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San Francisco Safety Net Chronic Pain Management Education Day Finding Common Ground in the Gray Zone.

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Presentation on theme: "San Francisco Safety Net Chronic Pain Management Education Day Finding Common Ground in the Gray Zone."— Presentation transcript:

1 San Francisco Safety Net Chronic Pain Management Education Day Finding Common Ground in the Gray Zone

2 WELCOME!

3 Why are we here today? 3

4 4

5 Objectives Identify and manage risk factors for opioid misuse Respond to patient behaviors that are concerning for opioid misuse Support patients in managing substance use disorders Examine systems-level interventions that support safe pain management Develop policies or procedures in your own clinic to improve pain management practices

6 Shape of the Day Keynote Case-based panel Break Lecture Lunch Facilitator breakout Small Groups CURES Table

7 Disclosures None of the speakers have financial disclosures to report 7

8 Managing the Risks of Opioid Prescribing

9 Mr. Anderson 46 year old man discharged from LHH 8 days ago Requesting refill of pain medications Hospitalized 4 mo ago s/p MVA Right femur fracture Pelvic fracture Multiple rib fractures s/p surgical fixation of fractures BZD, EtOH, opiates in blood and urine drug test

10 Mr. Anderson Discharged to Laguna Honda Discharged from rehab 8 days ago Currently with pain in right leg, right chest Leg pain constant ache, worst in cold Able to walk 2 blocks Increased irritability due to pain Poor sleep

11 Mr. Anderson Medications: MS contin 100mg TID Oxycodone 30mg q6 hrs PRN No change in this regimen over 10 weeks at LHH

12 Mr. Anderson Drank 2-4 beers daily before accident, none since h/o heroin use, none for 3y before accident Occasionally buys prescription opioids on the street, had taken Morphine the day before the accident Occasional benzodiazepine use “when they’re around” 1 ppd cigarettes Unemployed, on GA, applying for disability Mother with cocaine and EtOH dependence

13 Who is at high risk for harm from opioids?

14 Characterizing Risk of Opioid Misuse

15 What We Don’t Want I prescribe opioids to my patient Opioid Use Disorder (abuse, dependency ) Diversion HARM

16 Fishbain et al. Pain Medicine; 9(4): How Common is the Bad Stuff 296 HIV+, marginalized patients, lifetime (Hansen et al 2011) Purposeful oversedation -- Felt intoxicated from opioids 34% (used “to get high”) Meds from other doctors -- Using alcohol w/meds31% Hoarding pain meds41% (saved for later) Sold opioid analgesics18% Snorted, crushed, injected opioids 17% Addictio n 3.2% ADRBs 11% None

17 Risk Assessment Purpose of Risk Assessment – Prior to initiation of opioids – Ongoing monitoring How to do it – Formal instruments – Clinical evaluation Underlying principle: universal precautions Guidelines (APS, AAPM), 2009 Chou et al Journal of Pain. 10(2):

18 Risk Assessment Instruments Lots of them – Screener and Opioid Assessment for Patients with Pain (SOAPP) – 24 items – Pain Medication Questionnaire (PMQ) – 26 items – Prescription Drug Use Questionnaire –Patient Version (PDUQP) – 24 items – Opioid Risk Tool (ORT) – 5 items – Diagnosis, Intractability, Risk, Efficacy (DIRE) – 7 items – Alturi & Sudarshan – 6 items

19 Two Options: Opioid Risk Tool (ORT) Webster LR, Webster RM. Pain Med. 2005;6(6): Scoring patients: low risk (0-3) medium (4-7) high (≥ 8) High risk: 91% sensitivity for ADRB Positive LR 14

20 Second Option Atluri Tool – 6 clinical criteria 1.Focus on opioids 2.Opioid overuse 3.Other substance use 4.Low functional status 5.Unclear etiology of pain 6.Exaggeration of pain – Score >3  OR of 16 for opioid misuse Atluri SL et al. Pain Physician 2004; 7: Not willing to try non opioid modalities Always asking about opioids (inc 1 st visit) Upset when denied opioids Requesting particular med History of drug/EtOH abuse Currently using marijuana Feels need for benzos On disability or applying Pain “everywhere” Non-physiologic distribution ER visit for pain; Use up own supply too fast

21 Risk Assessment Tools Clinical Evaluation – Pain clinic study comparing: SOAPP-R, ORT, PMQ and a 45-min semi-structured interview with a psychologist – Psychologist’s evaluation of risk was the most sensitive predictor for later discharge from pain clinic Note: psychologist had 27 years of clinical experience – 6 years in substance abuse Jones et al. The Clinical Journal of Pain. 2012; 28(2):

22 Substance Use Screening Single Item screeners NIDA: “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” NIAAA: “How many times in the past year have you had more than 4/3 drinks in a day?”

23 Substance Use Screening

24 Our Patient ORT score: 18 = HIGH RISK

25 Second Option Atluri Tool – 6 clinical criteria 1.Focus on opioids 2.Opioid overuse 3.Other substance use 4.Low functional status 5.Unclear etiology of pain 6.Exaggeration of pain – Score >3  OR of 16 for opioid misuse Atluri SL et al. Pain Physician 2004; 7: Not willing to try non opioid modalities Always asking about opioids (inc 1 st visit) Upset when denied opioids Requesting particular med History of drug/EtOH abuse Currently using marijuana Feels need for benzos On disability or applying Pain “everywhere” Non-physiologic distribution ER visit for pain; Uses up own supply too fast

26 What to do with the risk evaluation? Atluri et al. Pain Physician; 2012; 15: ES177

27 Our Patient High risk for “ADRBs” Options Taper off opioids Continue opioids with close monitoring Frequent Utox (q month) Short refill interval (q 2 weeks) Frequent CURES report (3-4 times per year) Patient Agreement and Informed Consent with explanation of reasons for discontinuation (i.e. no show, refusal of alternative treatments, abnormal Utox results)

28 How do we assess and understand the impact of psychosocial issues on the pain experience?

29 Psychosocial Assessment Brief Intervention vs. Detailed Psychosocial Assessment Brief Intervention in Primary Care Behavioral Health Review presenting problem/referral question Assess/strengthen supports Identify/build coping skills

30 Detailed Psychosocial Assessment (may be gathered over time by various team members) Presenting problem/referral question Culture/family history Educational/work history Relationship history/interpersonal issues Trauma history Substance use history Psychiatric/medical history Current: Symptoms Supports Coping skills

31 Mr. Anderson’s Psychosocial Assessment

32 32 Culture/family history Born in Ohio, family background Irish/German/Danish No strong cultural/religious affiliations Middle of 3 kids, father left when pt. was 7 Mother and siblings moved around Educational/work history Completed 10 th grade, fair grades Has worked odd jobs, mostly house painting Currently on GA, in SRO

33 Relationship history/interpersonal issues Married twice, now lives with female partner History of anger management problems including IPV with partners No longer speaks to siblings Feels angry/disappointed with medical system for not curing his pain Trauma history Vague memories of IPV between parents, mother verbally and physically abusive, sexual assault by an older man age 11

34 ”I’ve tried everything” Drank 2-4 beers daily before accident, none since H/O heroin use, none for 3 years Occasionally buys prescription opioids on the street (Morphine) Occasional benzodiazepine use 1 ppd cigarettes Substance use history

35 Psychiatric history Long history of depressive sx, “I’ve been depressed all my life” No history of manic episodes, no psychiatric hospitalizations On various antidepressants with little effect Intermittent suicidal ideation, one non-lethal gesture as adolescent

36 Current Symptoms Depressed feelings, feeling “empty”, feeling like no one cares/no point in living, but no clear suicidal plan Reports daily “mood swings”, but not mania Feels that pain is intolerable, nothing helps Angry that “system” is not helping him, feels abandoned by medical team for “withholding” medication 36

37 Psychosocial Assessment: Strengths Support Has female partner of 3 years Has one “buddy” he sees quite regularly Coping skills Intelligent, resourceful Reasonably good eating/exercise habits Has managed to reduce/abstain from substances since the accident Can respond to encouragement, support

38 Psychosocial Assessment: Findings Does NOT currently meet criteria for major depression, more likely dysthymia Not acute PTSD (“complex PTSD”) Borderline personality features Mood instability Interpersonal issues, extremes Impulse control problems, suicidal thoughts/gestures Chronic feelings of emptiness Expectation/fear of abandonment

39 Patient’s Experience of Pain May experience pain as unrelenting, not distinguishing between physical and emotional pain Feels that no one/nothing can help May test limits to see if can influence you May see things in extremes, you are “a wonderful provider” when increasing meds, a “%#&^!?!” when setting limits

40 Discussing Risk Issues Use understanding of pt. when discussing limits and risk issues Interpersonal The relationship is paramount Stress partnership, trust, working together, listen to pt’s concerns Put in the context of caring for pt; communicate respect

41 Splitting, Thinking in Extremes Recognize the patient’s “all-or-nothing” thinking; help to find middle ground “It’s not exactly black and white. Let’s weigh the risks and benefits of going up on your dose together. We have to find a way to find some balance between how it helps and what the downsides are.”

42 Testing (Will you abandon me?) Clear limits, consequences, structure helpful “I want to be able to work with you to find our best options over time. The only way I can do that is if we have some agreement about how we’re going to do this.” Consciously give patient choices when possible “Would you prefer to take your meds twice a day or three times a day?”

43 Countertransference Understand your personal reactions Don’t let yourself be provoked by testing Don’t take patient’s anger at/rejection of you as a failure 43

44 How do we minimize the risks if we do prescribe? Clear patient-provider agreement Frequent visits Monitor function, not just pain score Urine drug testing CURES reports Pill counts

45 How can we use Naloxone to reduce the risk of death by overdose?

46 Lay Naloxone for Overdose Prevention Readily reverses opioid overdoses Patient & provider support Training easy & effective Frequent reversals reported Community-level mortality reduced Bazazi et al., J Health Care Poor Underserved Seal et al; Coffin et al., JUH Green et al., Addiction Enteen et al., JUH Walley et al., BMJ 2013; Albert et al., Pain Med 2011

47 Fatal Opioid Overdose Rates by Naloxone Implementation Adjusted ModelsRRARR*95% CI Cumulative enrollments per 100k No enrollmentRef > * Adjusted Rate Ratios (ARR) adjusted for city/town population rates of age<18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, year Walley et al. BMJ 2013; 346: f174.

48 DOPE Project Dispensing

49 Heroin Related Deaths: SF Naloxone distribution begins *Data compiled from San Francisco Medical Examiner’s Reports, **no data available for FY www.sfgsa.org

50 Potential Behavior Changes Risk of non-fatal opioid overdose U.S. Army Fort Bragg EMS/ED visits in SF Syringe sharing in Seattle Model Overdose may influence behavior

51 Why pain patients? Rx opioid deaths presaged an increase in heroin overdose and death (Unick et al., Plos One 2013) Prescribed opioids associated with a transition to heroin (e.g. Young & Havens, Addiction 2012) SF opioid analgesic overdose decedents engaged in primary care 69% on chronic opioids

52 San Francisco Naloxone Access Community-based dispensing Drug Overdose Prevention and Education (DOPE) Access for other populations Primary care patients at selected sites and connected pharmacies Mental health patients at CBHS clinics Buprenorphine/methadone patients dosing at CBHS

53 Intranasal Naloxone Kit Atomizer (2) Brochure Naloxone 2mg/2ml prefilled syringes (2)

54 Provider Education Training document on CBHS website Naloxone Training for Providers Key components Causes Recognition Actions (call 911, rescue breathing, naloxone administration)

55 Primary Care Clinic Rx Opioid Rx Naloxone Atomizer Brochure Education Pharmacy Dispense Opioid Dispense Naloxone Education

56 Mental Health Clinic Opioid user Rx Naloxone/disp Naloxone Atomizer Brochure Education Pharmacy Dispense Naloxone refill

57 OBOT Methadone/Buprenorphine Clinic OBOT Methadone order or Rx buprenorphine CBHS Pharmacy Methadone or buprenorphine Clinical Pharmacist Evaluation Rx Naloxone/Disp Naloxone Atomizer Brochure Education

58 SFDPH Naloxone Distribution Summary as of 4/11/2013 SettingSitesUnique individuals Reported Reversals DOPE50>3, Primary Care267-- Mental Health113-- Opioid Agonist Treatment 1382

59 Mr. Anderson part 2 You discussed your concerns about risk with the patient You signed a patient provider agreement May not use other controlled substances May not give medications to others Must take meds as prescribed Must inform you if he receives prescriptions from other providers Must follow up with diagnostic and treatment strategies Will have regular urine drug tests Will only receive refills in the context of scheduled appointments Will not receive early refills

60 Mr. Anderson, part 2 Start gabapentin for neuropathic component of pain Refer to behavioral health team for support with pain coping Group or individual

61 Mr. Anderson, Part 2 Over the next few months: Increase gabapentin dose, helping a little Patient adheres to the patient-provider agreement

62 Mr. Anderson, Part 2 4 months later Drops in to clinic 1 week before appointment requesting early refill Fell from a ladder, has been taking extra morphine and oxycodone for increased pain. Ran out early Gets an early refill from urgent care provider Misses his next appointment with you

63 Mr. Anderson, Part 2 Drops in one week later requesting morphine and oxycodone from urgent care provider States that insurance would not cover the full monthly amount of his last rx, so he needs early refill Provider requests urine drug test Patient becomes angry and leaves without providing a urine sample

64 Mr. Anderson part 2 You schedule an appointment with the patient Refill his medications Order a urine drug test Urine contains Oxycodone Morphine Hydromorphone Benzodiazepenes

65 What are your concerns at this point?

66 Labmed.ucsf.edu/sfghlab

67 Given these concerns, options include Discontinue prescribing of all controlled substances Require the patient to enter substance abuse treatment in order to continue prescribing Increase visit frequency, urine drug test frequency, check CURES Change to a medication that treats pain and substance abuse simultaneously

68 What is the role of buprenorphine/naloxone in the treatment of co-occurring pain and substance use disorder? Scott Steiger, MD Assistant Professor of Clinical Medicine Division of General Internal Medicine University of California – San Francisco

69

70 Outline 1.buprenorphine (bup) pharmacology 2.Buprenorphine/Naloxone (Bup/Nx) treats opioid dependence 3.Bup/Nx treats pain 4.Bup/Nx for this patient?

71 Buprenorphine is a partial agonist of the µ-opioid receptor *NABBT.org

72 Buprenorphine is a partial agonist of the µ-opioid receptor *NAABT.org RR <6

73 Buprenorphine Still Blocks Opioids as It Dissipates Courtesy of NAABT, Inc. (naabt.org) Imperfect Fit – Limited Euphoric Opioid Effect Buprenorphine Opioid Empty Receptor Withdrawal Pain Receptor Sends Pain Signal to the Brain Perfect Fit - Maximum Opioid Effect Empty Receptor Euphoric Opioid Effect No Withdrawal Pain

74 Buprenorphine formulations Temgesic (UK, sl) Buprenex (IM) Subutex and generic (sl) Suboxone, Orexa, generics: coformulated with naloxone (sl) Norspan and Butrans (td) ?Nabuphine (subq implants)

75 Buprenorphine formulations Temgesic (UK, sl) Buprenex (IM) Subutex (sl) Suboxone, Orexa, generics: coformulated with naloxone (sl) Norspan and Butrans (td) ?Nabuphine (subq implants)

76 Bup/Nx comes in a couple of forms

77 Bup/Nx is available for treatment of opioid dependence DATA 2000 Lower barrier to addiction tx Requires extra training, DEA waiver FDA approval in 2002 “Office based” opioid replacement Medicaid covers in CA

78 Addiction or chronic pain? Tolerance? Withdrawal? Loss of control over use? Use despite negative consequences?

79 Off label Bup/Nx is effective for pain Acute pain in patients already on Bup/Nx Chronic pain failing other opioids* Chronic pain in “extremely high risk” patient? *Malinoff et al Am J Ther 2005

80 Co-occurring disorders clinic VA retrospective cohort of 1 Referrals from PCP, pain mgmt, hospital, substance abuse treatment Screened, induced, then maintained Bup/nx stopped if… Uncontrolled pain on >28 mg bup/nx Tox + 3+, miss 3+ visits, 3+ early refills Pade et al. JSAT 2012

81 Change in pain scores and retention Pade et al. JSAT 2012

82 Bup/nx maintenance better than taper for high risk patients “we found that it was quite difficult to wean opioids among those with chronic non-cancer pain and co- existent opioid addiction.” Blondell et al J Addict Med 2010

83 Special considerations using bup/nx for chronic pain Induction More “off time” required, esp with methadone Low COWS? ?safer just to taper Dosing considerations POTENT Consider increased frequency for pain Payor considerations

84 Initial dose must be appropriate VA Co-occurring sorders clinic dropped everyone to MS 90 mg eq—and short-acting Prospective cohort study NYC (n=12) 3 highest doses (>300 MS eq) and 3 lowest doses (<20 MS eq) quit at induction 4 who completed reported better pain control Rosenblum J Opioid Manag 2012

85 46 yo M with high risk chronic pain Treat with bup/nx!! Meets criteria for opioid use disorder Risk < benefit of opiates Poor candidate for abstinence only or naltrexone Maybe we should hold off… MAY meet criteria for SUD for benzos Dose may be too high for easy transition MAY have greater benefit from MMTP

86 Summary Bup/nx’s pharmacology offers unique advantages compared to other opioids Consider bup/nx in Opioid dependence High risk chronic pain Pain refractory to other opioids Bup/nx requires a DEA waiver to Rx

87 How do I get the waiver? Buprenorphine.samhsa.gov May 15 Training

88

89 What else can we offer for pain? Pain Treatment ≠ Opioids

90 Suffering Physical Pain Emotional Trauma Addiction Financial Insecurity Depression, Anxiety

91 How do opiates compare? What about function? Drug ClassAverage Pain Reduction Opioids30-40% Tricyclics/AEDs 30-60% for neuropathic pain Acupuncture10% CBT/Mindfulness30-60% Exercise/ PT30-60% Massage30-40% for LBP

92 Pharmacologic Physical Complementary and Alternative Medicine Cognitive and Behavioral

93 Pharmacologic Neuroleptics Antidepressants Anesthetics (lidocaine patch) Muscle relaxants Topicals (capsacin) Opioid medications/Tramadol Baclofen pumps, lidocaine pumps Buprenorphine/naloxone Physical Complementary and Alternative Medicine Cognitive and Behavioral

94 Pharmacologic Neuroleptics Antidepressants Anesthetics (lidocaine patch) Muscle relaxants Topicals (capsacin) Opioid medications/Tramadol baclofen pumps, lidocaine pumps Buprenorphine/naloxone Physical Physical Therapy/Physiatry consults Joint injections Spine injections Surgery Stretching/strengthening exercises Heat or ice Trigger point injections Complementary and Alternative Medicine Cognitive and Behavioral

95 Pharmacologic Neuroleptics Antidepressants Anesthetics (lidocaine patch) Muscle relaxants Topicals (capsacin) Opioid medications/Tramadol baclofen pumps, lidocaine pumps Buprenorphine/naloxone Physical Physical Therapy/Physiatry consults Joint injections Spine injections Surgery Stretching/strengthening exercises Recommendations for pacing daily activity Heat or ice Trigger point injections Complementary and Alternative Medicine Acupuncture (community and schools) Mindfulness Based Stress Reduction and meditation Community yoga classes Tai-chi classes Massage schools Anti-inflammatory diets and herbs Supplements Guided imagery Breathing exercises Cognitive and Behavioral

96 Pharmacologic Neuroleptics Antidepressants Anesthetics (lidocaine patch) Muscle relaxants Topicals (capsacin) Opioid medications/Tramadol baclofen pumps, lidocaine pumps Buprenorphine/naloxone Physical Physical Therapy/Physiatry consults Joint injections Spine injections Surgery Stretching/strengthening exercises Recommendations for pacing daily activity Heat or ice Trigger point injections Complementary and Alternative Medicine Acupuncture (community and schools) Mindfulness Based Stress Reduction and meditation Community yoga classes SFGH Tai-chi classes Massage schools Anti-inflammatory diets and herbs Supplements Guided imagery Breathing exercises Cognitive and Behavioral Pain Groups Individual therapy Brief cognitive and behavioral interventions in clinic Visualization, deep breathing, meditation Sleep hygiene Gardening, being outdoors, going to church, spending time with friends and family, etc.

97 Questions 97

98 BREAK

99 How To Think About Concerning Behaviors

100 Concerning Behaviors Poor functionality Requests for a specific medication Tox (-) for drug prescribed Tox (+) for other drugs Early refill requests Multiple prescribers Hoarding Lost or stolen medications Comes for appointments only when opi needs refill Neglects other aspects of care plan Reports that pharmacy “shorted” the prescription Alcohol/drug use Forgery over sedation (purposeful or not) MVAs or other accidents Self-initiated dose changes Escalating/very high doses Refusal to sign ROI Drug cravings Reports “allergies” Refusal to take DOT

101 Prescribers Dilemmas Unproven standards Stigma associated with treating patients Conflicting guidelines and recommendations Pressure to prescribe opiates and liberally treat pain Wondering if pain is real Epidemic of Rx overdoses and misuse Addiction long associated with abstinence treatment models Provider disciplinary action/malpractice Mistrust of self/skills and patients

102 Goals in addressing concerning behaviors Improve pain and functioning Reduce risks Reduce suffering Improve feeling of provider effectiveness

103 Framework: How to structure thinking BenefitsRisks Avoid Rx Abuse Catastrophic SEs Treat Pain Patient rights

104 Framework: The Nursing Process Assess Diagnose Outcome Identification Plan Implement and Evaluate Pain Concerning behavior Function

105 Research and Risks Aberrant medication behavior rate: 5 % to 24% 1 For all patients on opioids for CNCP 2 Abuse/addiction rate = 3.27% Aberrant behavior rate = 11.5% For all patients excluding past or current SUD diagnosis: 2 Abuse/addiction rate = 0.19% Aberrant behavior rate = 0.59% 1. Martel et al, Fishbain et al, 2008.

106 Research and Risks Younger Age 1, 2, 3, 4, 5, 6 Male gender 2, 4 Caucasian/White 1 Mental Health Disorders 1, 3, 4, 5, 6, 7 Large dose or supply 3, 4, 8 Drug Cravings 7  relation to pain severity 2 1. Dowling et al, Ives et al, Edlund et al, White et al, Fleming et al, Reid et al, Wassan et al, Dunn et al, 2010.

107 Research and Risks FHx SUD 1 Personal Hx SUD 1, 2, 3 Specific Drugs Cannabis 4, 5, 6 Cocaine 4, 6, 7, 8 Alcohol 8, 9 Heroin 4 1. Webster & Webster, Edlund et al, Turk et al, Dowling et al, Reisfield et al, Fleming et al, Meghani et al, Ives et al, Dunbar & Katz, 1996.

108 Research and Risks Pain, SUDs, and Functionality SUD reported greater disability due to pain Pts w/ SUD more likely to be prescribed an opioid analgesic Pts w/ SUD less likely improvement in pain related function Morasco et al, 2011.

109 Assessment H & P: SUD history, FHx, and psychosocial assessment. Testing: UDT, other toxicology Risk Assessment & stratification.

110 Differential Diagnosis Psychiatric disorders Cognitive disorders Diversion Pseudo-addiction Opioid tolerance Allodynia or opioid-induced hyperalgesia Addiction/abuse

111 Substance Dependence Tolerance Withdrawal Larger amounts or longer time than intended Persistent desire or unsuccessful efforts to cut down A lot of time spent to obtain or recover from use Important activities given up Substance use continues despite having a related persistent or recurrent health problem

112 Planning Risks dictate structure Structure helps Reduce or resolve aberrant behaviors Result in self-discharge ID who needs higher level of care

113 Elements of Structure Visit Frequency Refill frequency Medication call backs UDT Presence/absence of rx’d drug Presence/absence drugs of abuse PDMP

114 Planning When plan is insufficient to reduce risk: change it. Explain why Offer options Refer: addiction care, ORT plus pain care, pain clinic

115 Opiate analgesics may not be appropriate if… Pain unimproved on upward titration Unmanageable side effects Recurrent non-adherence to treatment plan or agreement Non-resolution of risky drug behaviors with tight controls

116 Assess the “Four A’s” Analgesia ADLs Adverse events Aberrant Behaviors AAAAAAAA Passik & Weinreb, 2000.

117 Universal Pain Precautions 1)Make diagnosis 2)Psychological Assessment 3)Informed consent 4)Treatment agreement 5)Pre-Intervention assessment of pain level and functioning 6)Pharmacotherapy trial 7)Post-intervention assessment of pain level and functioning 8)Assess the “Four A’s” 9)Review diagnosis and co-morbidities 10)Documentation Gourlay, Heit & Almahrezi, 2005.

118 Opioid prescription management includes Both pharmacologic and psychosocial interventions Regular monitoring Routine evaluation of treatment goals Patient education Encourage patient to engage in the treatment process Inclusion of other supports for overall health

119 Summary Concerning behaviors: not always addiction Assess and identify risks, balance with benefits Formulate differential and diagnosis Create plan including risk stratification More risks indicate more elements of plan Use a consistent, standardized approach to opioid prescribing with all patients, e.g. “universal precautions” Join a team: multidimensional psychosocial, pharmacologic, non-pharmacologic, referrals and resources Team decision making based on risks and successes Apply essential elements of chronic disease management

120 Sources Chou, R, Fanciullo, GJ, Fine, PG et al. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The journal of pain, 10(2), Dowling, K, Storr, C L, & Chilcoat, H D. (2006). Potential influences on initiation and persistence of extramedical prescription pain reliever use in the US population. The Clinical journal of pain, 22(9), Dunbar, S A, & Katz, N P. (1996). Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. Journal of pain and symptom management, 11(3), Edlund, M J, Martin, B C, Fan, M, et al. (2010). Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study. Drug and alcohol dependence, 112(1-2), Fishbain, D A, Cole, B, Lewis, J, et al. (2008). What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug- related behaviors? A structured evidence-based review. Pain medicine, 9(4),

121 Fleming MF, Balousek, SL, Klessig, CL, et al. (2007). Substance use disorders in a primary care sample receiving daily opioid therapy. The journal of pain, 8(7), Gourlay, D L, Heit, H A, & Almahrezi, A. (2005). Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain medicine, 6(2), Ives, T J, Chelminski, P R, Hammett Stabler, C A, et al. (2006). Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC health services research, 6, Jamison, R N, Ross, E L, Michna, E, et al. (2010). Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain, 150(3), Martell, B A, O'Connor, P G, Kerns, R D, et al. (2007). Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146(2), Meghani, S H, Wiedemer, N L, Becker, W C, et al. (2009). Predictors of resolution of aberrant drug behavior in chronic pain patients treated in a structured opioid risk management program. Pain medicine, 10(5), Morasco, B J, Corson, K, Turk, D C, et al. (2011). Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain. The journal of pain, 12(3), Passik, S D. (2009). Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clinic proceedings, 84(7), Passik, S D, & Weinreb, H J. (2000). Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Advances in therapy, 17(2), Paulozzi, L J, Budnitz, D S, & Xi, Y. (2006). Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology and drug safety, 15(9),

122 Reid, M C, Engles Horton, L, Weber, M B, et al. (2002). Use of opioid medications for chronic noncancer pain syndromes in primary care. Journal of general internal medicine, 17(3), Reisfield, G M, Wasan, A D, & Jamison, R N. (2009). The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: a review of the extant literature. Pain medicine, 10(8), Savage, S R. (2002). Assessment for addiction in pain-treatment settings. The Clinical journal of pain, 18(4 Suppl), S28-S38. Savage, S R. (2009). Management of opioid medications in patients with chronic pain and risk of substance misuse. Current psychiatry reports, 11(5), Sehgal, N, Manchikanti, L, & Smith, H S. (2012). Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain physician, 15(3 Suppl), ES67-ES92. Turk, D C, Swanson, K S, & Gatchel, R J. (2008). Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. The Clinical journal of pain, 24(6), Warner, M, Chen, L H, Makuc, D M, et al. (2011). Drug poisoning deaths in the United States, NCHS data brief, (81), 1-8. Wasan, A D, Ross, E L, Michna, E, et al. (2012). Craving of prescription opioids in patients with chronic pain: a longitudinal outcomes trial. The journal of pain, 13(2), Webster, L R, & Webster, R M. (2005). Predicting aberrant behaviors in opioid- treated patients: preliminary validation of the Opioid Risk Tool. Pain medicine, 6(6), White, A G, Birnbaum, H G, Schiller, M, et al. (2009). Analytic models to identify patients at risk for prescription opioid abuse. The American journal of managed care, 15(12),

123 When and How to Taper Opioids

124 When to discontinue opioids Treatment goals not met/opioid trial failed Insufficient improvement of pain/function/quality of life Significant non adherence to treatment plan Risks/harms outweigh benefits Intolerable/dangerous side effects Concerning/dangerous behaviors suggesting: Active substance abuse (opioid, other) Diversion Psychiatric instability

125 When/Where to taper opioids When Patient taking medication Physiologic dependence Safe to do so If clearly unsafe or illegal behaviors, stop and assess for withdrawal Where “Although there is insufficient evidence to guide specific recommendations on optimal strategies, a taper … can often be achieved in the outpatient setting in patients without severe medical or psychiatric comorbidities.” Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009,

126 Where/How to taper opioids Assess patient’s opioid use, medical problems, and psychosocial issues Involve other team members Provide written instructions

127 Where/How to taper opioids Consider referral to methadone treatment program if opioid abuse Consider referral to addiction medicine/ substance abuse or psychiatric treatment if (risk of) unsafe behaviors (e.g., suicidality, lack of impulse control)

128 How to taper opioids “Evidence to guide specific recommendations on the rate of reductions is lacking, though a slower rate may help reduce the unpleasant symptoms of opioid withdrawal.” Factors that may influence rate: reason for discontinuing medical/psychiatric comorbidities withdrawal symptoms during process Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009,

129 How to taper opioids – rules of thumb One taper regimen (Univ of Mich Health System): Decrease 10% of original dose every week until 20% remains, then 5% of original dose until off Other considerations: Amount of opioid necessary to prevent withdrawal is 20% of previous day’s dose Convert multiple medications to 1 medication, then taper Reduce dose 20-50% because of incomplete cross tolerance Taper faster at higher doses (>200mg morphine), slower when reach 60-80mg morphine/d Some suggest the longer the treatment, the slower the taper

130 Opioid taper - example MSSR 60mg 3x daily plus MSIR 30mg 1 q4hr (DNE 3/d) Total daily dose: 60X3=180, 30X3=90→270mg Initial taper 100% to 20% initial dose → 270mg to 54mg 10%/wk →27mg/wk (round to 30mg/wk) Final taper 5%/wk →14mg/wk (round to 15mg/wk) MSSR pill strengths: 15, 30, 60, 100, 200mg

131 Opioid taper - example WeekTotal dose morphine/ day (mg)Script 1240 (begin 10%/wk taper) MSSR 60mg 3xd #21 MSIR 30mg 2xd prn # MSSR 60mg 3xd #21 MSIR 30mg 2xd prn #7 3180MSSR 60mg 3xd # MSSR 15mg 3 pills 2xd + 4 pills qhs # MSSR 15mg 3 pills 2xd + 2 pills qhs #56 690MSSR 15mg 2 pills 3xd # MSSR 15mg 1 pill 2xd + 2 pills qhs # (begin 5%/wktaper) MSSR 15mg 3xd #21 930MSSR 15mg 2xd # MSSR 15mg 1xd #7 110

132 Managing Withdrawal Symptoms Rarely life threatening May persist up to 6 mos Treat symptomatically Provide “kick pack” or have pt return if symptoms Avoid opioids or benzodiazepines

133 Managing Withdrawal Symptoms SymptomMedication Anxiety, restlessness hydroxyzine 25mg q6h prn, diphenhydramine 25mg q6h prn Insomnia hydroxyzine 25-50mg qhs, diphenhydramine 25-50mg qhs Nauseametoclopramide 10mg q6h prn Dyspepsia CaCarbonate 500mg 1-2 q8h prn mylanta 1-2 tsp prn Diarrhealoperamide 1-2 prn diarrhea Pain, fever APAP 325mg 1-2 q6h prn, ibuprofen 200mg 1-3 q6h prn Autonomic symptoms (rhinorrhea, sweating, hypertension, tachycardia) clonidine 0.1mg q6h prn or patch 0.1mg/24hr qwk

134 Other treatments/support Make efforts to preserve therapeutic relationship Pt may not feel pain taken seriously Pt’s clinical situation may deteriorate Pt may feel poor quality of care and threaten action

135 Other treatments/support Concerning behaviors may emerge during taper May be mitigated by initial plan Use clear, consistent message with focus on safety and harms/benefits Offer counseling/support if significant behavioral issues Make psychiatric, substance abuse referrals if indicated

136 Other treatments/support Consider others’ support (team, provider, pharmacist) If threats/intimidation occur, take appropriate steps, including preventive actions (other staff/ security present)

137 References Agency Medical Directors Group. Interagency Guidelines on Opioid Dosing for Chronic Non-cancer Pain. Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009, Group Health Cooperative. Chronic Opioid Therapy Safety Guideline For Patients With Chronic Non-Cancer Pain. University of Michigan Health System. Managing Chronic Non-Terminal Pain in Adults. es_290232_7.pdf es_290232_7.pdf VA/DoD. Clinical Practice Guidelines for Management of Opioid Therapy for Chronic Pain. apy_fulltext.pdf apy_fulltext.pdf

138 Treating Substance Use Disorders Stimulants, Opioids, and Alcohol 138

139 Stimulant Use: cocaine and methamphetamine Judith Martin, MD Medical Director of Substance Abuse Services, SFDPH

140 Question for you: A patient who is on your clinic’s chronic pain registry tests positive for cocaine when she comes in for her opiate prescription. You ask her what she has noticed about effects of cocaine on her body. She says it makes her heart “jump” in her chest. How would you explain this symptom, and how does your clinic protocol address a positive cocaine test?

141 Effects of stimulants: short term wakefulness, increased physical activity, decreased appetite, increased respiration, rapid heart rate, irregular heartbeat, increased blood pressure, and hyperthermia.

142 Effects of stimulants, long term Can be damaging to brain, emotions, and body. Cardiovascular: high pulse, BP may lead to heart attack or stroke, leads to atherosclerosis, myopathy Psychiatric: anxiety, paranoia, depression, egocentric delusions Neurostimulation: formication, excoriations, seizures, tremor

143 Stimulant use, treatment Many medications have been tried, none clearly useful. CBT, incentives and MI have all been successful. In the case of methamphetamine, brain recovery takes time.

144 Volkow et al., 2001 DATs Recover with Abstinence

145 Summary: stimulant use Evaluate patient’s stage of change Information about effects of drug Information about types of treatment Note: overlap with psychiatric and trauma histories, overlap with other risk behaviors, special urgency in cardiovascular disease.

146 Medically Assisted treatment for Opiate dependence

147 MAT for Opiate Dependence Reduces overdose Decrease illicit opiate use Reduced HIV and HCV transmission Reduces criminality Improves medical, psychiatric, and social functioning

148 NIH Consensus Statement on Opiate Dependence: 1997 Opioid addiction is a medical disorder that can be treated effectively All should have access to opiate agonist treatment Reduce unnecessary treatment regulations Coverage should be a required benefit in public insurance programs

149 Approved Medications Methadone Full opiate agonist Provided only at licensed specialized clinics Buprenorphine Partial opiate agonist Office based settings Naltrexone Opiate antagonist Office-based settings

150 Methadone Synthetic opioid Full μ agonist Repeated administration leads to physical dependence Hepatic storage and subsequent slow release Linear dose-response curve Half life: 15 to 60 hours

151 Methadone Special Alert (2009): Recommendations for QTc interval screening before and during methadone treatment CNS depression Respiratory depression Hypotension Consider synergistic effects with sedative or alcohol abuse CNS, central nervous system Krantz MJ et al. Ann Intern Med. 2009;150:

152 Methadone Prescribing For pain with a DEA license For opiate replacement At licensed NTPs Through OBOT methadone program: Tom Waddell and Potrero Hill Clinics only Federal and State Regulations: Title 9 in California Setting, dose limits, dosing frequency, drug testing, counseling (addiction) Liquid formulation

153 Methadone and Benzodiazepines 51% to 70% of MMTP patients use benzodiazepines (similar to buprenorphine patients and heroin users not in treatment) % to 50% with problematic use 1,3,4 In studies, benzodiazepine-related deaths for MMTP patients range from 10% to 80% Gelkopf M et al. Drug Alcohol Depend. 1999;55:63-68; 2 Stitzer ML et al. Drug Alcohol Depend. 1981;8:189–199; 3 San L et al. Addiction. 1993;88: ; 4 Ross J, Darke S. Addiction. 2000;95: ; 5 Maxwell JC et al. Drug Alcohol Depend. 2005;78:73-81; 6 Lintzeris N, Nielsen S. Am J Addictions. 2010;19:59-72; 7 Williamson PA et al. Med J Australia. 1997;166: ; 8 Zador D, Sunjic S. Addiction. 2000;95:77-84.

154 Methadone: Contraindications MAOIs: MTD within 14 days of MAOI increase the risk of serotonin syndrome 1,2 Phenothiazines: additive effects include ileus, cardiac arrhythmias (QT prolongation), CNS depression, psychomotor impairment 1,3 Venlafaxine: cardiac arrythmias (QT prolongation), serotonin syndrome, NMS 4 Ziprasidone: additive effects 5 1 Roxane Laboratories, 2009; 2 Gillman PK. Br J Anaesth. 2005;95: ; 3 Baxter Healthcare Corporation. Phenergan (prescribing information. 2009; 4 Wyeth Pharmaceuticals Inc. (venlafaxine) prescribing information. 2009; 5 Pfizer Inc. (ziprasidone) prescribing information

155 Methadone: Drug Interactions CYP450 system: metabolized at 3A4, 2B6, 2C19, and (lesser) at 2C9, 2D6 1,2 1 Roxane Laboratories. Methadone hydrochloride prescribing information. 2009; 2 Mallinckrodt Inc. Methadose Oral Concentrate (methadone hydrochloride oral concentrate) prescribing information

156 Methadone: Drug Interactions CYP inhibitors Fluoxetine and norfluoxetine: CYP3A4, 2D6, 2C9. No clinically significant interaction in vivo 1,2 Fluvoxamine: CYP3A4 and 2C9. Watch for methadone toxicity due to increase methadone levels. When stopping fluvoxamine watch for methadone withdrawal 2,3 Quetiapine: increased methadone levels (CYP2D6) 4 Grapefruit juice: moderate inhibitor at CYP3A4 2 1 Bertschy G et al. Ther Drug Monit. 1996;18: ; 2 McCance-Katz EF et al. Am J Addict. 2009;19:4-16; 3 Perucca E et al. Clin Pharmacokinet. 1994;27: ; 4 Uehlinger C et al. J Clin Psychopharmacol. 2007;27:

157 Methadone Drug Interactions Methadone may inhibit metabolization at CYP2D6 Desipramine: levels may double or more 1,2 Risperidone: 2D6 substrate, may have potential for adverse drug interaction, but no clinically significant reports of such and no human pharmacokinetic studies 3 Phenothiazines: 2D6 substrate, consider potential for adverse drug interaction 4 1 Kosten et al. Am J Drug and Alcohol Abuse. 1990;16: ; 2 Maany et al. Am J Psychiatry. 1989; 146: ; 3 McCance-Katz et al Am J Addict. 2009;19:4-16; 4 Ereshefsky et al. Clin. Pharmacokinet. 1995; 29(Suppl 1):10-18.

158 Methadone Drug Interactions CYP inducers St. John’s Wort: CYP3A4 and 2C9 1-3 Carbamazepine, phenytoin, and barbiturates: CYP3A4. Lower methadone levels and lead to opiate withdrawal 4,5 1 Izzo AA. Int J Clin Pharmacol Ther. 2004;42: ; 2 Puzantian T. Drug Interactions of Methadone and Psychiatric Medications; information brochure presented to staff and faculty of UCSF at San Francisco General Hospital. 1997; 3 McCance-Katz EF et al. Am J Addictions. 2009;19:4-16; 4 Bell J et al. Clin Pharmacol Ther. 1988;43: ; 5 Perucca E. Br J Clin Pharmacol. 2006;61:

159 Reduced Methadone Levels Consider: Risk for relapse to illicit opioids Non-adherence to prescribed medications McCance-Katz EF, Mandell TW. Am J Addict. 2010;19:2-3.

160 SF Methadone Clinics Ward 93* BAART Market Street* BAART Turk Street* Westside* Bayview-Hunter’s Point* Fort Help VA Ft Miley *Referrals through COPE

161 COPE Eligibility: Title 9, CHN, not Medi- Cal Referral to COPE: phone COPE assessment: toxicology & pregnancy testing, counseling and medical visits per Title 9; DADP exception Goal: methadone intake ASAP Funding limits

162 Buprenorphine Semi-synthetic derivative of thebaine (an opium alkaloid) Partial μ agonist, antagonizes κ receptor High binding affinity and slow dissociation for μ receptor Sigmoidal dose-response curve: ceiling effect Half life: 37 hours Side effects: sedation, CNS depression, hypotension

163 Buprenorphine Prescribing FDA approved in 2002 for opiate replacement, schedule III Buprenex (FDA 1985), Suboxone*, Subutex Requires 8 hours special training and DEA “waiver” MDs only..no mid-levels Office-based setting OBIC Clinic

164 Buprenorphine: Safety Hepatic impairment 1 Monitor CYP3A4 2 Monitor with other CNS depressants BZD-BUP drug related deaths reported as high as 80%. Deaths associated with IDU BUP and concomitant BZDs and neuroleptics 3-5 Phenothiazines: enhance the hypotensive effect? 6 Alcohol: enhanced CNS depression 1 Zuin M et al. Dig Liver Dis. 2009;41:38-e10; 2 Reckitt Benckiser Pharmaceuticals Inc. Suboxone prescribing information. 2010; 3 Kintz P. Clin Biochem. 2002;35: ; 4 Lintzeris N, Nielsen S. Am J Addict. 2010;19:59-72; 5 Lai SH, Yao YJ, Lo DS. Forensic Sci Int. 2006;162(1-3):80-86; 6 Thioridazine. Harrison’s Practice. * Reckitt Benckiser Pharmaceuticals Inc. Suboxone film prescribing information

165 OBIC Referral to OBIC: phone Intake: orientation appointment Induction appointment Stabilization. All OBIC notes in LCR. Transfer back out to the community: integrated care

166 OBIC Services Induction and stabilization Counseling and education: individual and group Provider Education and Support “Safety net” re-stabilization PRN PRN health and mental health assessments and referrals. Ancillary services PRN: pharmacy, UDT, counseling

167 IBIS: Integration Flow “any door the right door” OBIC Primary Care Psycho- Social Services Specialty Care Mental health Care

168 Naltrexone 1984: FDA approval for opiate dependence Opiate antagonist No significant drug interactions (opioids) Black box warning: dose-related hepatocellular injury is possible: avoid in acute hepatitis or liver failure Patients should be opioid-free for a minimum of 7 to 10 days

169 Naltrexone Most appropriate for those highly motivated and frequently monitored Poorly accepted by patients Long duration of action (24-72 hours) permitting less than daily dosing (TIW) Oral form 50mg tablet (25mg on day 1) I.M. 380mg Q 4 weeks Fram et al J Sub Abuse Treatment 1989; 6:

170 Alcohol and Opioids Oh My! James J. Gasper, Pharm.D., BCPP San Francisco Department of Public Health Community Behavioral Health Services 170

171 Alcohol: Scope of the Problem Alcohol abuse is common in chronic pain patients About 40% (5 % current, 35 % past) Preceded pain by average of 15 yrs Alcohol use is dangerous in combination with opioids Present in about 50% of heroin deaths and 30% of methadone deaths Deaths occur at lower opioid and alcohol blood concentrations Katon W, et al. Am J Psychiatry 1985;142: Hickman M, et al. Addiction 2008;103:

172 Approach Problematic Alcohol Use Address Opioid Address Alcohol psychosocial interventions pharmacotherapy Hold/taper Restrict supply Refer to methadone maintenance

173 Pharmacotherapy Detoxification: Medically assisted detoxification may be needed Maintenance: Naltrexone contraindicated with concurrent opioids Available options: disulfiram, acamprosate, topiramate

174 Evidence A few small studies of disulfiram use in methadone maintenance “Reinforced Disulfiram” Methadone dose contingent on taking disulfiram (N=25) 2% of days spent drinking vs. 21% Liebson IA, et al. An Int Med 1978;89:

175 Alcohol Treatment: Opioid Dependence Pathway Disulfiram CBHS Alcohol Dependence Guidelines 8/6/2009 Acamprosate or Disulfiram + Acamprosate Topiramate

176

177 Principles of Motivational Interviewing Matt Tierney, NP

178 Motivational Interviewing is: A collaborative and goal- oriented style of communication with particular attention to the language of change Rollnick S & Miller WR (2013). Motivational interviewing: helping people change. (3 nd Ed.) Guilford Press: New York

179 Spirit of MI Partnership Acceptance Absolute worth Accurate empathy Autonomy support Affirmation Compassion Evocation

180 MI: Four key processes Planning Evoking Elicit client's own motivations for change* Focusing Develop and maintain a specific direction Engaging Establish a helpful connection and working relationship Develop commitment to change AND formulate a concrete plan of action

181 MI is Not Based on the Transtheoretical Model of change A way of tricking people into doing what you want them to do A solution for all clinical dilemmas Decisional balance, equally exploring pros and cons of change A form of CBT Easy to learn Miller & Rollnick, 2008 & 2013

182 MI is about Exploring … the discrepancy between current behavior and a core value. A powerful motivator for change when explored in a safe and supportive atmosphere.

183 Common MI Traps 1)“Expert” trap 2)“Question-answer” trap 3)“I rectify gaps in knowledge.” 4)“Fear is a motivator” trap. 5)“I just need to tell them clearly what to do.”

184 Ethics and MI Three conditions that present ethical complexities in MI: 1.When client’s aspirations are dissonant with the interviewer’s or institution’s goals of what is in the client’s best interest 2.When the interviewer has an increasing personal investment in the direction the person takes 3.When the nature of the relationship includes coercive power of the interviewer to influence the direction the client takes Miller & Rollnick, 2008 & 2013

185 The Case 51 yo woman here to renew opioid prescription Pain began 3 years ago after a car accident 7/10, constant aching in the low back. No red flags. PMH: COPD, Depression SH: lives alone, on disability, smokes tobacco, recently cut down to 1/2ppd No h/o illicit drug use

186 The Case FH: Father died of cirrhosis, h/o breast cancer on mother’s side Meds: morphine SR 30 mg TID oxycodone IR 15 mg q6 PRN BTP bupropion 300 mg daily inhalers for COPD

187 The Case After attending a conference on pain management, you realize that you have not asked about alcohol use. 4 or more drinks in a day in last year? No. Drinks 1 beer a night, 7 days/week. Drinking not more than intended; no risk of bodily harm.

188 Motivational Interviewing Skills

189 How do you increase motivation?

190 Sharing information without generating resistance Ask-Tell-Ask Open ended question, listen to patient Respond with additional advice or information Ask how that advice or information lands for the patient

191 “ASKING”

192 “TELLING”

193 “ASKING”

194 Change talk Any speech in favor of changing a target behavior. The more a patient engages in change talk, the more likely he or she is to change.

195 Change Talk Desire: I want to… Ability: I can… Reasons: I should change because… Need: I really need to… I have to Commitment Talk: I’m going to… I intend to… I will… I plan to… Taking Steps: I started…

196 Find the change talk I want to stay clean and sober. But I can’t get a job because of this court thing, and so I have to live with my brother who drinks all the time.

197 Find the change talk I want to stay clean and sober. But I can’t get a job because of this court thing, and so I have to live with my brother who drinks all the time.”

198 Find the change talk I don’t want to die of lung cancer, but everyone has to die sometime.

199 Find the change talk I don’t want to die of lung cancer, but everyone has to die sometime.

200 Listen for the meaning in what someone is saying and repeat it back to them Reflections

201 Types of reflection Repeating Paraphrasing Reflect feeling Reflect values Double sided Amplified

202 Case Part 1 continued

203 Two major predictors of a patient’s likelihood to change are The amount of change talk that occurs in the visit The patient’s sense of self- efficacy

204 Affirmations

205 Reflective Listening Exercise Repeating Paraphrasing Reflect feeling Reflect values Double sided Amplified One thing I like about myself is… Speaker Reflector

206 Small Group Practice: Motivational Interviewing

207 Case Part II

208 Your Tasks 1.Affirm patient’s decision to engage in more intensive monitoring 2.Share your concerns about the potential harms of mixing alcohol and opioid analgesics in the setting of COPD 3.Learn the patient’s perspective 4.Provide information on reducing alcohol through self-management strategies

209 Your Tools Use reflective listening to find out what the patient thinks about her drinking Use Ask-Tell-Ask to give information on her risk of opioid analgesic overdose in the setting of alcohol and COPD strategies to reduce her alcohol consumption. When you find something to affirm in the patient’s behavior, express your affirmation of the patient’s strengths and ability to care for herself.

210 Small Group Practice: Difficult Conversations

211 Case Part 3 Difficult Conversations At this point, the case will become more complicated and the provider decides to discontinue opioids.

212 Your Tasks 1.Explain why observed behavior raises your concern for alcohol use disorder 2.Inform the patient that you cannot safely prescribe opioid analgesics; benefits no longer outweigh risks 3.Develop an opioid analgesic taper plan 4.Listen for signs that patient wants to change her behavior 5.Offer information and referral for alcohol treatment and/or depressed mood 6.Maintain your primary care relationship

213 Your Tools Maintain a non-confrontational stance: avoid arguments; resist the righting reflex Stay 100% in “Benefit/Risk” mindset Share decision making: include patient in treatment planning Respect her autonomy Use reflections and affirmations to reinforce patient’s strengths and any change talk Use Ask-tell-ask to provide information about alcohol treatment

214 Navigating the intersection between pain and addiction: SFHP’s role in supporting a system of safe, effective, patient-centered pain management Kelly Pfeifer, MD Chief Medical Officer 214

215 Beth’s story 38 years old, erratically employed Anxious and depressed – “counseling doesn’t help” Chronic LBP s/p MVA 8 Vicodin/day --> 180 mg daily of Morphine over 5 years Ativan for anxiety Some concerning behaviors: 1 urine positive for cocaine 1 drug test refused Didn’t follow through with PT or behavioral referral 215

216 Outcome Found dead of accidental overdose: Methadone Ativan Morphine Cocaine

217 What did the PCP do wrong? According to Chou and Portland clinics: Combined benzos and opiates Continued opiates after positive cocaine UDS Untreated depression and anxiety Methadone clinic client (not known) Poor indication (opiates not effective in chronic LBP) Over 120 mg a day 217

218 “We are not accountable for everything that leads up to drug deaths – poverty, addiction, childhood trauma, despair. But we are responsible. With our pens, we are writing the drugs into the hands of 8 th graders” Amit Shah, previous Medical Director, Multnomah County Public Health Clinics 218

219 Based on MMWR: 1:9:35:161:461 CDC/MMWR report Numbers of people in San Francisco Opiate deaths in SF in 2 years 261 Admitted for substance abuse treatment 2,349 Emergency Department Visits 9,135 Self-reported drug abuse or dependence 42,021 Self-reported nonmedical use of opiates 120,321

220 Myth # 1 More opiates means better pain relief 220

221 No change in pain score with large opiate increases J. Pain Vol 14 (4): 384

222 Myth # 2 We know when our patients are misusing meds 222

223 PCPs can’t accurately assess misuse 72% misuse in SFGH chronic pain cohort No concordance between PCPs’ opinions and participants’ self-reports of past- year misuse: Missed 38% of those who WERE misusing Misjudged 46% of those who WEREN’T misusing (often based on race) 223 Vijayaraghavan M, Penko J, Guzman D, Miaskowski C, Kushel MB. Primary Care Providers' Judgments of Opioid Analgesic Misuse in a Community-Based Cohort of HIV-Infected Indigent Adults. J Gen Intern Med. 2011;26(4):412–8.

224 Myth # 3 We know when our patients are diverting meds 224

225 The incentive to divert is overwhelming Typical yearly income for patient on SSI: $13,000 Typical street value: $1 per mg $370 mg a day or $135,000 per year Selling 10% of meds doubles income 225 This is the Oxy corner. Vicodin is next block. Can I get some Vicodin?

226 Partnership Health Plan Formulary implemented in Marin in 2009 Local cop: “Within months the level of Oxycontin on the street had dropped dramatically” 226

227 Mike’s story Occasional marijuana use as a junior, heavy use as a senior Tried Vicodin at State College… liked it 2 nd most common drug of abuse for 8 th graders Got too expensive; switched to heroin Now homeless 227

228 There is a lot of drug on the streets 585 mg of morphine equivalents prescribed per SF resident in 2010 Enough opiates for each San Franciscan to take the equivalent of 1 Vicodin every 6 hours for a month CURES data, courtesy of James Gaspar 228

229 Should we consider a dose ceiling in San Francisco? There is evidence that high doses of opiates: Do not improve pain; may make it worse J Pain, Vol 12(2): 288. Increase death rates (JAMA 2011:30(13): ; Annals of Internal Medicine, 2010:152: 85-92; Arch Intern Med. 2011:171(7): ) Increase depression, and increase pain perception (hyperalgesia) (General Hospital Psychiatry , )

230 There is evidence that lowering doses reduces mortality and pain scores Am J Ind Med Apr;55(4): J Opioid Manag 2: ,

231 “We are not at fault…. But we are responsible” 231 Medicaid patients have six times the death rate of the general population when given opiates

232 Current approach Practice Improvement Program measure For 2013: applies to only 6 clinics with 30 or more high-dose patients Requires all providers to agree to consistent best practices Requires population management: Updated pain management agreement in last 12 months Urine Drug Screen in last 12 months 232

233 Potential steps for SFHP : expand Practice Improvement Program measure All clinics Providers agree to consistent protocols Panel management of pain patients Opiate Oversight Committees Spread opportunity for technical assistance for clinics Registries Opiate Oversight Committees

234 Possible future directions for SFHP Should we implement lock-in programs? One pharmacy One prescriber Should we implement dose limits? PA requirements for high-dose patients? Waive PAs for clinics with good pain management infrastructure? 234

235 Are dose limits manageable? 487 SFHP members in DPH or SFCCC clinics on >120 mg morphine equivalents daily Only 6 clinics with over 30 on the list 21 prescribers have >6 patients on the list For these 21 prescribers: range 7 – 26 patients average 13 patients 235

236 Why would providers ask SFHP to take this role? SFHP could provide structure to liberate providers from policing and judging role 236 “Budget cuts – I’m good cop and bad cop.”

237 Mission of SF Safety Net Pain Management Workgroup: We aim to create a consistent system of patient-centered, effective and safe pain management across the safety net. I welcome your feedback. Thank you! 237


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