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Treating Acute Pain in Patients Maintained on Buprenorphine and Methadone AOAAM, October 26, 2010 Karen Lea Sees, DO, FA

Treating Acute Pain in Patients Maintained on Buprenorphine and Methadone AOAAM, October 26, 2010 Karen Lea Sees, DO, FAOAAM. Pain Treatment in Patients with or without an Addiction. Is the distinction important? Current, recent or remote addiction? Drug of choice?

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Treating Acute Pain in Patients Maintained on Buprenorphine and Methadone AOAAM, October 26, 2010 Karen Lea Sees, DO, FA

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  1. Treating Acute Pain in Patients Maintained on Buprenorphine and MethadoneAOAAM, October 26, 2010Karen Lea Sees, DO, FAOAAM

  2. Pain Treatmentin Patients with or without an Addiction • Is the distinction important? • Current, recent or remote addiction? • Drug of choice? • Acute versus chronic pain?

  3. Treating patients on opioid agonist therapy (OAT) who are experiencing acute pain is complicated. There is some research that can inform this discussion, and there are also clinical recommendations that can help guide treatment.

  4. Acute Pain Treatment in Patients on OAT • These patients suffer thrice: • from the painful disease • from the addiction, which makes pain management difficult • from the health care provider’s ignorance

  5. Acute Pain Treatment in Patients on OAT • Is it appropriate to bar the prescribing of controlled substances to anyone? • Is it just to deny a patient with an addiction pain medication simply because of their addiction status?

  6. Acute Pain Treatment in Patients on OAT • Definitions: • Physical dependence: normal physiologic adaptation defined as the development of withdrawal or abstinence syndrome with abrupt dose reduction or administration of an antagonist • Therapeutic dependence: Patients with adequate pain relief may demonstrate drug-seeking behaviors because they fear not only the reemergence of pain but perhaps also the emergence of withdrawal symptoms • Substance dependence: maladaptive behaviors, including loss of control

  7. Acute Pain Treatment in Patients on OAT • Definitions: • Cross-tolerance: Normal neurobiological event of tolerance to effects of medication within the same class • Opioid-induced hyperalgesia: A neuroplastic change in pain perception resulting in an increase in pain sensitivity to painful stimuli, thereby decreasing the analgesic effects of opioids • Drug-seeking behaviors: directed or concerted efforts to obtain opioid medication • Pseudoaddiction: behaviors such as drug-seeking that are secondary to inadequate pain control and not to addiction

  8. Acute Pain Treatment in Patients on OAT Must consider: • Potential for therapeutic efficacy • Risk of adverse consequences, including relapse • Possibility of iatrogenic addiction • High tolerance to medications • Low pain threshold

  9. Acute Pain Treatment in Patients on OAT • Four misconceptions: • Maintenance OAT provides analgesia • Use of opioids for pain treatment may result in relapse • Opioids for pain plus OAT will lead to respiratory depression • Pain complaint may be manipulation

  10. Acute Pain Treatment in Patients on OAT • Four misconceptions: • Maintenance OAT provides analgesia • Use of opioids for pain treatment may result in relapse • Opioids for pain plus OAT will lead to respiratory depression • Pain complaint may be manipulation

  11. Acute Pain Treatment in Patients on OAT • Suppression of withdrawal/abstinence syndrome is 24-48 hours • Analgesic duration is 4-8 hours • Because of cross-tolerance analgesia may not last as long as expected • Dose may need to be higher and more frequent than expected to achieve adequate pain control

  12. Acute Pain Treatment in Patients on OAT • Four misconceptions: • Maintenance OAT provides analgesia • Use of opioids for pain treatment may result in relapse • Opioids for pain plus OAT will lead to respiratory depression • Pain complaint may be manipulation

  13. Acute Pain Treatment in Patients on OAT • Small retrospective study found no difference in relapse in MMT patients who received opioids after surgery Kantor et al., 1980 • No relapse in MMT patients who received opioids to treat chronic cancer pain Manfredi et al., 2001

  14. Acute Pain Treatment in Patients on OAT • Study comparing addicts with AIDS to cancer patients and their response to undertreatment • Aberrant behavior was set in motion by under-treatment of pain Passik et al. 2002. • MMT patients claim pain plays a substantial role in their initiating and continuing drug use Karasz et al., 2004

  15. Acute Pain Treatment in Patients on OAT • Four misconceptions: • Maintenance OAT provides analgesia • Use of opioids for pain treatment may result in relapse • Opioids for pain plus OAT will lead to respiratory depression • Pain complaint may be manipulation

  16. Acute Pain Treatment in Patients on OAT • Risk is theoretical, but never been clinically or empirically demonstrated Alford et al., 2006

  17. Acute Pain Treatment in Patients on OAT • Four misconceptions: • Maintenance OAT provides analgesia • Use of opioids for pain treatment may result in relapse • Opioids for pain plus OAT will lead to respiratory depression • Pain complaint may be manipulation

  18. Acute Pain Treatment in Patients on OAT • Concerns are substantial, difficult to quantify, and emotion laden • Pain is subjective • Acute pain should have subjective findings • OAT dose will not treat the pain, but should block most of the euphoria effects from supplemental opioids, thus theoretically reducing the likelihood of abuse

  19. Acute Pain Treatment in Patients on OAT • Patients may be demanding: • Distrust of medical community • Concern about stigma • Fear of undertreated pain • Fear that OAT may be altered or discontinued • May be drug-seeking for good reason (pseudoaddiction)

  20. Acute Pain Treatment in Patients on OAT • Use adjunctive modalities and medications • Avoid the patient’s drug of choice • Use medication with lower street value • Avoid self administration, if possible

  21. Acute Pain Treatment in Patients on OAT • Explain potential for relapse • Explain the rationale for the medication • Educate the patient and the support system • Encourage family/support system involvement • Frequent follow-ups • Consultations

  22. Acute Pain Treatment in Patients on OAT • Address addiction • Use non-medication approaches, if effective • Use non-opioid analgesics, if effective • Provide effective opioid doses, if needed • Use ATC not PRN dosing • Treat associated symptoms, if indicated • Address addiction

  23. Acute Pain Treatment in Patients on OAT Symptomatic pain therapies: • Pharmacological • Rehabilitative • Psychological • Anesthesiologic • Surgical • Neurostimulatory • Lifestyle changes

  24. Acute Pain Treatment in Patients on OAT • Post-operatively • Acute medical conditions • Acute trauma

  25. Acute Pain Treatment in Patients on OAT • Must satisfy baseline opioid requirements before treating pain • The usual maintenance dose (e.g., methadone or buprenorphine) will not control the pain • The usual maintenance dose needs to be supplemented with appropriate medication(s) for pain control • May need slightly higher amounts for slightly longer periods of time

  26. Pain Control for OAT Patients • Mixed agonist and antagonist opioid analgesics such as pentazocine, nalbuphine, and butorphanol, must be avoided because they probably will displace the OAT from the mu-receptor, thus precipitating withdrawal • Combination products are often problematic because of the amount of acetaminophen

  27. Acute Pain in Patients on Buprenorphine Very little systematic research to guide recommendations Guidelines based on available literature, pharmacologic principles, and published recommendations Because of the highly variable rates of buprenorphine dissociation from the mu-receptor, naloxone should be available and level of consciousness and respiration should be frequently monitored

  28. Acute Pain in Patients on Buprenorphine Two general clinical situations for acute pain Pre-planned (an elective procedure) Unplanned (an accident)

  29. Buprenorphine • Buprenorphine has a slow weaning effect throughout 12 to 24 hours, may be up to 72 due to high affinity for but only partial activation of the mu-opioid receptors that prevent displacement and further activation by full opioid agonists

  30. Acute Pain in Patients on Buprenorphine If planned, can strategize steps to be taken beforehand Anticipated level and duration of pain Setting in which pain management will occur Timing of buprenorphine dosing relative to dosing of pain medication (especially if using a full agonist opioid for pain control) Supports to help the patient with the pain Discussion with patient regarding risks associated with use of opioids and nonopioids for pain management

  31. Acute Pain in Patients on Buprenorphine If planned Stop daily dose of buprenorphine 1 to 2 days before the scheduled procedure Convert to pure mu agonist

  32. Acute Pain in Patient on Buprenorphine If unplanned While the patient is generally not prepared for how to handle pain, the clinician can be prepared Consider in advance how unplanned acute pain will be managed for patients maintained on buprenorphine (e.g., identify preferred types of nonopioid and opioid medications)

  33. Acute Pain in Patient on Buprenorphine Treatment of unplanned acute pain Maintenance dose of buprenorphine will not provide pain relief – other treatments will be needed First consider use of nonopioid medications and/or regional analgesia added to buprenorphine

  34. Acute Pain in Patients on Buprenorphine Treatment of unplanned acute pain (continued) If nonopioids are not effective, use opioids; options include: Divide the daily dose of buprenorphine and administer it every 6 to 8 hours Add supplemental doses of buprenorphine to maintenance buprenorphine dose (a theoretical option, but no studies to date on this and may find ceiling effect limits amount of analgesia achieved)

  35. Acute Pain in Patients on Buprenorphine Treatment of unplanned acute pain (continued) If short acting opioid are needed: • Consider switching from buprenorphine to a full agonist opioid (e.g., methadone) • Combining buprenorphine with a short acting opioid could produce a precipitated withdrawal syndrome

  36. Acute Pain in Patients on Buprenorphine Treatment of unplanned acute pain (continued) If you need to use a short acting opioid and you decide to not switch from buprenorphine to a full agonist opioid (e.g., methadone): • Time buprenorphine administration to occur well after expected peak effect of short acting opioid • Note that higher doses of the short acting opioid may be needed to achieve pain relief (given buprenorphine’s high affinity for the mu opioid receptor)

  37. Acute Pain in Patient on Buprenorphine Treatment of unplanned acute pain (continued) If temporarily switching a patient from buprenorphine to a full agonist opioid, stop buprenorphine and: • Treat pain with full agonist opioid (short or long acting, may need more due to tolerance) • Once pain gone, stop full agonist opioid and allow mild withdrawal • Restart buprenorphine

  38. Acute Pain in Patient on Buprenorphine Treatment of unplanned acute pain (continued) If hospitalized the maintenance buprenorphine dose can be converted to 30 to 40 mg/d of methadone

  39. Injectable Buprenorphine for the Treatment of Pain Injectable form of buprenorphine is approved and available for treatment of pain, but sublingual form is not FDA approved for this indication Injectable buprenorphine is an effective analgesic; typical dose is 0.3 mg (IV/IM) given every 4-6 hours Rapid onset of effects Preclinical studies have shown bell-shaped dose response curve for analgesia

  40. Buprenorphine Overdose • Administration of 2 mg naloxone will have no effect on mild respiratory depression (onset 15 minutes, maximum effect at 45 minutes and lasts up to 6 hours) • Higher doses of 5 or 10 mg may have some effect of respiratory depression but little effect on mental status changes

  41. Buprenorphine Overdose • High-dose naloxone and/or rapid infused naloxone may cause catecholamine release resulting in pulmonary edema and cardiac dysrrhythmias • AND an acute withdrawal syndrome Dorp et al., informahealthcare.com, 2007

  42. Acute Pain in Patient on Methadone Treatment is the same for planned or unplanned acute pain Anticipated level and duration of pain Setting in which pain management will occur Supports to help the patient with the pain Discussion with patient regarding risks associated with use of opioids and nonopioids for pain management

  43. Acute Pain in Patient on Methadone Two approaches to opioids: Primary: Continued maintenance methadone dose Supplement with additional pure mu-agonists (e.g., morphine or hydromorphone) Wean supplemental opioids as pain resolves and continue maintenance dose Alternate: Divide and supplement the methadone maintenance dose for q 6-8 dosing regimen (analgesic duration 4-8 hours)

  44. Acute Pain in Patients on Methadone If patient is NPO then use IM or SQ in half to 2/3 the maintenance dose divided into 2 to 4 equal doses

  45. Pain Treatmentin Patients with an Addiction • Physicians must learn communication skills for discussing opioid misuse and abuse with patients • Because these discussions are potentially uncomfortable, they are often delayed, addressed poorly or never addressed at all

  46. Aberrant Drug Related Behaviors - Less Predictive of an Addiction • Aggressively complaining of the need for more drug • Drug hoarding during periods of reduced pain • Requesting specific drugs • Openly acquiring similar drugs from other medical sources • Unsanctioned dose escalation or other non-compliance on one or two occasions

  47. Aberrant Drug Related Behaviors - Less Predictive of an Addiction • Unapproved use of drug to treat another symptom • Reporting psychic effects not intended by the clinician • Resistance to change in therapy associated with “tolerable” side effects with expression of anxiety related to return of severe pain

  48. Aberrant Drug Related Behaviors - More Predictive of an Addiction • Selling prescription drugs • Prescription forgery • Stealing or “borrowing” drugs • Obtaining prescription drugs form non-medical sources • Concurrent abuse of alcohol or illicit drugs • Multiple dose escalations or other non-compliance with therapy

  49. Aberrant Drug Related Behaviors - More Predictive of an Addiction • Episodes of prescription “loss” • Prescriptions from other clinicians/EDs without seeking primary prescriber • Deterioration in function that appears to be related to drug use • Resistance to change in therapy despite significant side effects from the drug

  50. Differential Diagnoses of Aberrant Drug Related Behaviors • Addiction • Pseudoaddiction • Other psychiatric disorder • Encephalopathy • Family disturbance • Criminal intent • Exacerbation of pain syndrome • Side effect(s) of opioid

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