Substance Use in Palliative Care

Question 1

Objectives

• I______ patients with prior or current substance abuse and opioid misuse
• Propose a framework to add____ ongoing substance and opioid misuse
• Apply the framework to an outpatient _____ care population

Answer 1

• Identify patients with prior or current substance abuse and opioid misuse
• Propose a framework to address ongoing substance and opioid misuse
• Apply the framework to an outpatient palliative care population

Question 2

Patient A

Background

48 yo man with stage IV lung cancer with brain metastases. • 6 palliative medicine clinic visits, 5 physicians • Long standing history of heroin and cocaine abuse • Home regimen: MS Contin 30MG TID, Ativan 1mg prn

Admitted to hospital • Withdrawal symptoms • Urine drug screen • + opiates + cocaine • - benzodiazepines • Often doubles his MS Contin dose at home • Uses $60/ day’s worth of heroin

“If a patient is using heroin for recreational purposes would you still up titrate the MS Contin? And at what point would you stop with the up titration if the patient continues to use heroin when at home?

Answer 2

Probably would not up-titrate the MS Contin, switch to methadone and focus on harm reduction

Question 3

Patient A Prescriber Concerns

• Conversion of heroin to ____ equivalents
• Opioid ___use
• Ongoing substance use without int______
• _____dose
• Di______
• Medicol____ implications

Answer 3

• Conversion of heroin to morphine equivalents
• Opioid misuse
• Ongoing substance use without intervention
• Overdose
• Diversion
• Medicolegal implications

Question 4

Proposed Solutions

• Continue _____ care
• Dis_____ from clinic
• W_____ visits
• Refer to (1) clinic
• Intranasal ______
• Encourage heroin ces_____
• T_____ opioids
• Rotate to rx (1)

Answer 4

• Continue current care
• Discharge from clinic
• Weekly visits
• Refer to substance abuse clinic
• Intranasal naloxone
• Encourage heroin cessation
• Taper opioids
• Rotate to methadone

Question 5

RUMC Palliative Clinic Models

• P_____ Care Clinic
• Com________ Cancer Clinic
• Non M______ Pain Clinic
• Licensed Clinical S_____ Worker
• Medical A______

Answer 5

• Palliative Care Clinic
• Comprehensive Cancer Clinic
• Non Malignant Pain Clinic
• Licensed Clinical Social Worker
• Medical Assistant

Question 6

What does this graph show?

Answer 6

Over the past 10 years, there has been overall increase in visits to palliative care clinics and visits to interdisciplinary team members including social workers and increased staff such as CNA’s

Question 7

Non Malignant Pain Clinic

• 93% opioid agreements
• 74% opioid r___ screens
• 59% current ps_____ disorder
• 23% current or prior substance use dis_____

Answer 7

• 93% opioid agreements
• 74% opioid risk screens
• 59% current psychiatric disorder
• 23% current or prior substance use disorder

Question 8

Palliative Care/Comprehensive Cancer Clinics

• Is there a standard of practice for for opioid agreements, urine drug screens, opioid risk screens?
• Do we know the rates of substance use disorders?

Answer 8

• No standardized practice for opioid agreements, urine drug screens, opioid risk screens
• Unknown rates of substance use disorders

Question 9

What has been the trend in fentanyl related deaths in the US?

Answer 9

Overall increase

• In 2014, 20 fentanyl related deaths
• In 2016, up to 380 deaths
• >20% increase from heroin/fentanyl*
• rates of overdose by prescription medications decreased, now only 20% dt deprescribing and fear of prescribing*

Question 10

What types of communities have the highest heroin related arrests?

Answer 10

Majority low income neighborhoods

Question 11

What type of communities have the highest mortality rates related to opioid use?

Answer 11

Mortality way higher in lower income populations

Question 12

Chronic Non-Malignant Pain

• Prevalence estimates of pr_______ opioid misuse, abuse, addiction range from <1% to 40%
• 56.5% of non-medical use of opioids from a fr____ or rel_____
• Opioid agreements are?
• Universal precautions recommended - what is this?

Answer 12

• Prevalence estimates of prescription opioid misuse, abuse, addiction range from <1% to 40%
• 56.5% of non-medical use of opioids from a friend or relative
• Opioid agreements controversial
• Universal precautions recommended
• In order to receive controlled pain medications for chronic non-oncologic pain, patients often must sign a “narcotic contract” or “opioid treatment agreement” in which they* promise not to give pills to others, use illegal drugs, or seek controlled medications from health care providers.
• Universal precautions refers to the practice, in medicine, of avoiding contact with patients’ bodily fluids, by means of the wearing of nonporous articles such as medical gloves, goggles, and face shields.*

Question 13

Pain in the Palliative Population

• Increasingly caring for patients with chronic malignant and non-malignant pain
• Unique risks of ______treated addiction and substance abuse
• Are there any validated opioid risk screening tools?
• In one study < 5% patients had urine drug screens
  
  • > 50% screens were aberrant, which means?

Answer 13

• Increasingly caring for patients with chronic malignant and non-malignant pain
• Unique risks of undertreated addiction and substance abuse
• No validated opioid risk screening tools
• In one study < 5% patients had urine drug screens
  
  • > 50% screens were aberrant (abnormal)

Question 14

Framework for Approaching Patients with Possible Opioid-Dependence

• _______ outpatient clinic meeting
• P_______ MD and L_ _ _ Assessment
• Opioid _____ Tool (ORT) implementation
• _____ Drug Screens (UDS)
• Opioid Ag______
• Referrals including (1) referrals

Answer 14

• Weekly outpatient clinic meeting
• Palliative MD and LCSW Assessment
• Opioid Risk Tool (ORT) implementation
• Urine Drug Screens (UDS)
• Opioid Agreements
• Referrals including substance abuse referrals

Question 15

Outpatient Meeting Demographics

• More common in which gender?
• Chronic pain most common in what type of malignancies?

Answer 15

• More Often women who present to outpatient meeting backgrounds
• Chronic pain more common with solid tumors, less common with heme malignancies with exception of multiple myeloma

Question 16

Outpatient Meeting Background

• Format of discussion
  
  • Ag_____ arranged by LCSW
  • Patients fl_____ by MD, LCSW, APN, CMA
  • Medical d____ given by MD, APN
  • Open g_____ discussion format
  • LCSW documents in sh_____ Excel spreadsheet
• Decision by group con______
• T____ frame identified

Answer 16

• Format of discussion
  
  • Agenda arranged by LCSW
  • Patients flagged by MD, LCSW, APN, CMA
  • Medical data given by MD, APN
  • Open group discussion format
  • LCSW documents in shared Excel spreadsheet
• Decision by group consensus
• Time frame identified

Question 17

Outpatient Meeting Background

Reason for Discussion

• Non-ad______
• Cognitive/health l______ concerns
• Complex pain m_______
• Medical _______
• > 50% opioid misuse concerns
  
  • 48% pseudoaddiction vs. opioid dependence
  • 48% prior or current substance abuse
  • 4% diversion

Answer 17

• Non-adherence
• Cognitive/health literacy concerns
• Complex pain management
• Medical cannabis
• > 50% opioid misuse concerns
  
  • 48% pseudoaddiction vs. opioid dependence
  • 48% prior or current substance abuse
  • 4% diversion

Question 18

Palliative MD Role

Answer 18

Question 19

LCSW Intervention

• Indirect feedback to provider
  
  • Case con______
  • Outpatient meeting dis______
  • Electronic message communication vs in-person discussion
  • Coordination with other social workers/be_____ health providers
• Direct patient care
  
  • Completion of opioid ag_____
  • P____social & substance abuse assessment
  • Coordination of h____ services
  • Em____ support
  • Identification of appropriate be_____ health provider

Answer 19

• Indirect feedback to provider
  
  • Case consultation
  • Outpatient meeting discussion
  • Electronic message communication vs in-person discussion
  • Coordination with other social workers/behavioral health providers
• Direct patient care
  
  • Completion of opioid agreement
  • Psychosocial & substance abuse assessment
  • Coordination of home services
  • Emotional support
  • Identification of appropriate behavioral health provider

Question 20

LCSW Intervention

Patients with Opioid Misuse Concerns

• Follow up screening questions:
  
  • How l____ have you been using?
  • W___ did you quit?
  • If you weren’t ill, would you st___ be using?
  • Has anyone in your family ever com_____ about your use?
  • Have you sought tr_____ before?
  • What is your longest p______ of sobriety?
• Non-j______ phrasing of questions
• Evidence-based data (UDS, medical factors)
• Focus on s_____ to patient
• Talk with patient alone if possible before including f_____/caregivers

Answer 20

• Follow up screening questions:
  
  • How long have you been using?
  • Why did you quit?
  • If you weren’t ill, would you still be using?
  • Has anyone in your family ever complained about your use?
  • Have you sought treatment before?
  • What is your longest period of sobriety?
• Non-judgement phrasing of questions
• Evidence-based data (UDS, medical factors)
• Focus on safety to patient
• Talk with patient alone if possible before including family/caregivers

Question 21

Our Clinic Population

63% patients were assigned a long_______ provider

73% patients identified for joint visits with p_____ medicine LC___

Answer 21

63% patients were assigned a longitudinal provider

73% patients identified for joint visits with palliative medicine LCSW

Question 22

Opioid Risk Tool

1. _____ History of Substance Abuse
2. _____ History of Substance Abuse
3. ____ (Mark box 16-45)
4. History of Pre______ S____ Abuse
5. Ps_____ Disease

Low Risk __-__

Moderate Risk __-__

High Risk > ___

Answer 22

1. Family History of Substance Abuse
2. Personal History of Substance Abuse
3. Age (Mark box 16-45)
4. History of Preadolescent Sexual Abuse
5. Psychological Disease

Low Risk 0-3

Moderate Risk 4-7

High Risk _>_8

Question 23

Opioid Risk Tool Data

Greater Correlation with substance abuse in those that have a history of (1) drug abuse vs. (1) drug abuse, and (1) psychological condition

Answer 23

Greater Correlation with substance abuse in those that have a personal history of abuse of prescription drugs vs. illicit drugs, and depression

Question 24

Urine Drug Screen Data

(3) categories

• 54% of patients discussed had a urine drug screen
• 59% of screens were?

Answer 24

Expected, Illicit, Diversion

• 54% of patients discussed had a urine drug screen
• 59% of screens were abnormal

Question 25

Opioid Agreement Data

% of opioid agreements in who were labeled high risk on the opioid risk tools vs low risk?

Answer 25

Opioid agreements were completed most for those who scored higher risk on opioid risk tools

Question 26

Referrals Data

63% of patients were referred to other specialists

Most referred to (1)

More referrals in those with advanced disease or no evidence of disease?

1. SA =
2. IM =
3. Ps____
4. Anesth ____
5. Re____

Answer 26

Most referred to psych

More referrals in those with no evidence of disease

1. SA = Substance abuse
2. IM = Internal medicine
3. Psych
4. Anesth pain
5. Rehab (many will be deconditioned so need PT for strength training on top of treating pain with massage,relaxation, US )

Question 27

Non Malignant Pain Clinic Team

M__

M_ _

______ Therapist

Medical Interns

Answer 27

MD

MSW

Occupational Therapist

Medical Interns

Question 28

Non Malignant Palliative Pain Clinic Rush

Answer 28

Question 29

Clinical Characteristics of Non-Malignant Palliative Pain Clinic Patients

Answer 29

Question 30

Urine Drug Testing and Results

12 months pre vs. post intake

• UDT indicating illicit drug use increased or decreased?
• Patients who had UDT increased or decreased?
• Cocaine use increased or decreased?

Answer 30

• Illicit drug use increased 10-17%
• UDT decreased 54-515
• Cocaine use increased 5-8%

Question 31

HIV Pain Management Clinic

• P______ medicine physician embedded in a multi-specialty HIV primary care clinic
• All patients seen by Certified (1) Counselor
• Psy_____, Psy______and _____ Workers on-site
• Support from a n_____ manager
• Free Ac______ Program run by students and faculty from a School of Acupuncture

Answer 31

• Palliative medicine physician embedded in a multi-specialty HIV primary care clinic
• All patients seen by Certified Substance Abuse Counselor
• Psychiatrists, Psychologist and Social Workers on-site
• Support from a nurse manager
• Free Acupuncture Program run by students and faculty from a School of Acupuncture

Question 32

Clinical and Demographic Characteristics of the Study Population

HIV Clinic Trends

Highest HIV risk with (2) major factors

Answer 32

IV drug use

Heterosexual sex

Question 33

Pain Etiologies

HIV related 48.4%, HIV Unrelated 51.6%

• Multiple Pain _______ (54%)
• Degenerative _____ disease/Spinal St______ (48%)
• HIV Neur______ (22.86%)
• M______/Fibro______ (14.28%)
• Chronic osteo_____, osteo_____, _____ tissue disease/AVN (8.56%)
• Tr______ (5.72%)
• Abdominal/M___sitis (5.71%)

Answer 33

• Multiple Pain Syndromes (54%)
• Degenerative disc disease/Spinal Stenosis (48%)
• HIV Neuropathy (22.86%)
• Musculoskeletal/Fibromyalgia (14.28%)
• Chronic osteomyelitis, osteoarthritis, connective tissue disease/AVN (8.56%)
• Trauma (5.72%)
• Abdominal/Mucositis (5.71%)

Question 34

Analgesic Medication Use and Substance Abuse

• There were no significant differences in the proportion of persons with daily oral morphine equivalent doses (DMED) in excess of 200MG or below prior to or subsequent to intake into the pain clinic (Chi square test =0.94, p=0.33) or mean dose (t=1.13, p=0.26).
• The use of adjuvant medications ______ after intake into the pain clinic (p<0.0001).
• The mean number of episodes of self reported substance use was higher in the year subsequent to intake 3.99 versus 1.14 paired t-test statistic=-12.96, p<0.0001.
• and the mean number of positive drug tests for illicit substances was 2.67 in the year subsequent to intake versus 1.30 in the year prior to intake (paired t-test statistic - 2.96, p=0.007).

Answer 34

• There were no significant differences in the proportion of persons with daily oral morphine equivalent doses (DMED) in excess of 200MG or below prior to or subsequent to intake into the pain clinic (Chi square test =0.94, p=0.33) or mean dose (t=1.13, p=0.26).
• The use of adjuvant medications increased after intake into the pain clinic (p<0.0001).
• The mean number of episodes of self reported substance use was higher in the year subsequent to intake 3.99 versus 1.14 paired t-test statistic=-12.96, p<0.0001.
• and the mean number of positive drug tests for illicit substances was 2.67 in the year subsequent to intake versus 1.30 in the year prior to intake (paired t-test statistic - 2.96, p=0.007).

Question 35

Viral Outcomes and Health Service Utilization 12 months prior to- and subsequent to intake in the Center for Positive Living Pain Clinic

Overall use of health services before and after intake into pain clinics?

Overall _____ in use of mental health services, pain management interventions, diagnostics tests, and primary care visits

______ in emergency room visits, inpatient hospital days

______ in CD4, ______ viral load

Answer 35

Overall increase in use of mental health services, pain management interventions, diagnostics tests, and primary care visits

Decrease in emergency room visits, inpatient hospital days

Increase in CD4, Decreased viral load

Question 36

Patient A’s Outcome

• Ongoing heroin use ($30-40 every 3-4 days)
• Assigned a long_____ provider, joint LC__ visits
• Switched from MS Contin to (1)
• Ativan discontinued why?
• Prescribed ______ intranasal spray
• Referred to methadone cl____
• Referred to psychosocial oncology
• Remaining interactions during inpatient admissions
• Heroin use decreased as disease progressed
• Discharged home with home hospic

Answer 36

• Ongoing heroin use ($30-40 every 3-4 days)
• Assigned a longitudinal provider, joint LCSW visits
• Switched from MS Contin to methadone
• Ativan discontinued because not showing up in urine drug test
• Prescribed naloxone intranasal spray
• Referred to methadone clinic
• Referred to psychosocial oncology
• If possible test heroin and cocaine for fentanyl using fentanyl strips*
• Harm reduction strategies: do not take full dose, and use around people*
• naloxone less effective for synthetic drugs vs. prescription drugs so may need repeat dosing*

Question 37

Case #2

What do you think she is doing?

• 51 yo woman with diffuse visceral, neuropathic pain brain and liver metastases on 4th line chemotherapy for breast cancer •
• Medications:
  
  • Oxycodone IR 40 mg q4 hours prn (using every dose)
  • Diphenhydramine 50MG q 8 hrs prn itch (requesting dose increase)
  • Alprazolam 0.5MG BID prn (using every dose)
• Runs out of medications early
• Frequently sleepy when she comes in for chemotherapy

Answer 37

Suspecting she is using the oxy and benadryl bc of the anti-anxiolytic effects vs. the analgesia

Question 38

Case #2

• Depressed, not seeing a mental health provider
• Condominium recently repossessed
• You request involvement of her husband at her next visit so that he can help with monitoring of her prescription opioids
• She is skeptical of this. Her husband ‘doesn’t understand her’.

She is admitted to the hospital through the ED

• She is treated for pneumonia and dehydration
• She has initially received IV hydromorphone 3MG q hours as needed because of nausea and vomiting. She has been using every dose.
• She is observed to be taking 60% of her meals and her nurse doesn’t observe objective evidence of pain. She is ambulating around the unit.
• Much of the rounds by the hospitalist have been spent discussing the discontinuation of IV hydromorphone and resumption of oral medications.

Is she “addicted”? What do you do?

Answer 38

Consult Palliative medicine team

• You round with the palliative medicine consultant medical provider and social worker
• You try to get the patient to provide further history on her pain
• You ask the patient to summarize information that you have presented to her during your visit.
• There are big gaps in her recollection of key points discussed

Question 39

Factors that may make coming up with an agreed plan difficult

• High levels of a____ and d_____ make ability to process information difficult
• Patients ability to comprehend the role of em_____ pain in her experience of physical pain
• Possible underlying cog_____ deficits
• Rapid onset of analgesia with ___ administration and possible _____lysis with IV use and slower onset of action

Answer 39

• High levels of anxiety and depression make ability to process information difficult
• Patients ability to comprehend the role of emotional pain in her experience of physical pain
• Possible underlying cognitive deficits
• Rapid onset of analgesia with IV administration and possible anxiolysis with IV use and slower onset of action

Question 40

Case #2 Continued

• Over the next 2 days her use of __ hydromorphone lessens
• The patient’s husband takes part in conversations about medication s____: use of a l_____ box to store pain medications and alternative ___-medication approaches and medication and pain l___.
• The patient get seen by p___social oncology
• There is a discussion on outpatient n________ prescription

Answer 40

• Over the next 2 days her use of IV hydromorphone lessens
• The patient’s husband takes part in conversations about medication safety: use of a locked box to store pain medications and alternative non medication approaches and medication and pain log.
• The patient get seen by psychosocial oncology
• There is a discussion on outpatient naloxone prescription

Question 41

Case #3

• 51 YO woman with HIV, triple negative breast cancer HIV neuropathy, worsening pain
• Use of alcohol, MJ and subsequently cocaine and heroin consistently from age 14 until age 49
• Incarceration in her 30s for drug related offenses
• Has 2 teenage daughters in the custody of her mother.
• Lives alone, poor relationship with family • Gabapentin 600 MG TID, Topiramate 25MG BID
• New skeletal metastases – on oral chemo, XRT, NSAIDs

How would you manage this patient?

• Meets ______ with a substance abuse counselor that you work with in the HIV clinic
• Meets monthly with you in the clinic
• ____s always positive for ‘opiates’ and nothing else
• Participates in re_____ groups and ab_____ promotion groups
• Comes to all of her primary care appointments
• Getting ac______ in the clinic
• Excited to have recently had her 2nd anniversary of being sober.

Answer 41

• Meets weekly with a substance abuse counselor that you work with in the HIV clinic
• Meets monthly with you in the clinic
• UDT’s always positive for ‘opiates’ and nothing else
• Participates in recovery groups and abstinence promotion groups
• Comes to all of her primary care appointments
• Getting acupuncture in the clinic
• Excited to have recently had her 2nd anniversary of being sober.

Question 42

How does your patient use the health care system

Physical Dependence/Tolerance

• Actively managing their me____ problems
• Maintain ____patient appointments
• The focus of medical visits doesn’t center on p____ medications
• Goes for recommended workups and interventions such as ph____ therapy/ ps_____

Answer 42

• Actively managing their medical problems
• Maintain outpatient appointments
• The focus of medical visits doesn’t center on pain medications
• Goes for recommended workups and interventions such as physical therapy/ psychology

Question 43

How does your patient use the health care system

Addiction

• Frequent visits to the ___ without acute change in condition
• Doesn’t maintain scheduled ___patient appointments
• Lots of ___scheduled visits
• Focus of medical visits is on _____ medications
• Doesn’t go for recommended work___

Answer 43

• Frequent visits to the ED without acute change in condition
• Doesn’t maintain scheduled outpatient appointments
• Lots of unscheduled visits
• Focus of medical visits is on pain medications
• Doesn’t go for recommended workups

Question 44

Case #4

• 63 YO woman with combined variable immune disorder, COPD, multiple steroid induced thoracic vertebrael fractures, severe neuropathic pain, Sleep apnea, multiple allergies, frequent infections, bronchiectasis
• Has previously been managed by her PCP on 100MCG Transdermal Fentanyl 100MCG TD q 72 hours Oral Transmucosal Fentanyl Lozenges 600MCG SL q 4 hours as needed
• She is having increased pain on the third day that she has her Fentanyl patches on and wants to change them every 48 hours
• Her PCP refers to you because of concerns about opioid addiction
• You order a test for the OPRM-1 mutation which comes back positive for the mutation, what does this mean?
  
  • You prescribe Transdermal Fentanyl 48 hourly
  • Insurance will no longer cover OTFC
  • You switch to MSIR 22.5MG PO q 4 hours as needed
  • Chest CT during an episode of pneumonia shows LUL 3 by 2 CM lesion

Answer 44

OPRM-1 mutation = 15% of people metabolize opioids more rapidly than routine dosing intervals

Question 45

Methods of conversion from other opioids to Fentanyl

MSKCC Method

__MG IV morphine=___MCG Fentanyl IV

• e.g. Patient is on 80MG Oxycontin twice daily and 20MG Oxycodone immediate release four times a day
• 240MG oxycodone/ 24 hours =360MG morphine PO/ 24 hours
• 360MG morphine PO=120MG IV morphine/ 24 hours
• 120/24=5MG IV morphine
• 100% conversion=____MCG Fentanyl TD/ h patch
• 50% conversion=____MCG Fentanyl TD/ h patch
• Nearest equivalent for 75% equianalgesic conversion= ____MCG Patch

Answer 45

• MSKCC method 1MG IV morphine=25MCG Fentanyl IV
• e.g. Patient is on 80MG Oxycontin twice daily and 20MG Oxycodone immediate release four times a day
• 240MG oxycodone/ 24 hours =360MG morphine PO/ 24 hours
• 360MG morphine PO=120MG IV morphine/ 24 hours
• 120/24=5MG IV morphine. 100% conversion=125MCG Fentanyl TD/ h patch
• 50% conversion=62.5MCG Fentanyl TD/ h patch
• Nearest equivalent for 75% equianalgesic conversion= 100MCG Patch

Question 46

Alternative Method

360MG morphine/ 100= 3.6MG Fentanyl/ 24 hours

3.6mg/24=___MCG Fentanyl/ Hour TD 100% conversion

• 50% conversion =___ MCG/ Hour TD
• 75% conversion =112MCG/ Hour TD

Answer 46

360MG morphine/ 100= 3.6MG Fentanyl/ 24 hours

3.6mg/24=150 MCG Fentanyl/ Hour TD 100% conversion

• 50% conversion =75MCG/ Hour TD
• 75% conversion =112MCG/ Hour TD

Question 47

Buprenorphine and Palliative Care

Office based induction: Day 1

Start __mg buprenoprhine

• Reassess in __-__ h with peak plasma concentration __h after sub____ dose
• If withdrawal not relieved, _____ 2mg buprenorphine
• Reassess in 1-2h, if persistent withdrawal, _____ 2mg buprenorphine
• Reassess again in 1-2h if persistent withdrawal

Max dose of ___mg on Day 1

1. ______ full opioid agonist for ___ h (methadone for __h)
2. Evidence of mild to moderate opiate ______ using a validated scale
3. If worsening withdrawal with buprenorphine, do not resume buprenorphine for a minimum of __ h

Answer 47

Start 2 mg buprenoprhine

• Reassess in 1-2 h with peak plasma concentration 3h after sublingual dose
• If withdrawal not relieved, repeat 2mg buprenorphine
• Reassess in 1-2h, if persistent withdrawal, repeat2mg buprenorphine
• Reassess again in 1-2h if persistent withdrawal

Max dose of 8 mg on Day 1

1. Discontinue full opioid agonist for 12 h (methadone for 36 h)
2. Evidence of mild to moderate opiate withdrawal using a validated scale
3. If worsening withdrawal with buprenorphine, do not resume buprenorphine for a minimum of 12 h

Question 48

Buprenorphine Day 2 Induction

• Increase ___ mg dose to ___mg as a ____ daily dose
• May give an additional ___ mg several hours later
• Day 2 max dose = ___ mg

Answer 48

• Increase 8 mg dose to 12 mg as a once daily dose
• May give an additional 4 mg several hours later
• Day 2 max dose = 16 mg

Patient may require additional dose if persistent opioid withdrawal or cravings despite 8mg on day 1

Question 49

Buprenorphine Day 3-7 Induction

Most patients requires __-__ mg of buprenorphine per day to prevent withdrawal and manage cravings

Do not readjust dose for 3-7d to allow for ____ state

Answer 49

Most patients requires 12-16 mg of buprenorphine per day to prevent withdrawal and manage cravings

Do not readjust dose for 3-7d to allow for steady state

Question 50

Buprenorphine micro-dosing for replacement of mu-opioid agonist (the patient does not need to be in withdrawal or to stop using opioids before starting)

Answer 50

Question 51

Buprenorphine formulations for pain

• Rx (1)
• <30MG OME 75MCG Belbuca q12
• 30-89 OME 150MCG Belbuca q12
• 90-180 OME 300MCG Belbuca q12
• The 7 dose strengths include
• __ mcg
• 150 mcg
• 300 mcg
• 450 mcg
• 600 mcg
• 750 mcg
• ___ mcg

Answer 51

• Belbuca
• <30MG OME 75MCG Belbuca q12
• 30-89 OME 150MCG Belbuca q12
• 90-180 OME 300MCG Belbuca q12
• The 7 dose strengths include
• 75 mcg
• 150 mcg
• 300 mcg
• 450 mcg
• 600 mcg
• 750 mcg
• 900 mcg

Question 52

Formulations of Buprenorphine for Pain (patches)

• __ MG parenteral buprenorphine=75MG oral morphine or 25MG IV morphine
• __ MCG/H Butrans patch=0.12MG Buprenorphine/ day =9MG oral morphine
• Rx (1) is available in __MCG, 10MCG, 15MCG and __MCG formulations. Not a good choice for patients on more than 80 oral morphine equivalents/ day

Answer 52

• 1MG parenteral buprenorphine=75MG oral morphine or 25MG IV morphine
• 5MCG/H Butrans patch=0.12MG Buprenorphine/ day =9MG oral morphine
• Butrans is available in 5MCG, 10MCG, 15MCG and 20MCG formulations. Not a good choice for patients on more than 80 oral morphine equivalents/ day

Question 53

Case #5

Patient with longstanding opioid use for chronic pain (right sided abdominal “sharp”) in the context of a gunshot wound in 2005 (abdominal exit wounds) requiring a laparotomy with multiple complications, fistulas and a “fistula take down” He has bipolar disorder per a psychiatrist and reported history of depression anxiety and chronic pain and panic symptoms (saw his wife shot dead in 2016) Patient had a suicide attempt in 2016 (attempted hanging)

Answer 53

Case cont…

He received xanax, adderall, klonopin and ambien and oxycodone (50MG QID 20MG OXYIR and 30MG OXYIR) most recently klonopin 2MG TID previously from a psychiatrist at an OSH for many years but told by this MD that he would no longer be able to prescribe medications and as a consequence has had physical withdrawal symptoms to opioids.

He reports that he has a seizure disorder and is on dilantin and says had seizure in December per the patient last opioid use was 3 days prior to admission.

He had a telehealth visit with a new psychiatrist who offered buprenorphine (suboxone) but needed a urine drug screen (UDS) in office and had denied opioid withdrawal syndrome (OWS) at this visit also offered inpatient or outpatient detoxifcation but the patient declined this option.

Question 54

Case #5

UDS 11/9/20 positive for benzodiazepines and opiates 8/9/20 at outside hospital are negative for other substances UDS neg for alcohol.

The patient’s opioid risk tool (ORT) =4 (moderate) per his report or 8 (high) per the provider’s assessment due to some early fills for oxycodone per the prescription monitoring program.

Patient using multiple high-risk medications (oxycodone, clonazepam, ambien, adderall).

Answer 54

Patient refused care by pain clinic and palliative medicine providers

He arrives into the ER in opioid withdrawal. He had been rationing his medications for several weeks and was without opioids for> 72 hours

His Clinical Opiate Withdrawal Scale score is 14

You see him in the ER and advise him that you are starting him on buprenorphine/ naloxone 2/0.5MG QID

His UDS is positive for cocaine and negative for all else

He is admitted to medicine and then to inpatient psychiatry during this admission his buprenorphine/ naloxone is increased to 4/1MG QID with good control of his pain and no opioid cravings.

Question 55

Case #5

He is advised not to use shortly after fruit juice, caffeine or cigarettes (he smokes) and not to chew suck or bite but let absorb and sit with his head forward to allow saliva to pool at the front of his mouth this will facilitate absorption.

I reviewed UDS at outside hospitals for the last 6 years and all have been negative for cocaine and cannabis, positive for opiates and BDZ

Given the risk of contamination of cocaine with illicit fentanyl he should have a script for naloxone at discharge and is advised to only use street drugs around others who can administer naloxone if he has a respiratory arrest or depression and only to use a small part of the line of cocaine initially

Answer 55

He keeps his medication in a locked box. I explained that most people who require naloxone following prescription opioid consumption are not the person for whom the medication is prescribed so he could possibly need to administer naloxone were somebody to get into his medications.

He is interested in medical cannabis I advised him not to smoke cannabis as it is associated with an odds ratio of ~ 3 for the risk of a myocardial infarction in patients who have underlying risk factors for coronary artery disease. He smokes tobacco and is transparent about not being willing to stop tobacco at this time.

Question 56

Case #5

I endorsed that this is ok in the context of making multiple other adjustments currently to increase his safety but again stated that if he is able to stop tobacco that he should notice improved response to buprenorphine.

He acknowledges being tolerant to high dose opioids due to long term exposure I reminded him of the concept of opioid induced hyperalgesia and explained that he should continue on ________ for visceral induced hyperalgesia

Answer 56

I endorsed that this is ok in the context of making multiple other adjustments currently to increase his safety but again stated that if he is able to stop tobacco that he should notice improved response to buprenorphine.

He acknowledges being tolerant to high dose opioids due to long term exposure I reminded him of the concept of opioid induced hyperalgesia and explained that he should continue on Gabapentin for visceral induced hyperalgesia

Question 57

CDC Guidelines for use of opioids for chronic non-malignant pain 2016

• Discourages use of opioids for more than _____ periods of time
• Discourages using _____-acting medications
• Encourages maintenance on less than ____ MG oral morphine equivalents per day (OME/ Day)
• Recommends t______ opioids if doses exceed 100MG OME/Day
• Discourages their use in diagnoses for which they are commonly used e.g. ____ pain, fibro______
• Encourage use of r_____ tapering

Answer 57

• Discourages use of opioids for more than short periods of time
• Discourages using long-acting medications
• Encourages maintenance on less than 50 MG oral morphine equivalents per day (OME/ Day)
• Recommends tapering opioids if doses exceed 100MG OME/Day
• Discourages their use in diagnoses for which they are commonly used e.g. back pain, fibromyalgia
• Encourage use of rapid tapering

Question 58

Trend in overdose deaths from 2015 to 2020?

Answer 58

Overdoses increased exponentially

• Overdose deaths increased by 250% in 2020 there were more than 1600 overdose deaths in Cook County. Most involved heroin and illicit fentanyl
• This is expected to increase to over 2000 for 2021 once the results of laboratory tests are available from postmortem

Question 59

Differences in Opioid Deprescribing Patterns

• On average 21.2% re______ in opioid MME (morphine milligram equivalents) per capita prescribed
• Greater reductions in prescribing by E__ physicians (70.5%), ___ologists (59.5%) and _____iatrists (67.2%)
• Smaller reductions for pain specialists (15.4%)
• Greater reductions in m______ counties and non-metropolitan non-adjacent counties
• Greater reductions in counties with _____ rates of fatal overdose (34.6%)

RAND study Annals of Internal Medicine December 2021 Stein B

Answer 59

• On average 21.2% reductions in opioid MME per capita prescribed
• Greater reductions in prescribing by ER physicians (70.5%), oncologists (59.5%) and psychiatrists (67.2%)
• Smaller reductions for pain specialists (15.4%)
• Greater reductions in metropolitan counties and non-metropolitan non-adjacent counties
• Greater reductions in counties with higher rates of fatal overdose (34.6%)

Question 60

The evolving opioid epidemic

• Use of prescription opioids for pain may make it more difficult to access primary care
• A study published in JAMA online May 2019 found that 41% of surveyed primary care clinics would de_____ to accept patients into their practice if patients were recipients of prescription opioid medications
• JAMA Network Open, doi:10.1001/jamanetworkopen.2019.6928
• Pr_______ opioids now account for
• Per capita MG opioid prescriptions have ___creased by > 40% since 2012.

Answer 60

• Use of prescription opioids for pain may make it more difficult to access primary care
• A study published in JAMA online May 2019 found that 41% of surveyed primary care clinics would decline to accept patients into their practice if patients were recipients of prescription opioid medications
• JAMA Network Open, doi:10.1001/jamanetworkopen.2019.6928
• Prescription opioids now account for <20% of fatal opioid overdoses in the US and two thirds of those occur in persons other than for whom the medication was prescribed.
• Per capita MG opioid prescriptions have decreased by > 40% since 2012.

Question 61

Consider tapering to a reduced opioid dosage, or tapering and discontinuing opioid therapy, when……

• The patient experiences ____ effects that diminish ____ of life or impair f_____
• The patient experiences an ____dose or other serious event (e.g., hospitalization, injury), or has warning signs for an impending event such as con_____, se____, or sl_____ speech
• The patient is receiving medications (e.g., ben_______) or has medical conditions (e.g., lung disease, sleep apnea, liver disease, kidney disease, fall risk, advanced age) that increase r_____ for adverse outcomes
• The patient has been treated with opioids for a pro______ period (e.g., years), and current benefit-harm balance is ___clear

Answer 61

• The patient experiences side effects that diminish quality of life or impair function
• The patient experiences an overdose or other serious event (e.g., hospitalization, injury), or has warning signs for an impending event such as confusion, sedation, or slurred speech
• The patient is receiving medications (e.g., benzodiazepines) or has medical conditions (e.g., lung disease, sleep apnea, liver disease, kidney disease, fall risk, advanced age) that increase risk for adverse outcomes
• The patient has been treated with opioids for a prolonged period (e.g., years), and current benefit-harm balance is unclear

Question 62

HHS guidelines for tapering opioids

Consider tapering to a reduced opioid dosage, or tapering and is continuing opioid therapy, when…..

• Pain has im_____
• Patient re_____ dosage reduction or discontinuation
• Pain and f______ are not meaningfully improved
• The patient is receiving higher opioid doses without evidence of b_____ from the higher dose
• The patient has current evidence of opioid ___use

Answer 62

• Pain has improved
• Patient requests dosage reduction or discontinuation
• Pain and function are not meaningfully improved
• The patient is receiving higher opioid doses without evidence of benefit from the higher dose
• The patient has current evidence of opioid misuse

Question 63

Risks of Opioid Taper

• Opioids should ___ be tapered r______ or discontinued s______ due to the risks of significant opioid withdrawal.
• Risks of rapid tapering or sudden discontinuation of opioids in physically dependent patients include acute withdrawal symptoms, exacerbation of pain, serious psychological distress, and thoughts of s______.
• Patients may seek other sources of opioids, potentially including ____ opioids, as a way to treat their pain or withdrawal symptoms.
• Unless there are indications of a life-threatening issue, such as warning signs of impending overdose, HHS does ____ recommend abrupt opioid dose reduction or discontinuation.

Answer 63

• Opioids should not be tapered rapidly or discontinued suddenly due to the risks of significant opioid withdrawal.
• Risks of rapid tapering or sudden discontinuation of opioids in physically dependent patients include acute withdrawal symptoms, exacerbation of pain, serious psychological distress, and thoughts of suicide.
• Patients may seek other sources of opioids, potentially including illicit opioids, as a way to treat their pain or withdrawal symptoms.
• Unless there are indications of a life-threatening issue, such as warning signs of impending overdose, HHS does not recommend abrupt opioid dose reduction or discontinuation.

Question 64

CDC revises its guidelines 2022

• USA Today: CDC’s Opioid Prescribing Guide Differs For New, Existing Pain SufferersThe 229-page document advises doctors to ____ new opioid prescriptions and discuss al______ therapies with patients. But the new guidance largely avoids figures on dosage and length of prescription and warns against abruptly or r_____ discontinuing pain pills for some chronic pain patients.“We’ve built in flexibility so that there’s not a one-size-fits-all approach,” said Christopher Jones, acting director of the CDC’s National Center for Injury Prevention and Control. (Alltucker, 2/10)
• What is the controversy with the new guidelines?

Answer 64

• USA Today: CDC’s Opioid Prescribing Guide Differs For New, Existing Pain SufferersThe 229-page document advises doctors to limit new opioid prescriptions and discuss alternative therapies with patients. But the new guidance largely avoids figures on dosage and length of prescription and warns against abruptly or rapidly discontinuing pain pills for some chronic pain patients. “We’ve built in flexibility so that there’s not a one-size-fits-all approach,” said Christopher Jones, acting director of the CDC’s National Center for Injury Prevention and Control. (Alltucker, 2/10)
• AP: CDC Proposes Softer Guidance On Opioid Prescriptions One expert expressed initial wariness about a proposed revision. The 2016 guidance succeeded in helping to reduce inappropriate and dangerous prescribing, said Dr. Adriane Fugh-Berman of Georgetown University Medical Center. Its critics have included pain patients, but also painkiller manufacturers and groups they fund, she said. “There was nothing wrong with the original guidelines,” said FughBerman, a paid expert witness for plaintiffs in cases targeting pharmaceutical marketing practices. (Stobbe, 2/10)