Session 3 ballantyne management of the patient who is failing
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The document discusses several cases of patients struggling with opioid dependence and pain management. It provides guidance on tapering patients off high opioid doses slowly over time through multimodal treatment including behavioral therapy. For motivated patients wanting to taper, it suggests a slow reduction of 10mg per month for patients on very high doses. The document also discusses using suboxone to help induce tapering and reduce cravings when coming off opioids.
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Session 3 ballantyne management of the patient who is failing
- 1. Managing the patient who is failing opioid pain treatment Jane C Ballantyne, University of Washington, Seattle
- 2. A case of high dose and difficulty tapering
- 3. Video here of male patient who is having difficulty tapering despite wishing to taper
- 4. “Complex persistent dependence” • taper or maintain? • strong evidence that patients who taper from high doses improve in terms of general function and well-being • unfortunately many relapse • tapering is hard to achieve for all but the most motivated • rehab setting is more successful than outpatient setting
- 5. Rationale for opioid maintenance treatment for addiction •steady state opioid administration allows for physiological (cellular and molecular) normalization •prevents withdrawal and craving •blocks the euphoric effects of superimposed short-acting opioids
- 6. • Continue slow and painstaking taper vs. force off or to a lower, safer dose • If forcing dose lowering, how?
- 7. Principles • Patient must agree to the plan • Forcing off may require a degree of ruthlessness • Continue multimodal treatment, must include behavioral component
- 8. • Tapering regime does not need to be complicated • For this patient who is on very high dose, could reduce by 10 mg per month • On the basis that he is opioid dependent, it would probably be too ambitious to attempt to go lower than 80 mg/day DEBATABLE
- 9. A case of a patient on high dose, motivated to come off altogether
- 10. Video here of male patient who succeeded in coming off with the help of suboxone. Before and after videos.
- 11. Principles • Patient must agree to the plan • Use of a suboxone induction speed up the process of coming off opioids • Continue multimodal treatment, must include behavioral component
- 12. What is buprenorphine? • Partial opioid agonist, with high affinity for opioid receptors and slow dissociation • Originally launched as pain treatment (especially in Europe) • Later used for office based treatment of opioid dependence • Less likely to cause respiratory depression than full agonists, therefore safer • Less potential for abuse because of less dependence • Ceiling effect, therefore less good as an analgesic for severe acute or terminal cancer pain
- 14. Uses of buprenorphine in pain management • Analgesic • Rapid detox (office or home ‘induction’) • Maintenance treatment for opioid dependence • Theoretically, can only be used on its own, not in combination with other opioids
- 15. Buprenorphine induction • Instruct patient to abstain from any opioid use so they are in mild withdrawal at the time of first buprenorphine dose short acting opioids, 12-24 hrs long acting opioids, 24-48 hrs • Objective signs of mild-moderate withdrawal (use COWS) • If not in withdrawal, consider having patient return another day or wait in the office until evidence of withdrawal seen • For ‘experienced’ patients, can do induction at home
- 16. Using buprenorphine for pain • Manufacturers recommend 5μg/hr patch for 30 mg/day morphine and 10μg/hr patch for 80 mg/day morphine • 8 mg suboxone is equivalent to 10 mg morphine (single dose), but this is conservative, and the equivalence will be very different according to level of tolerance (available as 2mg, 4 mg and 8 mg) • Dosing principle for suboxone treatment of pain is start low, titrate upwards as needed, remembering that there is a ceiling effect, so 24 mg (8 mg 3 times daily) is probably the highest dose • Subutex has only one indication - pregnancy
- 17. A case of a patient who has behavioral issues but is not on a high dose
- 18. Video here of female patient with behavioral issues, but not on a hight dose
- 19. Principles • Patient must agree to the plan • She could stay on opioid treatment since the dose is not high, but would she better off if she hadn’t continued for so long? • Continue multimodal treatment, must include behavioral component
- 20. Treating Chronic Pain Chronic pain is never simple Use measurement tools as a means of understanding the scope of the problem PHQ-9 (depression) GAD (anxiety) ORT (opioid risk) Primary treatments for chronic pain i. Motivation/activation/self-help ii. Counseling Secondary treatments for chronic pain i. Low risk analgesics (eg gabapentin) ii. Psych meds for depression/anxiety/PTSD/psychosis
- 21. What is serious pain? Pain with a clear pathoanatomic or disease basis Underlying cause is disabling cannot be improved by primary disease treatment or lifestyle changes Goal of pain treatment is comfort All other treatments (best efforts) have failed NOTE: 90% pain complaints do not meet these criteria 1.Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. Feb 2009;10(2):113-130. 2.Sullivan MD, Ballantyne JC. What are we treating with chronic opioid therapy? Arch Int Med. 2012;172(5):433- 434.
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- 23. A case of a patient motivated to come off and does
- 24. Video here of female patient whose life is greatly improved after tapering off. She succeeded by means of a slow taper.
- 25. Principles • Patient must agree to the plan • Slow taper to off • Continue multimodal treatment, must include behavioral component
Editor's Notes
- The great value of the measurement-based approach is that by using measurement tools such as the PHQ-9 for depression, the GAD for anxiety and the ORT for opioid risk (which also highlights childhood abuse), psychosocial factors that profoundly alter the course of treatment are revealed early so that the chosen treatment course can be tailored appropriately. Medical treatments are not always the best option for chronic pain. Chronic pain is often a manifestation of underlying existential suffering that should be addressed directly. Medical interventions such as drugs and injections not only hold false promise, they also produce harm rather than benefit if misdirected. If patients can be directed and encouraged to use self-help mechanisms to manage their pain such as relaxation, distraction, sleep hygiene, exercise and other lifestyle changes, without resort to medication or injections, this is ideal. 30 minutes spent listening and encouraging may not seem like a medical intervention, but it is an intervention that works. When serious depression or anxiety is identified, pharmacological treatment with antidepressants might be indicated. PTSD may also be amenable to pharmacological intervention in conjunction with counseling.
- It becomes increasingly clear that opioids tend to be deactivating not activating. Many common chronic pain conditions respond best to maintaining a healthy and active lifestyle. Opioids are counterproductive for these conditions. One way to think about whether chronic opioids are a reasonable choice, is to think whether the goal of treatment is comfort (similar to palliation), or functional restoration. If the latter, then opioids are probably a poor choice, or a least a last resort.
- There is now a substantial body of evidence that shows that for these 3 common diagnoses, opioids are not helpful. In the case of axial low back pain and fibromyalgia, because of their ability to worsen hyperalgesia, opioids can actually make pain worse, especially once high doses are reached. Headaches are made worse when rebound headaches supervene. Studies of function show either no improvement or worsening of function when opioid are used to treat these conditions. There is strong evidence to support and multimodal, behavioral and exercise weighted approach for these conditions.