a family history of substance abuse? Are there underlying medical issues which may raise concern for respiratory depression when present in conjunction with opioid use? Do they have sleep apnea? Are they using benzos? You want to obtain collateral information from family, friends, therapists, other providers, and risk assessment tools can be helpful. We've already talked about a lot of this, such as the opioid risk tool or the SOAR. Stigma is a huge problem in our country, not just for people suffering from addiction, but also for people suffering from mental health disorders. Changing the words that we use can make a huge impact on decreasing that stigma, and it may help people to seek out treatment. Be careful not to use blaming language when speaking to the patient. Replace it with language that acknowledges that the patient suffers from a substance use disorder. DSM-5 is reclassified addiction as substance use disorder, and it's now classified as a disease rather than a mental deficiency. Opioid use disorder should only be used when referring to the use of opioids rather than each substance can be referred to individually, such as stimulant use disorder or alcohol use disorder. Let's look at the cycle of addiction a little bit. A person uses a substance, then they begin to progress, then they progress to misusing substance because they like the effect on them. We don't know how to determine who's going to abuse something versus who's not going to abuse it. After misuse, they move into abuse because their brain has adapted and they need more and more of the neurotransmitters. Once they begin abusing the substance, they develop a tolerance and dependence, which leads into the addiction. At this point, they're seeking out more drugs and using more drugs and becoming more dependent on drugs. Eventually, patients can go into recovery with the help of treatment and the help of therapy and the help of medications, but they're always at a risk of relapse. Relapse is an expected part of the cycle of addiction, and you need to adjust your treatment plan accordingly. The cycle of addiction is never-ending. They're never recovered. They're always in recovery. Tolerance occurs when the brain and body have had changes for which the original dosage no longer has the same effect for opioids. They may have less pain, especially with opioids. Opioids cause the brain to release more dopamine. By causing the brain to release more dopamine, it's inundating the brain and inundating the receptors with dopamine. As a result, it's like when you get in the car and the radio is too loud. What happens? You want to turn down the volume, right? The brain tries to turn down the volume by decreasing the number of dopamine receptors available and decreasing the endogenous dopamine production. When the opioids are not present, the brain is in dopamine withdrawal, causing the patient to have physical withdrawal symptoms. Their brain is screaming at them to go find dopamine to fulfill all these receptors. This creates a vicious cycle. The more they use, the more the volume is turned down, and the more drug they need to fill the receptors and achieve the same effect. It's important to recognize that addiction is a neurobiological disease. There's a pattern of compulsive use, loss of control, continued use despite negative consequences on their health and their relationships and their function. They no longer have control over what they are using and what they are abusing. Their brain's taken over. There's no evidence to tell us who is going to develop a substance use disorder. It isn't non-medical pain users versus pain patients. There's no distinction between who's going to develop the disease and who's not. There's a lot of treatment options out there, and it's important to get patients and family to realize there's options. So many family members still believe the stigma that it's some moral failure of the patient that they've developed this addiction. It's important to educate that this is a disease and there's treatments available. Non-pharmacologic therapies, things like group therapy, individual therapy, peer support meetings, and then pharmacologic treatments are also available. A combination of all the available treatments is usually the most beneficial to the patient, and it's important that the patient understands that no one treatment is the answer. The answer is typically multidisciplinary, and you need to use all the available treatments to be successful in your recovery. Medication-assisted treatment has become the gold standard for the treatment of opioid use disorder. There are several options available. Methadone is a full agonist, which generates an effect similar to the effect of an opioid. It satisfies the brain's need for dopamine, but in a way that the patient isn't doing illegal or illicit things to obtain the medicine. It requires enrollment in an opioid treatment program, which is federally certified. One of the bad things about methadone is that it's a full opiate agonist, so patients continue to develop a tolerance. They continue to require higher dosing. Methadone also can cause problems with their teeth with long-term use, and sweating is a very common side effect. Buprenorphine is a partial opioid agonist, and because it only binds to part of the opioid receptor, it has a sealing effect, so it only binds to that new receptor. Even if they take more than about 16 to 24 milligrams a day, the patient doesn't feel any difference, so because there's no incentive to take more, they tend to not abuse it. There's a lower abuse potential. Buprenorphine also binds really well to the receptor, so if a patient were to have buprenorphine on board and they were to use heroin or oxycodone on top of the buprenorphine, the heroin's not going to bind. It's not going to knock the buprenorphine off the receptor, so the patient wouldn't get high. Again, less abuse potential. With methadone, patients frequently abuse opioids in conjunction with the methadone. Buprenorphine is available as a sublingual formulation. It's also available as an extended release subcutaneous injection, and it's available in patches. The patches are actually not approved for the treatment of opioid use disorder. They're approved for the treatment of pain, so it gets confusing sometimes. Then there's the agonist therapy. Naltrexone is an agonist, and it blocks the opioid receptor. If a patient uses opioids, they don't get any results from them, any effect from them. The thought is if the patient doesn't get the response their body's expecting, then they get their brain back into the game and say, wait, what am I doing? I'm not getting any effect from this. Naltrexone is available both as a daily oral form and also an extended release IM injection. Non-pharmacologic options, there's multiple treatment settings. Patients can go to outpatient individual treatment, outpatient group treatment. They can go to inpatient or residential treatment. There's also peer support groups, things like Narcotics Anonymous. There's multiple peer support groups out there. There's Celebrate Recovery, Refuge Recovery, Dharma Recovery, AA, NA. It's important to encourage patients to find the peer support group that they feel comfortable in, and you want to be sure to assess and treat those co-occurring groups. What was going on in their life that they started abusing things to begin with? Make sure you're treating their depression, their anxiety, their childhood trauma. So if you have a patient on opioid therapy for pain management and you identify that they've developed a substance use disorder, what do you do? While you're trying to engage the patient in treatment and trying to get the patient to realize they need to go into treatment, you may want to start tapering the opioid down. You may want to start tapering the opioid down You don't want to abruptly discontinue it because that just harms the patient by placing them in abrupt withdrawal, and they're potentially going to go seek out illicit sources of medication of opioids. You want to consider transitioning them to buprenorphine and encourage patients to seek out that psychosocial support, attend an NA meeting, schedule an appointment with a therapist. They have to take the first step in recovery, and your encouragement may just be the push that they need. You most definitely want a collaborative care plan. Get consent signed for their addiction medicine provider. Talk to their family. Talk to their therapist. Educate, educate, educate. Talk to the patient and the family about the risks of addiction. Thank you very much. I appreciate you listening to me today.

non-cancer pain

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opioid epidemic

pain management

assessment

chronic pain

treatment options

opioids

safe prescribing

patient education

shared decision-making

opioid therapy

opioid use disorder