Team Based Approach For the Patient Suffering with Chronic Pain - Robin R. Ockey M.D. Medical Director Intermountain Utah Valley Pain Management ...
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Team Based Approach For the Patient Suffering with Chronic Pain Robin R. Ockey M.D. Medical Director Intermountain Utah Valley Pain Management
Disclosures Consultant with: • Collegium Pharmaceutical, Inc. • Pfizer, Inc.
Where Do You Start?
“Pain is a uniquely individual and subjective experience that depends on a variety of biological, psychological, and social factors, and different population groups experience pain differentially.” “For many patients, treatment of pain is inadequate not just because of uncertain diagnoses and societal stigma, but also because of shortcomings in the availability of effective treatments and inadequate patient and clinician knowledge about the best ways to manage pain.” IOM (Institute of Medicine): Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC, The National Academies Press, 2011
A quotation from a chronic pain patient (from a committee survey) “I have a master’s degree in clinical social work. I have a well- documented illness that explains the cause of my pain. But when my pain flares up and I go to the ER, I’ll put on the hospital gown and lose my social status and my identity. I’ll become a blank slate for the doctors to project their own biases and prejudices onto. That is the worst part of being a pain patient. It strips you of your dignity and self-worth.” IOM (Institute of Medicine): Relieving Pain in America: A Blue Parental for Transforming Prevention, Care, Education, and Research. Washington, DC, The National Academies Press, 2011
Acute Pain:
➢ Is generally “a relatively short, time-limited experience that abates
when the injury heals or the disease is cured.” (1)
❖ Is essential to survival
❖ Warns us of injury/disease.
❖ Encourages us to seek medical help
❖ Contributes to healing by promoting rest/recovery
❖ Its absence notifies us that is okay to resume activities
❖ Remembering acutely painful events helps as avoid future harm
➢ Without the capability of feeling pain, people typically do not live
beyond childhood (2)
1. Katz J, Rosenbloom BN, Fashler S (2015) Chronic pain, psychopathology, and DSM-5
somatic symptom disorder. Can J Psychiatry 60(4):160–167
2. Nagasako EM, Oaklander AL, Dworkin RH. Congenital insensitivity to pain: an update.
Pain. 2003;101(3):213–219.Chronic Pain or Persistent Pain (1, 2)
➢ Serves no adaptive purpose
➢ Persists past normal healing time
➢ When severe/intractable, it impacts the core of the person causing distress
and suffering
➢ Associated with significant emotional distress and/or significant functional
disability
➢ It ruins marriages and families
➢ Causes job loss, financial problems, social isolation, anxiety, worry, depression,
and even suicide
➢ It is difficult to define:
❖ Time based definitions suggests:
• Chronic nonmalignant pain is pain that persists 3-6 months
❖ Recent article separated chronic pain into 7 categories with multiple subcategories (2)
1. Katz J, Rosenbloom BN, Fashler S (2015) Chronic pain, psychopathology, and DSM-5 somatic symptom disorder. Can J Psychiatry 60(4):160–167
2. Treede RD, Rief W, Barke A, et al. A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003–1007Societal Impact of Persistent Pain
Incidence in US (millions)
From: http://www.painmed.org/patientcenter/facts_on_pain.aspx#incidence
Chronic Pain Diabetes Heart Disease Stroke Cancer
100
25.8*
16.3 11.9
7
*Diagnosed and estimated undiagnosed
1. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The
National Academies Press, 2011.
2. American Diabetes Association.
http://www.diabetes.org/diabetes-basics/diabetes-statistics/
3. Heart Disease and Stroke Statistics—2011 Update: A Report From the American Heart Association. Circulation 2011, 123:e18-e209, page 20.
http://circ.ahajournals.org/content/123/4/e18.full.pdf
4. American Cancer Society, Prevalence of Cancer:
http://www.cancer.org/docroot/CRI/content/CRI_2_6x_Cancer_Prevalence_How_Many_People_Have_Cancer.aspFinancial Impact of Persistent Pain • $530-$635 billion annually (about $2,000 for everyone living in the U.S.) • More than the 6 next most costly problems (in billions) oCardiovascular: $309 oNeoplasms: $243 oInjury/poisoning: $205 oEndocrine, nutritional, and metabolic: $127 oDigestive system: $112 oRespiratory system: $112 Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012; 13: 715-724
Physical
Somatic Event Vs. Tissue Damage
1. Pain is experienced by a chronic pain patient as a somatic event. It may or may not be related to tissue damage.
2. The patient may or may not recall an actual event resulting in injury.
3. Injuries may result in pain, but the presence of pain does not necessarily mean that an actual injury has
occurred.
4. We often erroneously assume that the greater the pain, the greater the degree of injury.
5. With acute pain, the correlation between the experience of pain and the degree of injury seems to be stronger.
With chronic pain the relationship is much more variable.
6. We should reassure patients that their reports of pain are accepted as valid regardless of the results of medical
testing.Memories of previous experiences of Expectations regarding
pain and events related to the implications of chronic
chronic-pain condition pain for one’s general
well being.
Thinking
Perceived coping Attitudes and beliefs
Physical
alternatives regarding oneself and
others
Focus of AttentionHopelessness Helplessness
Emotions
Fear
Thinking Anxiety
Frustration
Physical
Hostility
Irritability
Guilt
DepressionPain diverting activities Vocal utterances
Behaviors
Restricting activity Emotions Taking medications
Thinking
Facial grimaces
Moaning
Physical
Withdrawing from others Seeking medical assistance
Bracing
Overt Expressions of Pain LimpEnvironment
Living Conditions Spouse
Behaviors
Emotions
Weather Changes
Thinking Work
Physical
Finances
Social EnvironmentPain
Usually thought of as sensation arising from the stimulation of nociceptors
This is an OVERSIMPLIFICATION!
Defined by the IASP as:
“An unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage.” (1)
Suffering “can be defined as an affective or emotional response in the central nervous system,
triggered by nociception or other aversive events, such as loss of a loved one, fear, or threat.
Suffering is observed only in the indirect sense of the person's engaging in some behavior that is
attributed to suffering.” (2)
Pain Behaviors (2)
• Things people do when they suffer or are in pain
• May arise because of nociception
• May arise from other reasons as well
1. https://www.iasp-pain.org/Taxonomy
2. Fordyce, W. E. (1988). Pain and suffering: A reappraisal. American Psychologist, 43(4), 276-283.Biomedical model/Disease Model
• Pain behaviors are seen as symptoms with a clear underlying cause.
• It is assumed that an “underlying cause” must first be corrected
before symptoms - “pain behaviors” can abate.
• Results in an ongoing process of trying to find an answer to the
question:
o Why does this person have pain?
• The model is most useful in recent-onset pain problems
• The model begins to fail as time passes and chronicity is reached
o Spectrum of phenomena influencing pain behavior will have broadened
Fordyce, W. E. (1988). Pain and suffering: A reappraisal. American Psychologist, 43(4), 276-283Ways of Thinking about Pain
Disease or Biomedical Model
Assumes pain is a symptom of underlying body defect.
Vs
Biopsychosocial Model (1)
Suffering behaviors may occur for many reasons that may have substantial,
little or no relationship to nociception.
(Biology, behaviors, thoughts, feelings, beliefs, and the environment all play
a role).
Engel,G. (1977) The need for a new medical model: a challenge for biomedical science. Science, 196:126-9.Biopsychosocial Model
• With chronic pain disorders there is frequently a complex
interaction between psychological, physiological and sociocultural
factors.
• The biopsychosocial model of care acknowledges:
✓ Multiple influences shape the experience of pain and
✓ Contribute to how the patient acts and describes symptoms.
• Ideally the assessment and management of pain should:
✓ Go beyond a pure biomedical approach
✓ Address the various issues that are contributing to the overall suffering.
(In complex situations, this is best done utilizing a team approach)…”pain is a subjective perceptual event that is not solely dependent on the
extent of tissue damage or organic dysfunction.”
“The intensity of pain reported and the responses to the perception of pain are
influenced by a wide range of factors, such as meaning of the situation,
attentional focus, mood, prior learning history, cultural background,
environmental contingencies, social supports, and financial resources, among
others.”
…”treatment should be designed not only to alter the physical contributors but
also to change the patient’s behaviors regardless of the patient’s specific
pathophysiology and without necessarily controlling pain per se.”
Turk D, Monarch ES. Biopsychosocial perspective on chronic pain. In Psychological Approaches
to Pain Management, Turk DC and Gatchel JR eds. Guilford press, NY, NY, 2002. Pp 22Best Setting? Multi-Disciplinary or Interdisciplinary Treatment?
Dietician Pain Psychiatrist
Physician Physician PA/FNP
Physical Pain
Therapist Psychologist
Primary
Care
Physician
Radiologist
Patient Surgeon
FNP, PA Radiologist
Pain Case PTOccupational
Psychologist
Addictionologist
Drug
Manager Therapist
Treatment
Clark TS. Interdisciplinary treatment for chronic pain: Is it worth the money? Proc (Baylor Univ Med Center.) 2000; 13(3): 240–243.The Blind Men and the Elephant
Seek First to Understand
Build the Therapeutic Alliance
• Loss of hope
• Marginalized
• Not taken seriously
• “My doctor thinks its all in my head.”
There is no greater
• Guilty
disease than the
loss of hope.
-Yisroel SalanterAffective Contributions to the Chronic Pain Experience
Negative emotions are often associated with chronic pain.
• Around 50% of pts experiencing chronic pain have coexisting
depression
o The prevalence of pain in depressed cohorts and depression in pain
cohorts are higher than when these conditions are individually
examined (1).
o Depression in chronic pain patients is associated with increased
disability (2)
o Anxiety is commonly observed in chronic pain patients and can be
associated with maladaptive pain behaviors that reinforce both pain
and disability (3)
1. Bair MJ, Robinson RL, et al. Depression and pain comorbidity: a literature review. Archives of Internal Medicine 2003; 163(20):2433-2445.
2. Gaskin, ME, Greene AF, et al. Negative affect and the experience of chronic pain. Journal of Psychosomatic Research 1992; 36 (8): 707-713.
3. Vlaeyen JW, Linton SJ. Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain 2012; 153 (6): 1144-1147.Cognitive Contributions to the Pain Experience:
• Pain catastrophizing is basically an irrational negative prediction of
future events (regarding the pain and its consequences).
o Has been shown to be associated with more intense pain and more
disability in patients with chronic pain. (1)
• Patient expectations influence the course of pain and treatment
efficacy.
o Negative expectations regarding pain persistence, disability and return to
work can be self-fulfilling. (2)
o If patients believe that a treatment is not going to work it probably won’t. (3)
1. Quartana PJ, Campbell CM, et al. Pain catastrophizing: a critical review. Expert Review of Neurotherapeutics 2009;9(5):745-758
2. Johansson AC, Linton SJ, et al. A prospective study of cognitive behavioural factors as predictors of pain, disability and quality of life one
year after lumbar disc surgery. Disability and Rehabilitation 2010; 32 (7): 521-529.
3. Klinger R, Colloca L, et al. Placebo analgesia: Clinical applications. Pain 2014; 155 (6): 1055-1058.The Patient’s Sociocultural Experience Impacts Pain • Observing parents or others can affect pain and pain behavior.(1) • Pain behaviors may be reinforced by how others react to those behaviors (attention, sympathy etc.). • Pain may be expressed differently in different cultures. (2) • Cultural differences also exist regarding beliefs about pain and how treatment is typically sought.(2) 1. Goubert L, Vlaeyen JW, et al. Learning about pain from others: An observational learning account. The Journal of Pain 2011; 12 (2): 167-174. 2. Shipton EA. The pain experience and sociocultural factors. The New Zealand Medical Journal 2013; 126 (1370): 7-9.
Cognitive behavioral therapy (CBT) • Improves multiple psychological
• A central feature of interdisciplinary dimensions of chronic pain. (2)
management of chronic pain. (1) ❖Coping
❖Pain behavior
• Key purpose is to identify/replace ❖Social function
maladaptive cognitions, emotions,
and behaviors with more adaptive • Examples of cognitive areas
ones. (1) addressed by CBT (3)
❖Catastrophizing
❖ Hopefully results in:
❖Acceptance of the pain condition
o Improved benefit from other interdisciplinary
care components (such as physical therapy) ❖Avoidance of activity due to
unrealistic concerns about harm
o Enhanced functional capacity through
improved coping
❖Expectations of pain treatment
1. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am
Psychol. 2014; 69 (2):119–30.
2. Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of
cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. Pain, 80, 1–13.
3. Vowles, K. E., McCracken, L. M., & Eccleston, C. (2007). Processes of change in treatment for chronic pain: The contributions
of pain, acceptance, and catastrophizing. European Journal of Pain, 11(7), 779–787.We should: • Educate the patient about how the nervous system processes, experiences, and responds to pain (from both a biological and a psychological perspective). This has been shown to result in: • Improved function and quality of life (whether or not pain decreases). Louw, A., Diener, I.D., Butler, D.S. & Puentedura, E.J., 2011, The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain, Archives of Physical Medicine Rehabilitation 92, 2041–2056
A Team Based Approach May Help In Various Scenarios
in Chronic Pain (Our Experience at UVPM)
• Fibromyalgia program
• Functional restoration program
• Co-management with psychology when there is a pain associated
mood disorder (severe anxiety/depression).
• Particularly helpful in addressing:
❖ Maladaptive cognitions, emotions, and behaviors commonly associated
with a wide variety of chronic pain situations.
• As part of a universal precautions approach in managing patients
who are prescribed opioid medications for painHow Can A Team Based Approach Help in
Managing the Chronic Pain Patient on Opioids?
• Can assist with opioid risk assessment by adding a psychological perspective.
• Provides input/help in management of aberrant behaviors that occur in conjunction
with opioid therapy use.
• Support during tapering
• Increases the options available to these patients (i.e. adds more non-opioid strategies)
• Assists with management of associated mood disorders.
• May help in functional restoration as well as functional assessment in conjunction
with opioid therapy.
• Co-management with psychology when simplifying polypharmacy (i.e. on both opioid
medication and benzodiazepine medication).
• Psychological support in working a program in conjunction with on label use of
buprenorphineStatement Found in the Prescribing Information for Opioids:
5 points from this statement:
1.Assess each patient’s risk for opioid addiction, abuse, or misuse prior to
Assess each patient’s risk for opioid addiction, abuse, or misuse prior
prescribing
to prescribing *****, and monitor all patients receiving *****
2.Monitor all patients receiving opioids for the development of these behaviors
for the
development
and conditions.of these behaviors and conditions. Risks are increased
in patients
3.Risks with a personal
are increased in patientsor family
with history
a personal or of substance
family abuse
history of substance
(including drug or
abuse (including drugalcohol abuse
or alcohol abuse ororaddiction)
addiction) or mental illness (e.g.,
major depression).
4.Risks are Themental
increased with potential for(e.g.,
illness these risks
major should not, however,
depression).
prevent the proper
5.The potential management
for these of however,
risks should not, pain in any given
prevent thepatient.
proper
management of pain in any given patient.Opioid Use Disorder Predictors
• A personal or a family history of alcohol or drug abuse is the strongest
predictor of drug use disorder (1)
• History of physical, emotional or sexual abuse (2)
• Presence of a mental health disorder (3)
• Male gender (3)
• Younger age (3)
• Higher average daily dose (3,4)
• Longer duration of therapy (4)
• Prescriptions filled at more pharmacies (3)
1. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10:113.
2. Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA). Treatment
Improvement Protocol (TIP) 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. DHHS Pub. No. (SMA)
12-4671. Rockville, MD: CSAT, SAMHSA, 2012
3. Cochran BN, Flentje A, Heck NC, et al. Factors predicting development of opioid use disorders among individuals who receive an initial opioid
prescription: mathematical modeling using a database of commercially-insured individuals. Drug Alcohol Depend 2014; 138:202.
4. Edlund MJ, Martin BC, Russo JE, et al. The role of opioid prescription in incident opioid abuse and dependence among individuals withRisk Stratification Before Prescribing Opioids
• Has become standard of care (1)
• Per 2017 FSMB Guideline (2)
❖ “Assessment of the patient’s personal and family history of alcohol
or drug abuse and relative risk for substance use disorder also
should be part of the initial evaluation”
o Ideally completed prior to deciding to prescribe opioid analgesics
❖ Should inquire into history of physical, emotional or sexual abuse
(known risk factors for substance use disorder)
❖ Validated screening tools for substance use disorder may be used
for collecting and evaluating information and determining level
of risk.
1. Jones T, MSchmidt T, Moore T (2015) Further Validation of an Opioid Risk Assessment Tool: The Brief Risk Questionnaire. Ann Psychiatry Ment Health 3(3): 1032.
2. Federation of State Medical Boards (FSMB) 2017 Guideline for the Chronic Use of Opioid AnalgesicsAlso from the 2017 FSMB Guideline • “Assessment of the patient’s personal and family history of mental health disorders should be part of the initial evaluation” ❖ Ideally should be completed prior to a decision as to whether to prescribe opioid analgesics. • “All patients should be screened for depression and other mental health disorders, as part of risk evaluation.” ❖ Patients with untreated depression and other mental health disorders are at increased risk for misuse or abuse of controlled medications, including addiction and overdose. ❖ Additionally, untreated depression can interfere with the resolution of pain.
Risk Assessment Tools (per 2016 CDC guidelines)
• Type 3 evidence for accuracy (observational studies or randomized clinical trials
with notable limitations).
• Insufficient evidence in reducing harms.
• Screening tools (ORT, SOAPP-R etc.) “show insufficient accuracy for classification
of patients as at low or high risk for abuse or misuse”
• “Clinicians should always exercise caution when considering or prescribing
opioids for any patient with chronic pain…. and should not overestimate the
ability of these tools to rule out risks from long-term opioid therapy.”
• “Clinicians should ask patients about their drug and alcohol use”
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.
MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1Not mentioned in either guideline
(FSMB or CDC)
Combining the SOAPP with the psychologist’s
interview, lead to a marked increase in sensitivity
(0.9) in predicting aberrant behaviors in conjunction
with opioid use in chronic pain patients.
Moore, T.M., Jones, T., Browder, J.H., Daffron, S., & Passik, S.D. (2009). A comparison of common screening
methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain
management. Pain Medicine, 10, 1426-1433Universal Precautions (UP) Approach When Prescribing Opioids
➢ We need to use a universal precautions(UP) approach when prescribing opioids in
pain management
o This has been emphasized by pain societies, pain specialists, and government agencies (1-6)
➢ This is a familiar concept to medical professionals
(i.e. the blood of all patient should be treated as potentially infectious)
➢ With opioid prescribing, we need to apply a uniform set of practices for all patients
who are being considered for long-term opioid therapy.
1. Chou et al; J Pain. 2009
2. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on
Opioid Dosing for Chronic Non-cancer Pain 2010 Update.
3. Manchikanti et al; Pain Physician. 2012
4. Webster LR, Fine PG. J Pain. 2010
5. Gourlay DL, Heit HA, Almahrezi A. Pain Med. 2005
6. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice
Guideline for Management of Opioid Therapy for Chronic Pain. 2010.(UP) Before Prescribing an Opioid: Assess the patient • Detailed history ❖Medical history ❖History of the pain problem (include review of prior workup/testing) ❖History of substance abuse ❖Psychological history ❖Family history (especially history regarding substance abuse and mental health disorders) • Thorough physical examination • Arrive at differential diagnosis for causes contributing to the pain and suffering.
(UP) Before Prescribing an Opioid: Perform a risk assessment • Includes an attempt to predict risk of future aberrant behaviors o Take into account history of previous aberrant behaviors and a personal or family history of substance abuse • Baseline drug screening (typically urine) • Review state monitoring program • Consider psychological factors (including input from psychology in our situation) • Use validated instruments in this assessment (i.e. SOAPP-R, ORT etc.) • When appropriate, communicate with previous prescribers or review their records • Dosage of medication • Includes an assessment of risk for potential medical complications of opioid therapy— including overdose and death o Help the patient understand that they can be taking the opioid as prescribed and still overdose/develop respiratory depression/die. • Try and quantify this risk for the patient (Zedler et al., Pain Medicine ,2017)
(UP) Before Prescribing an Opioid: Educate the patient (Be specific) • Risks of opioid medication • On the limited benefits of opioid medications A team based approach can help with this educational process • Team members can talk about opioids from their unique perspectives (i.e. prescriber, psychology). • A team member can reinforce the education given by other team members
(UP cont.)
If the decision is made to prescribe consider the following general principles:
• Prescribing should be done on a trial basis.
• Prescribing should continue only if the trial is successful and if benefits continue to outweigh
risks/side effects.
• Consider the patient’s medical status, psychological status, prior opioid use history, and
history of substance abuse.
• Take into account the patient’s dose (as dose increases, risk increases)
• Sometimes tapering is necessary even if the decision to prescribe is made.
• Discuss treatment expectations, potential risks/side effects, and benefits
(i.e. informed consent)
❖ This should include a discussion about functional goals
• Include a discussion about compliance monitoring (medication counts, random drug screens,
securing medication).
• As part of this discussion, review the medication management agreement and have the
patient sign that agreement.(UP cont.)
Regularly monitor the patient:
➢ More frequent follow-up may be necessary in higher risk situations.
➢ Prescribing is not a one-time decision
➢ This is an ongoing process. The decision to prescribe should be made at every visit after
counseling with the patient.
➢ Regularly assess “5 A’s” and act on this reassessment
❖ Analgesia: Is the pain better managed because of the opioid?
❖ Activity: Is he/she more functional and reaching treatment goals because of the opioid?
❖ Adverse effects:
o Does the patient report sedation, constipation, nausea, vomiting, itching etc.
o Is there evidence for respiratory depression.
o Has the situation changed from a risk standpoint (for example has the patient developed a new problem with their lungs etc.)
❖ Aberrant behaviors:
o Is there any evidence for misuse or abuse?
o Is there any evidence for diversion?
❖ Affect: How is the patient’s mood?Possible Tapering/Discontinuation Needs to Be Considered Regularly (UP cont.)
Potential Reasons to Taper/Discontinue
❖Lack of efficacy ❖Aberrant behaviors
❖Intolerable side effects ❖Opioid hyperalgesia
❖Pain has resolved ❖Other medical situations resulting in
unacceptable risk for opioid-induced
❖Failure to improve quality of life despite respiratory depression/death
reasonable titration
❖Other harms (falls, motor vehicle etc.) that
❖Failure to achieve pain relief or could reasonably be attributable to the
functional improvement or opioid medication
✓Deterioration in physical, emotional, or social
functioning attributed to opioid therapy ❖Cognitive impairment (either from the
❖Persistent nonadherence with opioid or separate from the opioid) or
medication management agreement mental health issues resulting in an
increased and potentially unmanageable risk
❖Development of opioid use disorder for unintentional or intentional misuse
Patients should continue to be treated with
non-opioid options for their chronic pain.Other Reasons Why Tapering/Dose Reduction Be Considered (UP cont.)
• There were more than 33,000 opioid overdose deaths in 2015 (includes heroin
and prescription opioids). (1)
• Higher doses are also associated with increases in the following:
❖ Overdose risk (2-4)
❖ Opioid use disorder (5)
❖ Depression (6)
❖ Fracture (7)
❖ Motor vehicle accidents (8)
❖ Suicide (9)
• Decreasing the dose or discontinuing the opioid obviously may lower risks.
1. Rudd RA, Seth P, David F, Scholl L. 2016, 6. Scherrer JF, Svrakic DM, Freedland KE, Chrusciel T, Balasubramanian S, Bucholz KK et al. 2014
2. Bohnert AS, Valenstein M, Bair MJ, et al. 2011 7. Saunders KW, Dunn KM, Merrill JO, Sullivan M, Weisner C, Braden JB, et al. 2010
3. Dunn KM, Saunders KW, Rutter CM, et al. 2010 8. Gomes T, Redelmeier DA, Juurlink DN, Dhalla IA, Camacho X, Mamdani MM. 2013
4. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink, DN. 2011 9. Ilgen MA, Bohnert AS, Ganoczy D, Bair MJ, McCarthy JF, Blow FC. 2016
5. Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. 2014Be Aware!
“Clinicians should remain alert to signs of anxiety, depression,
and opioid use disorder that might be unmasked by an opioid
taper and arrange for management of these co-morbidities” (1)
1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States,
2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1Tapering May Be Difficult
• Expert guidelines suggest tapering when benefits are outweighed by risks. (1,2)
• The challenges of tapering:
❖ In clinical practices, discontinuation of long-term opioid therapy (LTOT) is uncommon ranging from 8-
35%. (3,4)
❖ Over half of pts receiving high doses of opioids want to cut down or stop their medication--yet 80%
are still receiving high doses one year later. (5)
❖ 91% of patients on LTOT who experience a nonfatal overdose continue using opioids following that
overdose. (6)
❖ There is not a lot of evidence guiding clinicians in the process of opioid tapering
❖ There are risks associated with tapering (withdrawal symptoms, possible increased pain, and losing
the patient to follow-up).
• Some patients do report improved function and improve quality of life after tapering. (7)
1. Dowell D, Haegerich TM, Chou R. 2016 4. Vanderlip ER, Sullivan MD, Edlund MJ, Martin BC, Fortney J, Austen M, et al. 2014
2. Department of Veterans Affairs; Department of Defense; Opioid Therapy for Chronic Pain Work Group. 2017 5. Thielke SM, Turner JA, Shortreed SM, Saunders K, Leresche L, Campbell CI, et al. 2014
3. Martin BC, Fan MY, Edlund MJ, Devries A, Braden JB, Sullivan MD. 2011 6. Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF. 2016
7. Frank JW, Levy C, Matlock DD, Calcaterra SL, Mueller SR, Koester S, et al. 2016When Discontinuing an Opioid (UP cont.)
• Physical dependence can occur with even short term exposure to an opioid.
This is manifested by withdrawal.
• It is generally agreed the patient should gradually be tapered off of opioids.
o There is a lack of evidence in terms of determining the optimal weaning strategy.
o A taper of less than 25% dose reduction per week minimizes withdrawal symptoms in
most cases.
o Slower tapers of 10% per week have also been recommended.
o Some have proposed rapid tapers initially that are slowed as doses reach lower levels.
o According to the CDC 2016 guideline, “patients tapering opioids after taking them for
years might require very slow opioid tapers as well as pauses in the taper to allow
gradual accommodation to lower opioid dosage”
• When opioids are discontinued because of an opioid use disorder, patients
may require inpatient treatment with detoxification.
• Psychological support/CBT can be helpfulTapering Considerations with Concurrent Benzodiazepine and Opioid Use.
• Per CDC: “because of greater risks of benzodiazepine withdrawal relative
to opioid withdrawal, and because tapering opioids can be associated with
anxiety, when patients receiving both benzodiazepines and opioids require
tapering to reduce risk for fatal respiratory depression, it might be safer
and more practical to taper opioids first.” (1)
• Though the above is obviously very important:
❖ There are situations where anxiety is the bigger issue and other situations where
pain may be the bigger issue and each situation should be considered individually
❖ My opinion--In addition to the CDC statement above, the prescriber should consider
multiple additional factors before deciding which to taper first:
o Patient’s input
o Psychology input
o The medical situation (both from a pain perspective and a psychological perspective).
1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep
2016;65(No. RR-1):1–49If Tapering a Benzodiazepine, the CDC Guideline (1) Suggests:
• Taper benzodiazepines gradually because abrupt withdrawal can be associated
with rebound anxiety, hallucinations, seizures, delirium tremens, and, in rare
cases, death.
• A commonly used tapering schedule that has been used safely and with
moderate success is a reduction of the benzodiazepine dose by 25% every 1–2
weeks.
• CBT increases tapering success rates and may help patients struggling with the
taper.
• If benzodiazepines are tapered/discontinued, or if patients receiving opioids
require treatment for anxiety, the following option should be offered:
o Evidence-based psychotherapies (e.g., CBT) and/or
o Specific anti-depressants or other nonbenzodiazepine medications approved for anxiety
1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep
2016;65(No. RR-1):1–49“Alone we can do so
little; together we can
do so much.”
--Helen Keller--Thank You!
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