J. Paul Seale, M.D., FAAFP Daniel P. Alford, M.D., M.P.H., FACP, FASAM

1. An SBIRT Approach To Managing Pain and Prescription Opioid Abuse: Maximizing Benefits and Minimizing Risks J. Paul Seale, M.D., FAAFP Daniel P. Alford, M.D., M.P.H., FACP, FASAM H. E. Woodall, M.D., FAAFP, FAAHPM October 30, 2013

2. Module 3: Addressing Concerning Behaviors J. Paul Seale, M.D., FAAFP Daniel P. Alford, M.D., MPH, FACP, FASAM H. E. Woodall, M.D. FAAFP, FAAHPM October 30, 2013

3. Concerning Medication-Taking Behaviors The Spectrum of Severity Note: For most of these, need to track pattern and severity over time Butler et al., 2007

4. Concerning Medication-Taking Behaviors: Differential Diagnosis 1Weissman & Haddox, 1989;2Evers, 1997; 3Chang et al., 2007 • Ineffective analgesia: “Pseudoaddiction”1 • Disease progression • Opioid-resistant pain (or pseudoresistance)2 • Withdrawal-mediated pain • Opioid-induced hyperalgesia3 • Addiction • Opioid-analgesic tolerance3 • Self-medication of psychiatric and physical symptoms other than pain • Criminal intent:diversion

5. Screening:Assess for Opioid Benefit PEG scores: Lack of improvement may indicate a failure of therapy Changes in function: Is opioid therapy achieving the patient’s goals? Use these findings in your “risk-benefit” decisionmaking

6. Brief Intervention:Discuss Concerning Medication-Taking Behavior Passik & Kirsh, 2005 • Nonjudgmental stance • Use open-ended questions • State your concerns about the behavior • Examine the patient for signs of flexibility • Is the patient focused more on the opioid or pain relief? • Discuss the need for increased monitoring

7. Prescription Opioid Monitoring Framework: Guidelines for Discontinuing Opioids: Funded by: www.sbirtonline.org 2 Rev. Apr 2013

8. Continuation of Opioids • Assess and document benefits and harms • To continue opioids • Does the PEG show evidence of benefit? • Is the patient achieving his/her functional goals? • Does the benefit outweigh observed or potential harms? • Note: You do not have to prove addiction or diversion to justify tapering opioids—lack of benefit and/or high level of risk is enough

9. Options for Addressing Concerning Behaviors & Continuing Pain When Etiology is Unclear Increase monitoring: more frequent visits, return for pill counts, call in for UDT Reassess & treat underlying disease and comorbidities with non-opioids Re-explore possible non-opioid adjunct s If concerning behaviors decrease or disappear, consider escalating opioid dose as a “test” If simply no benefit after several months, begin opioid taper If concerning behaviors continue, consider a discontinuation strategy Begin opioid taper If signs of addiction, switch to buprenorphine/methadone or refer to treatment

10. View Video 3:Follow-up Interview Observe this physician-patient encounter between a patient who is requesting increased medication and a physician who discovers behaviors that concern him.

11. Practice Session: Addressing Concerning Behaviors, Increasing Monitoring • Conduct Role-Play 3 • Follow-up Interview With Concerning Behaviors Supporting materials including role play scripts may be found at www.sbirtonline.org

12. Discontinuing Opioids* • Opioids may be discontinued when the physician’s assessment indicates: • Lack of benefit (monitor using PEG scores and patient’s functional goals) • Risk outweighs benefit *This topic will be discussed in greater depth in Module 4

13. Discontinuation of OpioidsDiscussing Lack of Benefit Give specific feedback about lack of improvement in PEG or functional goals Stress how much you believe/empathize with patient’s pain severity and impact Express frustration regarding lack of good pill to fix it Focus on patient’s strengths Encourage therapies for “coping with” pain Show commitment to continue caring about patient and pain but without opioids

14. Discontinuation StrategyDiscussing Lack of Benefit Stress that some patients experience improvement in function and pain control when chronic opioids are stopped Make it clear you are not discharging the patient but discontinuing an ineffective treatment Whenever possible, taper patient slowly to minimize opioid withdrawal

15. Discontinuation StrategyDiscuss Any Concerns About Addiction • Give specific feedback on what previous behaviors raise your concern for possible addiction/loss of control • You may have to agree to disagree on your diagnosis • Benefits no longer outweighing risks • “I cannot responsibly continue prescribing opioids as I feel it could cause you more harm than good.” • Offer a menu of treatment options: taper off opioids and use non-opioid approaches; switch to buprenorphine or methadone • Stay 100 percent in “Benefit/Risk of Medication” mindset

16. How To Taper Opioids • Opioid withdrawal reactions are very uncomfortable but are not life threatening • If possible, decrease by 10–20 percent each week • Pill formulations may dictate amount of drop in dose • Rate of decrease determined by circumstances of withdrawal • Allow supply of short-acting medications to treat “breakthrough” symptoms • Build up alternative pain treatment modalities • Comfort medications (see next 2 slides) • Schedule close follow-ups

17. Treatment: Clonidine

18. “Comfort” Meds

19. Summary • When concerning behaviors are present • Consider underlying reasons/differential diagnoses • Discuss risk versus benefit of opioids with patient • Consider other non-opioid alternatives • Decide whether to increase monitoring or taper and discontinue