Assessment and Evidence-based Treatments for Opioid Use Disorder
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Moderator: Dr. Loretta Jackson-Brown
Presenters: Deborah Dowell, MD, PhD; Joseph O Merrill, MD, MPH; Mark Sullivan, MD, PhD
Date/Time: November 29, 2016, 2:00 – 3:00 pm ET
Coordinator: Welcome and thank you for standing-by. At this time all participants are in a listen only mode. During the question and answer session, please press star 1 and record your name as prompted.
Today’s conference is being recorded. If you have any objections, please disconnect at this time. I would now like to turn today’s meeting over to Dr. Loretta Jackson-Brown. Thank you. You may begin.
Dr. Loretta Jackson-Brown: Thank you (Carolyn). Good afternoon. I’m Dr. Loretta Jackson-Brown and I’m representing the Clinician Outreach and Communication Activity, COCA, with the Emergency Risk Communication Branch at the Centers for Disease Control and Prevention.
I’m delighted to welcome you to today’s COCA Call “Assessment and Evidence-based Treatments for Opioid Use Disorder.” You may participate in today’s presentation by audio only via webinar or you may download the slides if you are unable to access the webinar.
The PowerPoint slide set and the webinar link can be found on our COCA Webpage at emergency.cdc.gov/coca. Continuing education is offered for this COCA Call. Instructions on how to earn continuing education will be provided at the end of the call.
CDC, our planners, presenters and their spouses/partners wish to disclose they have no financial interest or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters with the exception of Dr. Mark Sullivan and Dr. Joseph Merrill.
They would like to disclose that their employer, the University of Washington received a contract payment from the Center of Disease Control and Prevention. Planners have reviewed content to ensure there is no bias. This presentation will include discussions of the unlabeled use of product or products under investigation or use.
At the end of the presentation, you will have the opportunity to ask the presenters questions. On the phone, dialing star 1 will put you in the queue for questions. You may submit questions through the webinar system at any time during the presentation by selecting the Q&A tab at the top of the webinar screen and typing in your questions.
Questions are limited to clinicians who would like information on prescribing opioids. For those with media questions, please contact CDC media relations at 404-639-3286 or send an email to email@example.com. If you are a patient, please refer your questions to your healthcare provider.
At the conclusion of the session, the participant will be able to describe Diagnostic and Statistical Manual of Mental Disorders 5th edition, DSM-5 assessment criteria for opioid use disorder, discuss the evidence for opioid use disorder medication assisted treatment with types of medications and settings used in medication assisted therapy.
Review considerations for buprenorphine, methadone and naltrexone used for opioid use disorder and outline the opioid, process used when opioid harms exceeds opioid benefits but opioid use disorder DSM-5 criteria are not met.
COCA is excited to partner with CDC’s National Center for Injury Prevention and Control to offer this call series on CDC’s Guidelines for Prescribing Opioids for Chronic Pain.
Save the dates for upcoming calls scheduled for December 6 and December 13. And plan to join the discussions starting at 2 p.m. Eastern time.
Today’s first presenter is Dr. Deborah Dowell. Dr. Dowell is Senior Medical Advisor for the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention. She previously led CDC prescription drug overdose team and served as advisor to New York City’s Health Commissioner. Dr. Dowell is lead author of the 2016 CDC’s Guidelines for Prescribing Opioids for Chronic Pain.
Our second presenter Dr. Joseph Merrill is an associate professor in the Department of Medicine at The University of Washington. He has extensive clinical, teaching, and research experience in addiction medicine and opioid use prescribed for non-cancer pain. Board certified in addiction medicine by the American Board of Addiction Medicine, Dr. Merrill developed both methadone maintenance and buprenorphine programs in primary care settings. He is a tele-medicine panel expert in chronic pain, hepatitis C and opioid addiction programs.
Today’s third presenter, Dr. Mark Sullivan is a professor of psychiatry and behavioral science at the University of Washington. He is an attending physician at the University of Washington Medical Center’s Center for Pain Relief. And he is provider for chronic pain management through the university’s tele-pain program. Dr. Sullivan helped to develop opioid guidelines for Washington State and has received research funding related to opioid therapy for chronic pain from several federal agencies.
As a reminder, the PowerPoint slide set and the webinar link can be found on our COCA Webpage at emergency.cdc.gov/coca. At this time please welcome Dr. Dowell.
Dr. Dowell: Thank you Dr. Jackson-Brown. Today’s webinar content on “Assessment of Opioid Use Disorder and Evidenced-based Treatment” is based on the CDC Guidelines for Prescribing Opioids for Chronic Pain. Released in March in the Morbidity and Mortality Weekly Report and in JAMA. Here are some key relevant findings from the evidence reviewed from the guidelines.
Prevalence of opioid dependence among primary care patients on opioid therapy for chronic pain ranged from 3% to 26% in fair quality studies. Opioid agonist treatment, which activates opioid receptors, has been demonstrated to prevent relapse.
This includes both the full opioid agonist Methadone and the partial opioid agonist buprenorphine. Buprenorphine attaches to and blocks opioid receptors from being activated by other opioids, while it partially activates opioid receptors. It can reduce cravings and pain and suppresses respiratory depression somewhat but to a lesser extent than a full opioid agonist.
Naltrexone, an opioid antagonist, blocks opioids from attaching to opioid receptors, and prevents their effects without activating opioid receptors itself. It can be effective although studies have found high dropout rates. Behavioral therapies combined with medication assisted treatment may reduce opioid misuse and increase retention.
Here is recommendation 12 from the CDC guidelines. Clinicians should offer or arrange evidence based treatment, usually medication assisted treatment with buprenorphine or methadone in combination with behavioral therapies for patients with opioid use disorder.
Opioid use disorder was previously classified as opioid abuse or opioid dependence in the DSM-4. In the DSM-5, it is defined as the problematic pattern of opioid use leading to clinically significant impairment or distress manifested by at least two defined criteria occurring within a year.
Here are the first nine of eleven criteria for opioid use disorder two of which must be present within a year for diagnosis. They include taking opioids in larger amounts or over a longer period than was intended. Persistent desire or unsuccessful efforts to cut down or control opioid use.
Spending a great deal of time in activities necessary to obtain, use, or recover from the effects of opioids. Cravings, or a strong desire or urge to use opioids. Failure to fulfill major role obligations at work, school, or home due to recurring opioid use. Continued opioid use despite persistent or recurrent ]social or interpersonal problems caused or exacerbated by opioids.
Giving up or reducing important social, occupational, or recreational activities because of opioid use. Recurrent opioid use in situations in which it’s physically hazardous and continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by opioids.
The last two of the eleven criteria for opioid use disorder, tolerance and withdrawal, are not considered to be met for patients taking opioids solely under appropriate medical supervision. If you suspect opioid use disorder, discuss your concerns with your patient and provide an opportunity for your patient to disclose their concerns.
Assess for opioid use disorder using DSM-5 criteria and importantly, do not dismiss patients from care. Identification of opioid use disorder is an opportunity to initiate lifesaving interventions. Collaborate with the patient regarding their safety. This increases the likelihood of successful treatment.
If opioid use disorder is present, offer or arrange medication assisted treatment, either buprenorphine through an office based buprenorphine treatment provider or opioid treatment program, methadone maintenance therapy through an opioid treatment program or naltrexone.
Offer pregnant women with opioid use disorder medication assisted therapy with buprenorphine without naltrexone or treatment with methadone which have been associated with improved maternal outcomes. If you’re unable to provide medication assisted treatment yourself, assist patients in finding qualified treatment providers.
Here are more details about the different medication assisted treatments. Buprenorphine can be prescribed for opioid use disorder by qualified clinicians with a data waiver. Sublingual tablets or sublingual or buccal soluble filmstrips are available with or without naltrexone.
Buprenorphine should be initiated when the patient is in mild to moderate opioid withdrawal. And most patients are stabilized on 8 to 16 milligrams per day. It’s important to note that the morphine milligram equivalent threshold in the CDC guidelines for prescribing opioids for chronic pain are intended for application when opioids are used for chronic pain and are not applicable to opioid agonist treatments of opioid use disorder.
Buprenorphine needs to be tapered gradually when it is discontinued. For example, reduce the dose by two milligrams every one to two weeks. Gradual tapers over months are more effective and better tolerated than rapid tapers. Probuphine, a new long-acting subdermal Buprenorphine implant, was approved by the FDA in 2016.
Probuphine treatment requires that patients are first clinically stabilized on sublingual or buprenorphine at 8 milligrams or less. It also requires a minor procedure for insertion or removal. Probuphine needs to be removed at six months. Treatment can be continued for another six months by inserting new implants into the other arm.
Some notes on methadone. When used for the treatment of opioid use disorder, it can only be dispensed by a SAMHSA certified opioid treatment program. Patients need to go to the program daily, early in Methadone treatment. After demonstrating progress and compliance, patients may be allowed to take Methadone at home between program visits.
A minimum of 12 months has been recommended for methadone treatment, but patients may require treatment for years. When a patient is ready to stop methadone treatment, it must be stopped gradually to prevent withdrawal. naltrexone can be prescribed by any clinician licensed to prescribe medication. It can only be used in non-pregnant adults.
Because it causes immediate withdrawal if opioids are in the patient’s system, naltrexone cannot be started if the patient recently took opioids or has withdrawal signs. It should be started three to ten days after last opioid use and after more than ten days if the patient recently used longer-acting opioids.
It requires adherence to daily oral tablet therapy or monthly long-acting IM injections. And therefore, it is best suited for highly motivated or closely supervised patients. Here are several resources to help arrange medication and assisted treatment. SAMHSA maintains a locator to find physicians prescribing buprenorphine and an opioid treatment directory.
SAMHSA’s provider clinical support system for opioid therapies offers extensive experience in the treatment of substance use disorders and specifically of opioid use disorder as well as expertise on interface of pain and opioid misuse. And SAMHSA’s provider clinical support system for medication assisted treatment offers expert physician mentors to answer questions about assessment for and treatment of substance abuse disorders.
In addition, SAMHSA offers free electronic resources for clinicians providing medication assisted treatment. MATX, a new mobile app from SAMHSA, supports medicated assisted treatment of opioid use disorder. It’s available on Google Play and in the app store.
If your community lacks sufficient capacity to treat opioid use disorder, try working with other clinicians to ensure sufficient treatment capacity at the practice level and consider training and obtaining a data waiver that allows you to prescribe buprenorphine to treat patients with opioid use disorder.
Physicians not already certified to provide buprenorphine in an office based setting can undergo eight hours of training to receive a waiver from SAMHSA that allows prescribing buprenorphine to treat patients with opioid use disorder. Information about qualifications and the process to obtain a waiver are available on the SAMHSA Website.
Sometimes you will encounter patients who have problematic opioid use but do not meet criteria for opioid use disorder. For these patients you can offer to taper and discontinue opioids. For patients who chose to but are unable to taper, we assess for opioid use disorder and offer opioid agonist therapy if opioid use disorder criteria are not met.
View our Website for more information on drug overdose and on the guidelines and you can follow @DebHouryCDC and @CDCInjury for important guideline updates. I’ll now turn the floor over to Drs. Joe Merrill and Mark Sullivan who will discuss how to apply these principles with examples you might see in practice.
Dr. Joe Merrill: Thank you. This is Joe Merrill. I appreciate the opportunity to be here. I’m going to talk about patients with opioid use disorder and we’re going to start with a case. Ron is a 50 year old man with a history of alcohol use disorder in remission and long-term high dose opioid treatment after a work accident years ago.
He quit drinking alcohol after falling off a ladder at work and sustaining multiple traumatic injuries resulting in high dose opioid therapy and that therapy was never tapered. So now he is taking morphine extended release, 90 milligrams three times a day and then also short acting morphine, 30 milligrams per dose up to four times per day.
So his total opioid dose in morphine equivalence is 390 milligrams per day. Since he transferred from another provider to you, you’ve noticed aberrant behaviors. First of all, his urine test was negative for prescribed morphine and positive for oxycodone. The patient, when confronted with this information, admitted to borrowing oxycodone from a friend after running out of his usual medication because he’d taken more during a pain flair.
He does admit to having some difficulty controlling the medication use when his pain flairs resulting in some withdrawal symptoms when medication runs out. You check the prescription monitoring program and there were two additional prescribing physicians, small amounts of opioids. The patient denies obtaining these medications.
So looking at the criteria for opioid use disorder, there’s some that are pretty clear and then there’s some that are not so clear and some clearly he doesn’t meet. So he takes more than intended. Sometimes, yes. Does he want to cut down? No, he feels like his medication is necessary for his pain. Does he spend extra time with obtaining opioids? Maybe, but probably not.
When you ask about craving, he really reports it’s the pain, not any kind of addiction craving. He feels he can distinguish those two. Does he have problems related to role? Maybe but again like social problems, activities given up, the patient describes them mostly as chronic pain and less as opioids specifically.
He’s not using opioids in physically hazardous situations. He does not report that he’s using in spite of problems that he recognizes in terms of medical or psychological problems. He clearly has tolerance. Clearly has withdrawal. So how do you interpret this? Well, if you look at the details of DSM-5, tolerance and withdrawal would not generally count towards a diagnosis of an opioid use disorder, if the medication is taken as prescribed.
However, in this case, the patient is not taking them as prescribed. Sometimes he’s taking other people’s medicine. Sometimes he’s taking his, not prescribed a higher dose. So the tolerance and withdrawal criteria here would count and he clearly has then to tolerance and withdrawal plus taking more than intended. So clearly three criteria and maybe more.
So a diagnosis of an opioid use disorder in this case would be possible. So when you’re talking to the patient about this, this is a patient setting-up as someone who’s not looking at his own case as a case of an opioid use disorder or especially not as an addicted patient. So how do you present the diagnosis?
It’s just some ideas about wording you might use. If you do meet the criteria, I use the term “opioid use disorder” because a lot of times the people, when they’re confronted with the addiction diagnosis, really recoil from that. So trying to explain to them what that is can be helpful.
When you have trouble controlling the medication that makes the medication unsafe. And overall the medication may have become a problem in itself. So those are different ways to present the diagnosis. Discussing treatment options can also be cumbersome with patients like this. But you need to start to talk about them.
Continuing the treatment does not appear to be safe, but you do need opioid medication for the use disorder and taking to them about what the options would be for that. If you use opioid use disorder medications that can really stabilize the brain but medications really help turn your attention towards the treatment of chronic pain and less towards the use of opioids themselves.
And other kinds of pain treatments will work a lot better if the brain is more stable on opioid agonist treatment or partial agonist treatment than it is on more chaotic use of opioids that are prescribed.
Helping patients accept the diagnosis is always a challenge. Many patients will talk about make stigmatizing statements about patients with opioid use disorder, so making it clear from your perspective that opioid use disorder is a medical condition like others.
I’ve said things like all kinds of people have opioid use disorder. I’ve treated many patients with opioid use disorder that are like you. I don’t see it as a bad person doing a bad thing. Many people will see addiction as some kind of personal failing and trying to reflect back that that’s not your attitude towards it.
Sometimes the medications cause problems. It could be due to genetic factors or factors that you had no control over and that we cannot anticipate. When your prescription was given, those years ago we didn’t understand the problems that they can cause.
And getting help for this kind of problem should really be like getting help for any other chronic medical problem and trying to destigmatize the treatment so that patients can more easily access it. So discussing opioid use disorder treatment options for buprenorphine/naloxone, usually this is recommended as the first medication option, if possible.
There are fewer barriers to treatment as patients can obtain the medication in a medical setting. They don’t necessarily have to go to a specialized addiction treatment program where they might not feel that they fit in. buprenorphine or naloxone can be available in specialized addiction treatment programs but also available in office based settings.
It’s clearly far safer than what the patient is on now. High dose opioids for pain that are prescribed monthly or even every couple of weeks are much less safe than buprenorphine or naloxone because buprenorphine will block other opioids and only activate the opioid receptor partially.
It doesn’t really matter how high the prescribed opioid dose. As long as the medications are short acting medications, then that would include long acting versions of oxycodone or morphine. Those are short acting medicines in an extended release format and those medications, it’s easy to transition to buprenorphine or naloxone.
Ideally it would be the same physician who is prescribing, who’s been treating the chronic pain who would prescribe the buprenorphine/naloxone for that patient with an opioid use disorder. So I really encourage people to get trained. It becomes a great tool in your arsenal for treating chronic pain in patients who end up having an opioid use disorder.
Insurance coverage for buprenorphine/naloxone is primarily for the opioid use disorder, not for chronic pain. So if you write the prescription and say that the indication is for pain, that’s legal. It can be done but many insurance companies won’t accept that and won’t pay for the medication.
The Butrans Patch, which is a buprenorphine patch, that’s approved for the treatment of chronic pain but not opioid use disorder, incorporates much lower doses of buprenorphine than the buprenorphine that’s given under the tongue or as a strip or implantable version. That’s a much lower does on the butrans patch so would not be indicated for an opioid use disorder.
Other options for opioid use disorder treatment include Methadone maintenance. It is really the most effective treatment. And it is more effective than buprenorphine/naloxone in one way and that is it retains a higher proportion of patients in treatment.
And we know that retaining patients in treatment for opioid use disorder is really the key to success. The longer people are in treatment the better that they do. So methadone does have some advantages. However it does also present a higher barrier for treatment. Patients do have to go to a specialized program where methadone maintenance treatment is provided.
They’re called opioid treatment programs and many patients feel that they don’t fit in that if they’re coming from the position of taking opioids for chronic pain. Patients who are going into methadone maintenance treatment, they need to call the program. They need to seek addiction treatment, not pain management.
If they say that they want methadone treatment for pain management, methadone maintenance programs will turn them away and say, no, we don’t treat chronic pain. We treat addiction. And patients who have both problems, addiction and pain, can get treatment with methadone maintenance and it actually vastly simplifies pain management, the chronic pain management, if they do get that.
Methadone maintenance is really set-up so that patients who are, even in unstable psychosocial situations can get safe treatments. Patients do have to go every day at the beginning of treatment so it provides really a lot of structure for patients who have a lot more severe psychosocial challenges.
Patients should know that even though they’re going six days a week at the beginning of treatment that if they do well and stop using other drugs have urine test that are, have methadone and nothing else and make all their appointments, they do get take home doses and can over time go up to getting the medication once a week or even once a month.
What about patients who are prescribed methadone for chronic pain? These are a special case. methadone has been used for the treatment of chronic pain historically although we do think that it’s probably the least safe of the long term opioid prescribing medications. But if methadone is what is used for chronic pain, it does have long acting metabolites that make it difficult to transition a patient to buprenorphine treatment.
The risk is a precipitated withdrawal when starting the buprenorphine. Patients, even if they’re in withdrawal from methadone may experience worsening withdrawal from initiation of buprenorphine. So it can be very difficult to make that transition. And it’s recommended that patients reduce their methadone dose to 30 to 40 milligrams daily to decrease the risk of precipitated withdrawal.
But that decrease can be very difficult to tolerate if they’ve been on higher doses. They may get withdrawal. They may start using other elicit opioids because of that withdrawal. So patients who are on higher doses of prescribed methadone will really likely need to transfer to methadone maintenance rather than buprenorphine treatment.
And you can try and help patients get into that treatment and continue the prescription of methadone while they’re seeking to transfer their care to a methadone maintenance program but sometimes you do have to really require it to coerce the patient saying ‘I’m going to either taper you or you need to transfer to this treatment’ and not make it an option.
While that can create some conflict with a patient in a patient with opioid use disorder methadone, continuing methadone as prescribed is really risky. So the conclusions, opioid use disorder diagnoses can be a little bit difficult in the setting of patients with long term opioid prescribing but the use of DSM criteria and good communication skills can really help make that diagnosis.
Pharmacotherapy is really the most important aspect of effective treatment of opioid use disorder. So getting people either buprenorphine or naloxone or methadone maintenance treatment is important. Obtaining a waiver to prescribe buprenorphine really can be an effective management tool for your patients who have chronic pain when there’s co-occurring opioid use disorder.
And facilitating opioid use disorder treatment really does require some effective communication strategies for patients. So I will stop there and turn this over to Mark Sullivan.
Dr. Mark Sullivan: Thank you Joe. I’m going to be talking about a bit of a different situation where the patient does not meet the criteria for opioid use disorder but does have problematic opioid use that needs addressing. So I will also begin with a case. This is (Suzanne) is a 46 year old woman with chronic neck pain following a whiplash injury when she was rear-ended in a motor vehicle crash five years earlier.
She’s been on opioids for these last five years prescribed by a colleague of yours that has recently retired, so she’s now a patent you’re inheriting. Her opioid does has gradually escalated over the years due to requests by her that she negotiated with the previous prescriber. Pain flair-ups, minor motor vehicle accidents that worsened her neck pain so that she’s now currently taking extended release Oxycodone, at 40 milligrams twice daily plus she’s getting immediate release Oxycodone, 5 milligrams for breakthrough pain up to five pills per day.
This means her total opioid dose per day is 157.5 milligrams of Morphine equivalent. So when you look at Suzanne and her situation concerning her opioid use, there is a fair bit of good news. She has no history of illicit drug use and her urinary tox screen have not shown any illicit drugs. She has not sought out multiple opioid prescribers nor has she been going to the emergency department for extra doses.
This is confirmed by you through consulting your state’s prescription drug monitoring program. She has had some early opioid refill requests years ago but your colleague told her that this wasn’t allowed and she has not made further early refill requests. However, as you look more thoroughly into her situation, there is some bad news about problematic opioid use and its consequences.
First of all, she reports that despite her ongoing opioid therapy, her pain intensity is high. It’s eight out of a possible ten. The pain interferes with her general activities at a rate of seven out of ten and her pain interference with her enjoyment of life is nine out of ten. These three measurements are what we call the PEG scale.
There’s good evidence from Erin Krebs and colleagues that this PEG scale captures most of the information of the much longer brief pain inventory and we feel it’s a minimal but much superior measure of pain treatment success than just simply following pain intensity.
So she’s reporting high levels of pain and pain interference and is asking for an increase in her Oxycodone. And I think what you need to notice here and take seriously is that her opioid therapy is not working. This is not a person who’s just starting on opioids. She’s been on them for years. And yet she’s really not doing well.
She’s at a significant dose. Over the recommended dose that is in the CDC guideline and yet she’s not doing well and wants more. And I think the important teaching point here is that a dose increase is not the appropriate thing to do. It’s to start talking about the fact that her opioid therapy is really not working for her.
Secondly, she is 5’4”, 245 pounds so she is at high risk for sleep apnea and in fact when you ask her, her husband says she does snore. So this puts her in a pretty high risk group for sleep apnea which is a dangerous co-morbidity and consequence of opioid therapy that increase her risk of dying in her sleep. This is quite concerning.
She is also a cigarette smoker. She has no illicit drug use but she does have a nicotine use disorder. She smoked about a pack a day for 25 years and this clearly puts her at risk for chronic pain, bad chronic pain outcomes and specifically bad opioid outcomes.
So it’s tipping the balance towards risks rather than benefits. And finally, she takes Alprazolam or Xanax a milligram PRN for panic attacks. She doesn’t take it every day. Some days she takes a number of milligrams. Some days she doesn’t take any. And she has been doing this for a while.
Now unfortunately, this combination of opioids plus Benzodiazepines really suppresses respiration by two separate mechanisms that are very hard to predict and control so that they increase the risk of an overdose, the fact of a fatal overdose by possibly a factor of ten.
This combination of opioids plus Benzos is a really dangerous combination that we should not be using. So all of these are reasons why going further with her opioid therapy in terms of refills and especially dose increases are not advised. So to summarize, you know, the picture for Suzanne, after five years of opioid therapy, she is not doing well. Her pain scores are high and she’s seeking more opioids. I think there’s a temptation to meet her request and prescribe more opioids, but I think that now the consensus about good care with opioid therapy would be to not do that.
She’s at high risk for serious adverse events due to likely sleep apnea, tobacco use and Benzodiazepine use. And these risks will decrease with opioid risk reduction but would increase with an opioid dose increase. Importantly, her pain level may not increase with opioid dose reduction and may in fact decrease.
It is not inevitable that pain scores will increase significantly. They may even get improved, they may improve with opioid dose reduction depending on what else is done for the patient. So it can be difficult, same as Dr. Merrill talked about difficulty in introducing the diagnosis of opioid use disorder.
It can be challenging to introduce the idea of opioid taper to a patient who is seeking the opioid dose increase. One important thing to start with is that you can see her opioid therapy is not working and that she’s at high risk for bad events. These risks will not get better with further dose increases but may get better with dose decreases.
This is a frightening idea to a lot of patients. And so it’s very important to introduce the idea gradually. It’s usually better to introduce the idea that opioid taper is coming before you actually start it. So you give people a visit to get used to the idea.
Combined with the idea of opioid taper, particularly if you’re the patient’s primary care provider, it’s really important to pledge that you will not abandon the patient and that you will make sure through whatever means that they have adequate pain relief. And you can almost always do this without opioid increases.
But patients are really afraid of overwhelming pain and they need to be reassured that this will not happen. That said, it’s really best to get the patient to agree even just on an experimental basis to try the taper. And voluntary tapers are difficult for both patient and provider and have definitely lower rates of success. But you can tell the patient that there is no need to rush the taper.
I frequently say, as long as the dose is going down, I’m not really concerned about how quickly it’s going down. In a recent taper trial that we conducted, we allowed the patients to pause the taper at any point meaning they can say, ‘I need to get used to this dose. I don’t want to go down any further at this point in time.’
But we do make sure that the door is kind of one way meaning that as we initiate the taper we can slow it down but you can’t reverse it. We don’t allow opioid doses to be increased. We allow patients as much choice about the taper process as much as possible. Notably if they’re on both long and short acting opioids, they get to pick.
It’s interesting but almost all of our patients have chosen to taper their long acting opioids first because that gets them to take their short acting opioids when they feel like they need them the most. If somebody like Suzanne is on Benzodiazepines as well, we also include that in the choice list because it’s important that the Benzodiazepines go down and if she wants to do that first, that’s, we can go with that.
If I have to choose which is first, I often go for what people have been on the least amount of time or at the lowest dose. I go for the easiest thing first. If they’ve been on their Alprazolam or ten years and their opioids for two then let’s go for opioids. Or if the doses are much higher for one I’ll go for the other one because you’ve really reduced risk once you’ve gotten away from that combination of Benzos and opioids.
Everybody asks about what the right rate of taper is and I think that’s not the most important thing. You could start with 10% per month. Initially we start with 10% per week. Most people find that’s too quick but I think the important point is the rate of taper is not that important as long as you’re moving in that direction, you can negotiate the rate of taper.
So one way to set-up opioid taper as a success is to get information about the patient’s own ambivalence about opioid therapy. Just like people who smoke cigarettes, people on opioid therapy are almost always ambivalent about being on opioid therapy. It’s got some good parts for them maybe but it’s also got bad parts.
People complain about being a zombie or being emotionally responsive or being constipated or groggy or being uninterested in things or unable to concentrate. We validated a scale, Dr. Merrill and I, called the PODS, the prescription opioid difficulty scale. You can find it in the literature. It’s free to use.
And that’s one thing that we’ve used in our clinics to illicit people’s own problems about opioids and then that provides a basis for discussion of opioid taper about why they might feel better after an opioid taper. In our opioid taper trial, we found it very important to monitor depression, anxiety, insomnia before and during taper.
If these are controlled, then pain did not usually increase. Sometimes you may need to address these other problems by starting or adjusting antidepressants. Once again, I would not go to start benzos. I would not increase benzodiazepine doses but antidepressants are safe to use with opioids and opioid and opioid taper.
There are a wide variety of pain self-management resources. If there’s people who specialize in that in the community, you can refer to pain psychology or other people who do these kind of things. There’s good books out there. We use the pain survival guide by Dennis Turk. There’s other good books. There’s also some validated Website pain self-management programs that can be used to assist opioid taper.
It is something that you need to be involved with as the prescriber and the primary care provider to help usher your patient through to the other side. So in conclusion, opioid taper is appropriate for patients without opioid use disorder who’s opioid therapy has low efficacy and high risks.
These people who are candidates for opioid taper are often ambivalent about their opioid therapy. They really think there are bad parts to it as well as good parts and have their own reasons for tapering that can be elicited and supported. However, patients are fearful, sometimes very fearful of opioid taper and they need to be reassured that you will not abandon them to their pain.
In our experience, attention to depression, anxiety, insomnia is crucial for successful opioid taper. So that is the end of my comments now and I think we can open the floor up for questions.
Dr. Jackson-Brown Thank you presenters for providing our COCA audience with such a wealth of information. We will now open up the lines for our question and answer session. Questions are limited to clinicians who would like information on prescribing opioids. For those who have media questions, please contact the CDC media relations at 404-639-3286 or send an email to firstname.lastname@example.org.
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Coordinator: Thank you. We will not begin the questions and answer session. If you would like to ask a question from the phones, please press star 1. Make sure your phone is unmuted and record your name to introduce your question. And to withdraw that request, you may press star two.
Once again, for questions for comments from the phones, please press star 1. One moment please. And we do have a question or comment coming from (Warner Hudson). Your line is open.
Warner Hudson: Thank you. That was excellent. I’m a physician occupational medicine, Medical Director, occupational medicine and employee health at UCLA. And my question has to do with what functional restrictions are indicated for individuals on buprenorphine for driving, for crane operating, say, for a surgeon operating?
And I’m not talking about those in the CDL/FAA regulatory realm. I’m talking about the rest of the population of people who are being placed on buprenorphine. Thank you.
Dr. Joe Merrill: This is Joe Merrill. I can at least start to answer that question. So a lot of work has been done actually in the methadone maintenance population looking around exactly those questions around driving and operation of heavy machinery. And for patients who are on methadone treatment and opioid use disorder, as long as their dose has been stabilized, those patients are not, don’t have decreased ability to drive or to operate machinery.
Those are studies that were done a long time ago. They haven’t been repeated with buprenorphine, but there’s not really any reason to think that a patient who’s on a stable dose of buprenorphine would have difficulty with driving or operating heavy machinery.
Most patients don’t actually get an opioid effect from buprenorphine when being treated by for an opioid use disorder. They just feel that they’re not having withdrawal. So I don’t think it’s a major concern.
Warner Hudson: Thank you.
Coordinator: Thank you. And again, as a reminder, for questions or comments from the phone, it is star 1. Make sure your phone is unmuted to record your name. And to withdraw that request, you may press star two. Once again, that’s star 1 and record your name. Our next question or comment comes from (Aime Chai). Your line is open.
Aime Chai: Hi. I’m (Aime Chai). And I’m going to be working with the Clean Slate Program which is an opioid medical treatment program. And I’m wondering about the patients who have chronic pain and you said to make sure you tell them that you’re not going to abandon them to their pain.
And that the taper didn’t typically cause increase pain levels unless there was uncontrolled depression, anxiety, or insomnia. But my question was, when you’re following this and so many of these patients do have all three of these problems, what is your preferred method of treating depression, anxiety, insomnia and controlling any pain that does crop up as you do this type of a taper?
Dr. Joe Merrill So I would have to say that the most common medication that I’ve used is the Tricyclic Nortriptyline because it does provide depression, anxiety, insomnia and pain benefits. It of course has some side effects and is limited in its use by some medical comorbidities but it is a multi-function medicine that was quite helpful in our taper trial.
There are patients with more complicated comorbidities, particularly post-traumatic stress disorder that could need a more involved Psychopharmacology approach. But I would say that the first choice and often an adequate solution was kind of adding relatively low dose Nortriptyline, 25, 50 milligrams is often quite helpful at the outset of taper and to stay-off increasing problems during the taper.
Coordinator: Does that conclude the question or comment?
Aime Chai: Yes, thank you.
Coordinator: Thank you. And again as a reminder, it is star 1 and record your name for a question or a comment and to withdraw that request, you may press star two. Our next question or comment comes from Dr. Fred Goldstein. Your line is open.
Dr. Fred Goldstein: Hi. Thank you for the presentation. I know this is sort of going against the tide today but have you folks found any case where somebody may be on Methadone maintenance almost as a lifetime option?
I know it’s kind of risky to even think about these days Methadone maintenance has been around for I’m sure everybody knows, over 30 years. So I’m just wondering what your opinion is about it?
Dr. Joe Merrill: This is Joe Merrill. So methadone maintenance treatment as you said has been around for decades, since the 60s. And there are patients who’ve been on methadone maintenance treatment for an opioid use disorder for decades. It’s actually quite well tolerated and patients can go about their life without experiencing opioid withdrawal or intoxication.
I don’t think it’s going against the tide in the sense that we know that for both buprenorphine and methadone maintenance treatment that the longer people are on it, the better they do. So mostly as physicians, we need to be encouraging our patients to stay in treatment more than they want.
A lot of time patients because they have to go so often will want to leave treatment before they’re ready. So always assessing what the complications of their addiction have been in the past and making sure that those are really stable, that they have good place to live and their work is okay. Their mental health is okay before even trying a taper is usually what we recommend. And then to do that taper very slowly, if at all.
So it’s definitely fine for people to stay in treatment for long term. If they do well in that treatment they can get more take home doses and not have to have such intensive treatment. And those patients can do well for decades.
Dr. Fred Goldstein: Okay great. Thank you.
Dr. Mark Sullivan: Can I add a piece about that. This is Mark Sullivan. I think was has been influx and is controversial now is long term methadone treatment of chronic pain. We did this a lot in the 80s and 90s. I certainly trained a lot of trainees about how to use pain cocktails in long term methadone treatment.
It’s now clear when methadone is used for pain in that way, it does have some added, maybe a lot of added mortality risk, so that’s a problem although there were also patients, particularly the ones that were consistent and reliable in their dosing and were dosed at low doses who seemed to do well.
There are some hypothetical reasons why methadone might work better over long term for chronic pain having to do with NMDA antagonism. So I would say that expert consensus on that issue is evolving, and it’s somewhat unsettled as opposed to Joe’s talking about Methadone and long term use for opioid use disorder where I think the consensus is strong that it’s working and is it advised.
Dr. Fred Goldstein: Thank you.
Dr. Jackson-Brown: All right Coordinator, Let’s go to the Webinar for questions. So presenters, we have a participant who says, can you please explain why tobacco use increases the risk of bad outcomes. And I think Dr. Sullivan that was in your case study?
Dr. Mark Sullivan: We don’t know. The short answer is, we don’t know why pain and opioid outcomes are worse in smokers. The thought is that both opioid and nicotine effects are ultimately mediated by the dopamine system.
And that there is something about the dopamine system in smokers that is different and inclines to higher and more risky opioid use and behaviors. But I don’t think that there’s a consensus about why. But I would say it’s a well replicated and validated finding that it does happen.
Dr. Jackson-Brown: Thank you. Coordinator, do we have any more questions on the phone?
Coordinator: Yes we do. We have a couple more questions. Again, as a reminder it’s star 1 for a question or a comment. Our next question or comment comes from (Doug Ballen). Your line is open.
Doug Ballen: Hi, yes. I did notice that your recommendation at least in the first case was this is a fellow who was on escalating doses and you let him know that this is something you’re going to help with. About what percentage of people do you find saying ‘thanks but no thanks – I don’t want that help?’
And another concept, I’m sorry if I’m hogging it I’m asking two questions, would be the, what methods do you use to find out where the pain is coming from most commonly and how to make it better?
Man: So I can try the first one. For a patient, are you saying that they make, that you present the option of a taper or are you in the taper case or the opioid use disorder case that you’re referring to?
Doug Ballen: I’m sorry. Could you ask that question again? I missed it.
Man: I’m wondering, were you talking about the first case where the patient has an opioid use disorder and they say, no thanks. I don’t want treatment for that? Is that …
Doug Ballen: Right. And then there’s the second patient who’s got chronic neck pain, you know, spine pain that’s been bothering her for a long time. And, you know, how often, you know, what methods to you use to say wait a minute, why aren’t we treating where this pain is coming from?
Man: I see. So the, so I think, for patients who either resist taper or have an opioid risk disorder diagnosis that you feel requires treatment itself, the goal is really to try to get the patient to be on your side about what’s going to happen. And that’s really, you know, making sure the patient feels understood and well heard.
But at some point you need to be able to present also the risk side of things and hopefully getting it from the patient what their concerns about the therapy are as the driving force to change the treatment. But at some pint there does need to be some change because in both those cases you’re facing really high risks.
So that’s the general approach to, you’re trying to nudge people. Get their support for moving to a different treatment plan. But ultimately it’s your prescription and you need to, need to be pushing that through when safety is at risk. I think I’m going to turn it over to Mark for the question about the specific origin of the pain.
Dr. Mark Sullivan: I’m going to have to defer on that question. I mean it’s a huge question and important one for sure. But it’s difficult in this venue in a quick way to talk about when do you say we’ve worked up the neck pain or the back pain enough? I’ll have to defer to a different session for that.
Doug Ballen: And I don’t blame you. I’ve been doing this for a long time also and, you know, back where it was an anathema to treat somebody with chronic opioids for pain that you hadn’t diagnosed the origin and done everything you could to fix it. It wasn’t until later that you realized that that was good advice.
Dr. Jackson-Brown: Thank you. So from our Webinar system’s presenter we have a participant who says, how does hyperalgesia complicate tapering to patients from opioids? For example, can you determine if a patient has high pain or just high pain perception as a result of long term use of opioids?
Dr. Mark Sullivan: So this is Mark Sullivan. I’ll start with that. Opioid induced hyperalgesia is a real phenomenon. It has been well studied in animal models. It’s also been studied in humans in methadone maintenance programs and in cancer patients on very high dose opioids.
It is thought to be a separate process from opioid tolerance. It’s not just more rapid Catabolism of the opioids. It’s an opponent process thought by some to be an MDA mediated process. There’s no official diagnostic criteria for opioid Hyperalgesia but what we teach is that it tends to be a very generalized pain.
It’s often associated with Allodynia meaning non-noxious stimuli. Light touch becomes painful. That’s the clearest example of opioid induced hyperalgesia. There’s questions about whether more focal or less allergenic pain qualify as opioid induced Hyperalgesia.
The recommendation with a lot of hyper sensitivity syndromes is to taper the opioids because you’re not going to make the hyperalgesia better through dose increases although you may mask it temporarily. And I would say that in our experience hyperalgesia reverses or responds on a variable time course.
I’m afraid I can’t be real specific about when it disappears but it is not immediate and may take weeks to months if, and I think for some people it may not reverse. I’ll let Dr. – Dr. Merrill says he really doesn’t have anything to add. Okay.
I think it’s an evolving question. I think even the prevalence figures about how, what percent of patients who are getting long term opioid therapy for chronic pain have hyperalgesia is unclear. I know that some fibromyalgia experts think even though fibromyalgia looks like opioid induced Hyperalgesia and some people think that’s what it is, you know that’s thought to be a particularly high risk group for that syndrome getting worse with opioid treatments so.
Dr. Jackson-Brown: Thank you so much Dr. Sullivan. Operator we have time for one more question.
Coordinator: All right. Thank you. Our last question comes from (Ronald Bergman). Your line is open. You may ask your question.
Ronald Bergman: Yeah, hi Mark and Joe. Nice to talk to you again. Can you hear me okay?
Dr. Mark Sullivan: Yeah.
Ronald Bergman: Okay. I’m starting to see a change in the suboxone or the buprenorphine. I have three questions. I’m inheriting patients that are on fairly high doses, have been on for a long time, let’s say, two, three, five years.
So my first question is on buprenorphine for opioid problems, how long should we be treating them with this suboxone. Question number two is, should we be tapering them down to a lower dose?
I have some that are on four sublingual tablets a day. And the last question and it concerns me a lot is that I’m beginning to pick up diversion in the patient population that I’m treating with suboxone. Those are my three questions. Thanks.
Dr. Joe Merrill: This is Joe Merrill. So, hi Ron. Nice to hear your voice. So patients who are on high doses like you’re talking about, like 32 milligrams of buprenorphine, generally people don’t need that much. But sometimes early in treatment, people will be prescribed escalating doses as they either don’t stop using opioids or report cravings.
A lot of time when those patients have actually stabilized on the Suboxone and they’ve stopped using opioids and the rest of their life has gotten more stable, they are able to tolerate a taper especially from the high doses down to moderate doses.
And that is totally a reasonable thing to do especially in a setting where you’re concerned about diversion. You could report that, you can tell the patient that you’re, you think their brain is fairly stabilized compared to when they were put on that high dose and start to go down, usually go down four milligrams at a time and just see how they do.
Most patients won’t have any trouble coming down to a dose of 16 milligrams or even less. Sometimes patients who’ve been stabilized can go down to 8 or 4 milligrams without withdrawal but at some point they will have some withdrawal.
So you do need to stabilize the dose at a dose where they’re not having withdrawal or craving. And then how long to treat people with buprenorphine? Same advice as for methadone. Get the rest of their life stabilized.
Problems that were caused by their addiction take time to resolve and make sure that they have essentially resolved because a taper of buprenorphine like a taper of methadone at some point will become stressful.
They can expect to have some craving. And they need to have the psychosocial support and the stability to withstand that when they get off the medication. But there’s really not a compelling reason to get someone off Buprenorphine if they’re doing well, if the dose is stable, they’re not using other drugs and their life is improving.
Ronald Bergman: Yeah, Joe that kind of confirms a little bit what I’m finding is basically we’re started on suboxone. Maybe 18 to 20, 22. They’re now 25, married, have children, have a job. And I’m inclined to at least maybe taper some of it to keep them on the suboxone. So I think a time factor is important and is positive in this case. And thanks for that. Yes.
Dr. Jackson-Brown: So on behalf of COCA I would like to thank everyone for joining us today with a special thank you to our presenters, Drs. Dowell, Merrill, and Sullivan. The recording of this call and the transcript will be posted to the COCA Webpage at emergency.cdc.gov/coca within the next few days.
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Coordinator: Thank you for your participation. That does conclude today’s conference. You may disconnect at this time.
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