APA Archived Webinar: Managing Pain in Patients with an Addiction History

pain collagePCCS-MAT has a new webinar archived on their website made available from the American Psychiatric Association on “Managing Pain in Patients with an Addiction History”. The webinar can be accessed at: http://pcssmat.org/education-training/archived-webinars/apa-archived-webinar-managing-pain-in-patients-with-an-addiction-history/.

The 1 hour webinar is presented by Jan Kauffman, RN, Vice President, Addiction Treatment Services North Charles Foundation, Inc., and Assistant Professor of Psychiatry, Harvard Medical School. One CME credit is available.

The goal of the presentation is to familiarize clinicians with the tools to identify chronic pain patients at risk for misuse of opioids, and provide strategies for managing chronic pain patients with addictive disorders. Guidelines for risk stratification, safe prescribing, and assessing, monitoring and managing errant behavior will be discussed.

Source: PCSS – MAT Training – May 13, 2014

The Joint Commission Issues Revised Standards for Opioid Treatment Programs

Joint CommissionWorking closely with the Substance Abuse and Mental Health Services Administration (SAMHSA), The Joint Commission has revised several standards for Opioid Treatment Program (OTP) accreditation. For The Joint Commission to be allowed to accredit OTPs, accreditation standards must be in alignment with SAMHSA’s regulations and guidelines. The Joint Commission, to keep up with SAMSHA regulations and guidelines, has added some new elements of performance and some new notes.

The new revisions to standards for OTPs, which took effect March 23, cover a range of issues, including administrative discharges, neonatal abstinence syndrome, parenting support groups, child care services, and prenatal care. The first topic covered is pain—a key issue for OTPs and for patients with opioid dependence.

“Some OTP patients may have co-occurring pain that existed with their opioid addiction prior to entering treatment, and some are in treatment and in recovery from addiction, but have pain,” said  Megan Marx, associate director at The Joint Commission, in an interview with AT Forum.

The Joint Commission’s biggest concerns are 1) that patients with pain be treated for their pain, and 2) that patients’ methadone or buprenorphine dose not be lowered as a result of their being put on pain medication. “This is language that came from SAMHSA,” said Ms. Marx. “We’re saying that if you have a patient, you need to adequately treat their opioid addiction, and not change the dose just because that patient is now accessing pain treatment. You need to confer and make sure that your patient is treated adequately.”

Asked whether the OTP should treat pain in its patients, Ms. Marx responded, “That’s not for us to say.” If the best way to meet the patient’s needs is to have the pain treated by another provider in the community, that is what should happen, she said.

It is clear that The Joint Commission is not telling OTPs they need to be able to treat pain—quite the opposite. They can, but they don’t have to. “I don’t know that all OTPs are in a position where they can treat pain,” she said.

What led The Joint Commission to the pain standard was SAMHSA, which, as the agency that regulates OTPs, has great interest in the standards promulgated by The Joint Commission—and vice versa. Since 2001, SAMHSA has required OTPs to be certified by a “deemed” accrediting body—and The Joint Commission has such deeming authority. A review of The Joint Commission’s most recent renewal application for deemed status, submitted to SAMHSA two years ago, prompted the clarification and revisions to The Joint Commissions standards.

The discussion about pain has taken time, said Ms. Marx. “But it is SAMHSA that wants to make sure that all patients are assessed for pain. Where there may be challenges in treating people who have pain issues, OTPs need to be aware of their limitations.”

And there may be an oblique indication that non-opioid pain relief is something both SAMHSA and The Joint Commission want to see offered. “When we talk about treating pain, there is treating pain with medication, but also a variety of other ways,” said Ms. Marx. “We don’t want to leave those people out of the loop either.” For example, there are pain management specialists who may use physical therapy, acupuncture, and other methods.

OTPs are good at recognizing drug-seeking and the pain of withdrawal, she said. “But so much more comes with the patient who has pain,” she said. People can have pain in addition to drug addiction, she added, citing the need to evaluate short-term pain related to an injury, and chronic pain related to disease.

Case-By-Case Administrative Discharges

The Joint Commission makes it clear that OTPs cannot institute across-the-board rules for “administrative discharges.”  Some OTPs discharge patients because they can’t pay, or more often because they have tested positive for other drugs, like benzodiazepines. “It has to be on a case-by-case basis,” said Ms. Marx. And The Joint Commission checks documentation to make sure that, indeed, decisions are made on a case-by-case basis. There can be no policy that says a certain number of positive tests for benzodiazepines, for example, results in an automatic discharge.

“Ongoing multi drug use is not necessarily a reason for discharge. We all know that when people come into treatment, many are not using just heroin,” she said.

There was a reason for patients to use drugs, and that’s why they’re in treatment, Ms. Marx pointed out. “They didn’t get the way they are overnight, and they’re not going to change overnight. We don’t want patients to be taken out of programs simply because they have issues reducing their use of other substances.”

Benzodiazepine abuse is very worrying to OTPs, because of the risk—like opioids, benzodiazepine is a central nervous system depressant, and combining it with methadone could result in overdose, even death. But the way to approach benzodiazepine use is not to terminate treatment, “it’s to work with your team and your patient to come up with the best plan,” she said.

In addition, a patient who is dependent on benzodiazepines and is threatened with administrative discharge could try to stop using the benzodiazepines on their own. Withdrawal from benzodiazepines is life-threatening and is typically managed in an inpatient setting, she said.

The field is now able to use harm-reduction terminology, which is helpful in accreditation of OTPs. For example, if patients are no longer using opioids, even if they are misusing benzodiazepines, harm is being reduced. “You have to use common sense and ask whether it is safer for the patient to be in treatment, because at least they’re successful with the opioid addiction,” said Ms. Marx. She added that by staying in treatment, eventually the patient can be helped to stop using other substances as well.

Neonatal Abstinence Syndrome

If there is a risk of neonatal abstinence syndrome (NAS)—such as when a pregnant patient is taking methadone or buprenorphine—The Joint Commission now requires the OTP to help obtain comprehensive care for the baby. “This goes back to the issue of making sure that everyone has access to the best care,” Ms. Marx said. “Because OTPs deal with this on a more regular basis, they have information to share with patients about where this care can be provided. If it’s not something that the obstetrician knows about, then the OTP should be able to provide patients with the information.”

It’s helpful for the OTP to let the obstetrician know how the mother has been doing in the OTP during pregnancy, she said.

Parenting Support Groups

OTPs should also be able to provide referrals for parenting support groups—something that isn’t new, but that SAMHSA has “gotten more specific about,” said Ms. Marx. “There used to be one sentence about it in the old guidelines, and programs were confused about whether they had to offer these support groups.” While parenting support is important, especially when children have special needs, there’s no funding for it, she pointed out. She added that programs should at least be able to offer referrals, even if they don’t have to offer the actual groups.

She stressed that OTPs are not required to report parenting support problems to social services. But programs may realize, through their work with patients, that some families and children have specific needs and require prevention services. “If OTPs are aware of the fact that there are some behavioral health needs, as a responsible care provider, they need to see that there is a referral,” she said.

Child Care Services

This revised standard makes it clear that a program must either offer or provide referrals to child care services. “There was a lot of confusion about this,” said Ms. Marx. “In more remote locations, there are few services available for anything—it’s a geographic problem. This revision makes it clear that if you can’t provide a referral, you don’t have to have a day care center in the OTP.”

Prenatal Care

While some OTPs have the clinical expertise to care for pregnant patients, some do not. This standard provides for reciprocity in exchange of clinical information with the obstetrician providing care. In addition, if the patient refuses prenatal care, OTPs are now required to have the patient acknowledge in writing that she was offered the services, but refused them.

Treating pregnant patients who are not getting prenatal care is a liability issue for OTPs, which is why it’s important for them to get the signed documentation of refusal, she said. Why would a patient refuse prenatal services? Ms. Marx said for some women in treatment who plan on remaining pregnant there may be affordability or transportation issues.

“We do care about OTPs’ liability, because we want them to stay open,” she said. “We don’t want them to close, unless they’re really providing substandard care. There’s a shortage of treatment in the country. We need more treatment, not less.”

The revised standards are available at: http://www.jointcommission.org/assets/1/18/Opioid_BHC.pdf

New Methadone Safety Guidelines Published for Opioid Addiction and Chronic Pain Management

shutterstock_114229831In recent years the safety of methadone has been questioned by data indicating a large rise in the number of methadone-associated overdose deaths occurring at the same time as a marked increase in methadone use to treat chronic pain.

Between 2008 and 2011, several medical groups issued methadone safety guidelines to address the increased mortality. Published in BMJ Supportive & Palliative Care, Annals of Internal Medicine, and Journal of Addictive Diseases, these guidelines focused on preventing cardiac arrhythmias. None addressed other methadone safety issues; nor did they grade the strength of their recommendations or the quality of the evidence.

The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned a 16-member interdisciplinary expert panel to address these shortcomings. The panel’s careful review of the evidence led to specific guidelines for methadone use for treating opioid addiction in licensed opioid treatment programs, and for treating chronic pain in primary care or specialty settings. The Journal of Pain published the guidelines in April.

The new guidelines focus on promoting patient safety and mitigating avoidable harms. They include patient risk assessment, patient education and counseling, selective use of electrocardiography, dose initiation and titration, diligent monitoring and follow-up, and medication interactions.

Zeroing in on the risk of respiratory depression, a major cause of methadone-associated deaths, the panel stressed safety issues—low initial methadone doses, careful titration, and the use of alternative opioids for selected patients. Panelists concluded that the safe use of methadone “requires clinical skills and knowledge to mitigate potential risks, including serious risks related to overdose and cardiac arrhythmias.”

Methadone-Associated Deaths: Overdoses or Arrhythmias?

The panel noted factors that make it difficult to identify the cause of methadone-associated deaths, among them prescribed vs. illicit methadone use, concurrent use of other medications or substances, and uncertainty about links between increased methadone prescribing and a rise in the death rate. In the vast majority of cases, the panel could not determine whether death was due to “respiratory depression related to overdose, or to other factors, such as arrhythmia.”

The characteristics of methadone present special challenges. Methadone has a long and variable half-life, and can interact with many medications. It is difficult to adjust methadone dosages safely when switching patients from a different opioid.  Methadone is associated with a prolonged QTc interval, “which may predispose patients to the ventricular arrhythmia known as torsades de pointes [TdP].” Also, “the proportion of methadone-associated deaths related to arrhythmia is likely to be small relative to the proportion related to accidental overdose,” the panelists found.

The panel gave each recommendation a separate grade for the strength of the recommendation and the quality of the evidence. This Addiction Treatment Forum article includes only the strong recommendations. The published guidelines include additional recommendations and practice advice. The table below describes the grading system.

 

Strength of Recommendation Quality of Evidence
Strong: The panel believes that the potential benefits of following the recommendation “clearly outweigh potential harms and burdens” (or vice versa); most clinicians and patients would choose to follow a strong recommendation.
Weak: Benefits outweigh potential harms and burdens (or vice versa), “but the balance of benefits to harms is smaller or evidence is weaker.” Clinical circumstances or patient preferences could affect the decision.
The type, number, size, and quality of studies, strengths of associations, and comparative consistency of results determine the quality of the evidence that supports a recommendation.

High: A low probability exists that new evidence would affect the recommendation.
Low: A high probability exists that new evidence would affect the recommendation.

 

Because of a lack of published evidence-based studies on methadone safety, panelists were obliged to base their recommendations on what they had—evidence they considered to be of generally low quality. Panelists reviewed more than 3,700 abstracts and 168 primary studies, solicited input from more than 20 external peer reviewers, and eliminated the lowest-ranked recommendations. All of the approved recommendations received unanimous or near-unanimous consensus. In contrast, as the authors point out, two of guidelines published earlier “were not fully endorsed by a professional society or government entity, and the third was endorsed by the Substance Abuse and Mental Health Services Administration.”

The following provides highlights of this panel’s recommendations for adult patients.

Patient Assessment and Selection – When considering methadone treatment, perform an individualized medical and behavioral risk-and-benefits evaluation (low-quality evidence).

Patient Education and Counseling - Before prescribing methadone, educate and counsel patients about the indications for treatment, goals of therapy, availability of other therapies, ongoing management, and other factors (low-quality evidence).

Baseline Electrocardiograms - On the controversial key topic of baseline ECGs, the panel has two strong recommendations, both based on low-quality evidence.

  • Obtain an ECG before starting methadone in patients with risk factors for QTc interval prolongation, any previous ECG showing a QTc > 450 ms, or a history suggesting previous ventricular arrhythmia. In patients without new risk factors for QTc interval prolongation, an ECG within the previous 3 months with a QTc < 450 ms can serve as the baseline study.

In contrast, some previous guidelines required a baseline ECG screening for all patients.

  • The panel recommends against methadone use in patients with a baseline QTc interval  > 500 ms.

Some previous guidelines allowed methadone use in selected patients in this category.

Panelists provided a lengthy discussion of ECGs and risk factors for TdP and for QTc interval prolongation.

Initiating Methadone Therapy - The panel offers two strong recommendations:

  • Start with low doses, based on treatment indication and the patient’s previous opioid exposure; titrate slowly; and monitor for sedation (moderate-quality evidence). The panel’s emphasis on low initial dosing and careful titration echoes previous guidelines. It  prioritizes patient safety and takes into consideration methadone’s long, variable half-life—usually assumed to be about one day, but, according to some reports, occasionally as long as 120 hours. The panel stresses the need to withhold the dose temporarily if patients show evidence of sedation, and to restart treatment cautiously.
  • When restarting methadone, consider patients who have not taken opioids for 1 to 2 weeks to be opioid-naïve (low-quality evidence).

Monitoring and Follow-up ECGs

Three strong recommendations for follow-up ECGs, all with low-quality evidence:

  • Base follow-up ECGs on baseline ECG findings, methadone dose changes, and other risk factors for QTc interval prolongation.
  • Switch patients with a QTc interval ≥ 500 ms to a different opioid, or immediately lower the methadone dose; evaluate and correct reversible causes of QTc interval prolongation; repeat the ECG after lowering the methadone dose.
  • In patients with a QTc interval ≥ 450 ms but < 500 ms, consider switching to an alternative opioid or lowering the methadone dose (otherwise, discuss with the patient the potential risks of continuing methadone therapy); evaluate and correct reversible causes of QTc interval prolongation; repeat the ECG after lowering the methadone dose.

Adverse Events – Two recommendations:

  • Monitor patients for common opioid adverse effects and toxicities; consider adverse-effects management to be part of routine therapy (moderate-quality evidence).
  • The panel recommends discussing adverse events with patients—either face-to-face or by phone—within 3 to 5 days after starting methadone and within 3 to 5 days after each dose increase (low-quality evidence).

Urine Drug Testing – Two recommendations, both low-quality evidence:

  • Obtain urine drug screens before starting methadone treatment for opioid addiction and again at regular intervals.
  • Consider urine drug testing in all patients, regardless of risk status, before starting therapy and at regular intervals; the panel recommends such testing for patients who are prescribed methadone for chronic pain and have risk factors for drug abuse (low-quality evidence).

Medication Interactions - Use methadone with care in patients taking other medications that may have additive side effects or pharmacologic interactions with methadone (low-quality evidence).

Methadone Treatment During Pregnancy – Monitor neonates whose mothers received methadone; if neonatal abstinence syndrome occurs, provide appropriate treatment (moderate-quality evidence).

Need for Additional Research

Two related articles appear in the same issue of The Journal of Pain. One discusses in more detail methadone overdose and cardiac arrhythmia potential; the second highlights research gaps related to methadone safety. These gaps include lack of enough evidence to evaluate the comparative mortality associated with of methadone treatment versus treatment with other opioids, and to determine the effectiveness of ECG monitoring and other risk-mitigation steps.

A clear need exists for additional randomized clinical trials and large, well-controlled observational studies to provide additional data. This would allow the expert panel to update the guidelines and provide additional recommendations. The panel plans an update by 2018; earlier, if critical new evidence becomes available.

The article is available online at: http://www.jpain.org/article/S1526-5900(14)00522-7/fulltext

Links to Resources Mentioned in This Article                        

Chou R, Cruciani RA, Fiellin DA, et al. Methadone safety: A clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014;15(4):321-337. http://www.jpain.org/article/S1526-5900(14)00522-7/abstract.  Accessed June 3, 2014.

Chou R, Weimer M, Dana T. Methadone overdose and cardiac arrhythmia potential: Findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline.  J Pain. 2014;15(4):338-365. http://www.ncbi.nlm.nih.gov/pubmed/24685459?dopt=Abstract. Accessed June 3, 2014.

Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MD. QTc interval screening in methadone treatment. Ann Intern Med. 2009;150(6):387-395. doi:10.7326/0003-4819-150-6-200903170-00103. http://annals.org/article.aspx?articleid=744382. Accessed June 3, 2014.

Martin JA, Campbell A, Killip T, et al. QT interval screening in methadone maintenance treatment: Report of a SAMHSA expert panel. J Addict Dis. 2011; Oct;30(4):283-306. http://www.tandfonline.com/doi/pdf/10.1080/10550887.2011.610710. Accessed June 3, 2014.

Shaiova L, Berger A, Blinderman CD, et al. Consensus guideline on parenteral methadone use in pain and palliative care. Palliat Support Care. 2008;6:165-176. http://journals.cambridge.org/action/displayFulltext?type=1&fid=1885936&jid=PAX&volumeId=6&issueId=02&aid=1885928&bodyId=&membershipNumber=&societyETOCSession=. Accessed June 3, 2014.

Weimer MB, Chou R. Research gaps on methadone harms and comparative harms: Findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline.  J Pain. 2014;15(4):366-376. doi:10.1016/j.jpain.2014.01.496. PMID:24685460. http://www.ncbi.nlm.nih.gov/pubmed/24685460. Accessed June 3, 2014.

Click here to access additional related resources.

Study Suggests Chronic Pain is Widespread and Undertreated in MMT Programs By Guest Author Stewart B. Leavitt

shutterstock_119720380Pain is a worldwide epidemic and more than a third of all adults, or 100 million persons, in the U. S. alone suffer from chronic pain conditions of some sort, as estimated by the U.S. Institute of Medicine (IOM 2011). Even more troubling, newly published research suggests that the prevalence of clinically significant, persistent pain among patients in methadone maintenance treatment (MMT) programs is nearly twice that  of  the general population—and most of that chronic pain is going untreated.

Survey Provides Bleak Picture of Pain in MMT

Writing recently in the journal Pain Medicine, Kelly E. Dunn, PhD, and colleagues reported on a survey of MMT patients at the Johns Hopkins Bayview Medical Center in Baltimore, Maryland (Dunn et al. 2014). Approximately 80 percent of all patients at the clinic responded to a self-report questionnaire widely used in the pain field—the Brief Pain Inventory (BPI)—which assesses severity of pain and its interference with daily activities. Additional data were gathered on patient demographics, pain location, drug use, and current treatments for pain and addiction.

Overall, the 227 survey participants were 45 years old, had been in MMT for 4.5 years on average, and roughly half were male (47%) and Caucasian (49%). Sixty percent of respondents (N=137) indicated on the BPI that they had chronic pain. Also, there were some statistically significant differences in this group compared with MMT patients not reporting such pain: Patients with chronic pain were older (mean age 46 vs. 42 years, respectively), had higher average daily methadone doses (86 mg/d vs. 71 mg/d), and had a higher rate of benzodiazepine-positive urine samples in the past 90 days (7% vs. 3%).

Chronic pain was reported in multiple body areas by roughly a third (36%) of patients with pain, but the most common locations were the back (51%) and lower extremities (59%). Average pain during the past 24 hours on a 0-to-10 scale was reported as 5.8, with worst pain averaging 7.2. Also, using a 10-point scale to rate how pain affected daily life, interference with sleep was ranked highest (6.0 on average), followed by interference with general activity, normal work, and enjoyment of life. Interference in relationships with other people was least affected by chronic pain (rated 4.1 on average).

Merely 13 percent (N=18) of study participants with chronic pain reported receiving pain management treatment, and these patients were significantly more likely to be female, report less income from employment, and have a lower rate of benzodiazepine use. MMT patients being treated for pain most commonly reported back pain, and the majority of those being treated (89%) were prescribed medications; half received short-acting opioids and a third received nonopioid medications (eg., NSAIDs, gabapentin). Only 28 percent received nonpharmacologic therapies for their pain, such as physical therapy. Overall, those treatments were effective; study participants indicated that pain management provided, on average, 51 percent relief from their pain (range 0%-90%).

In sum, this study found that a substantial proportion of patients in a large MMT program reported clinically significant and persistent pain, for which only a relative handful were receiving pain management therapy. Dunn and her coauthors state, “Overall these data suggest that pain was not being adequately evaluated or treated in the majority of this sample. These findings are remarkable . . . and they illustrate what little progress has been made in the past 10 years regarding the concurrent treatment of pain and opioid use disorders.

Better and More Research is Needed

Similar to Dunn et al., in 2008, Cruciani and colleagues reported a study that found 61 percent of 390 MMT patients had experienced persistent pain for more than 6 months, and greater than a third of those patients (37%) had severe chronic pain (Cruciani et al. 2008). In an Addiction Treatment Forum interview article last year (see AT Forum, Winter 2013), it was noted that pain in patients attending MMT programs is commonplace, and a recent study of 489 patients had found that 237 (48.5%) had clinically significant chronic pain. Generally, past research surveys have reported high but varying prevalences of chronic pain among MMT patients, ranging from approximately 27 percent to 80 percent, with relatively few receiving pain care (references in Dunn et al. 2014).

While the newly reported study by Dunn and colleagues is consistent with most of the past research, it also exhibits many of the limitations in this area of scientific inquiry:

  • Dunn et al. gathered data for their study between December 2006 and January 2007, but were just reporting on results now in 2014; so, the outcomes may or may not reflect current circumstances. Unfortunately, it is not unusual in the pain research literature or government surveys for the reporting of data to come long after its collection.
  • Chronic pain was defined in the Dunn et al. study as answering “yes” to the BPI question, “Have you had pain other than everyday kinds of pain today?” And, even though locations of pain also were reported by patients and recorded by the investigators, this was a somewhat vague definition of chronic pain.This is a common problem encountered in most surveys of chronic pain, since there usually are no readily observable clinical signs or imaging evidence (eg., on X-ray, MRI) of pathology to confirm the presence, severity, or duration of pain. Pain most often is what the patient says it is, without sufficient clinical confirmation; so, it is understandable that there are wide variations in the prevalence of pain reported in different studies of pain in MMT patients, as well as in the general population.
  • There was a small, but significant, increase in benzodiazepine use among patients with pain (small differences between groups in illicit opioid and cocaine use were not statistically significant). However, considering that sleep disturbance was ranked high in persons with pain, this might account for their greater use of sedatives like benzodiazepines; additionally, Dunn et al. did not distinguish between prescribed vs. illicit use of these medications.
  • There was no assessment by Dunn et al. of which came first, pain or addiction, patients’ histories of pain or its treatment, and how MMT might have affected chronic pain. For example, although patients with pain were receiving higher average methadone doses (86 mg/day), the researchers acknowledge that persistent symptoms of opioid withdrawal in some persons were likely confused with chronic pain. Dunn and coauthors also note that some patients might have been receiving certain treatments in the MMT clinic—eg., antidepressants, cognitive behavioral therapy, biofeedback—that were intended for pain management, but not identified as such.
  • In general, the study by Dunn and colleagues surveyed a relatively small sampling of MMT patients in a single clinic setting, which cannot be assumed to represent the larger MMT population. While they present statistical data on those patients receiving pain care during MMT, their numbers were so small (N=18) that the validity of results in this group need confirmation in a larger sampling. For example, the findings that patients receiving pain care were more likely to be women, making less money from employment, and less likely to be using benzodiazepines should be cautiously considered in view of such small numbers.

Dunn et al. do not speculate as to why there is such a high prevalence of chronic pain among MMT patients, or why so few patients receive pain management for those conditions. Clearly, more and better research is needed to understand these problems and to develop strategies for providing effective pain management in the presence of the disease of addiction. At the least, there is a need for prospective studies examining large numbers of patients upon entry to MMT—or buprenorphine therapy—for addiction and during long-term follow-up to determine the progress of those with clinically diagnosed pain conditions.

Challenges and Opportunities

As Dunn and colleagues point out, patients with opioid addiction are likely being “systematically undertreated for pain.” And, while surveys have found that MMT clinic staff are interested in receiving education on treating pain in persons with substance-use disorders, there could be important barriers for MMT patients when it comes to receiving adequate pain care.

Opioid analgesics have been demonstrated as effective for relieving most types of moderate to severe pain, although their long-term use for chronic pain needs further investigation. Dunn and colleagues found that half of their respondents being treated for pain (N=9) were administered short-acting opioids, and Cruciani et al. similarly had noted that 47 percent of MMT patients with pain in their survey were receiving opioid pain relievers. Methadone itself is an excellent analgesic; however, to be effective for pain, it requires more frequent administration than the once-daily (or even split-dose) regimen provided during MMT for addiction. At the same time, many staff in MMT programs are uneducated in, or uncomfortable with, the concurrent administration of methadone and other opioids.

Often multiple types of pain treatment are necessary—spanning the medication and nondrug spectrums—which can be costly and required for extended periods of time. Yet, Dunn and her coauthors note, patients in addiction treatment have historically had limited access to insurance or other financial resources for such care. Furthermore, the pain-care field is highly fragmented, with the various specialists—eg., rheumatologists, orthopedists, neurologists, physiatrists—in high demand and short supply in most communities.

Dunn et al. conclude that their study should illustrate to health care professionals in both the substance abuse treatment and pain management fields that “patients with both disorders are not necessarily intractable hopeless cases and that they deserve the same level of attention and clinical care as chronic pain patients in the general population.” However, unless the many challenges are overcome, the plights of persons with chronic pain in methadone or buprenorphine maintenance treatment are unlikely to improve. There is an important opportunity here for the addiction treatment and pain care fields to forge alliances that can serve the mutual goal of achieving better care for patients with co-occurring pain and opioid use disorders.

References

Cruciani RA, Esteban S, Seewald RM, et al. MMTP patients with chronic pain switching to pain management clinics. A problem or an acceptable practice? Pain Med. 2008;9(3):359-364. doi: 10.1111/j.1526-4637.2006.00224.x. http://www.ncbi.nlm.nih.gov/pubmed/18366514

Dunn KE, Brooner RK, Clark MR. Severity and interference of chronic pain in methadone-maintained outpatients [Epub ahead of print April 7, 2014]. Pain Med. doi:10.1111/pme.12430. http://www.ncbi.nlm.nih.gov/pubmed/24703517

IOM (U.S. Institute of Medicine). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. June 2011. http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx.

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Stewart B. Leavitt, MA, PhD, is a former editor of Addiction Treatment Forum and most recently was director/editor of Pain Treatment Topics.

Saying “Farwell” to Pain-Topics.org

At the end of January, the Pain-Topics.org website was permanently shut down. However, most of the Pain-Topics.org resources, including proprietary research/review articles, will be moved to The Pain Community (TPC) website — at http://paincommunity.org — allowing continued and free access by all interested persons.

The Pain-Topics News/Research UPDATES will continue to be posted on a periodic basis at http://pain-topics.blogspot.com. If you would like to receive notification of when the UPDATES are posted you can subscribe via FeedBurner at: http://feedburner.google.com/fb/a/mailverify?uri=PainTopicsUpdates&amp;loc=en_US

Source: PainTopics.org – January 2014

New Resources Available From SAMHSA

Based on TIP 53: Addressing Viral Hepatitis in People with Substance Use Disorders – A Quick Guide for Clinicians and Administrators

Offers clinicians information to address viral hepatitis when working with people with substance use disorders. Covers hepatitis prevention, screening, treatment, and service coordination, and guides administrators on how to add or improve hepatitis services.

http://atforum.com/addiction-resources/documents/TIP53QuickGuide_000.pdf


Based on TIP 54: Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders – A Quick Guide for Clinicians and Administrators

Summarizes guidelines for clinicians treating chronic pain in adults with a history of substance abuse. Covers patient assessment, chronic pain management, managing addiction risk in patients treated with opioids, and patient education.

http://atforum.com/addiction-resources/documents/TIP54QuickGuide.pdf

Source: Substance Abuse Mental Health Services Administration – November 2013

Poorly Managed Pain Relief Can Have Devastating Consequences for Addicts

pain“Research led by King’s College London’s National Addiction Centre (NAC) calls for systemic attempts to reduce stigma and raise awareness amongst healthcare professionals when treating current or former addicts

The mismanagement of pain in current and former addicts can have disastrous, life-threatening consequences, according to a report published today by researchers from King’s NAC.

The report, which was commissioned by Action on Addiction and is endorsed by the Royal College of Psychiatrists, warns that current and former addicts are at risk of relapse to addiction, compromised medical care and potentially fatal overdose when being treated for pain in hospitals and doctors’ surgeries. The report, entitled The management of pain in people with a past or current history of addiction, identifies the stigma surrounding addiction as the main barrier to safe and effective pain relief.”

http://www.healthcanal.com/substance-abuse/39786-poorly-managed-pain-relief-can-have-devastating-consequences-for-addicts.html

Source: HealthCanal.com – June 13, 2013

New Poll Ranks Chronic Pain Well Below Drug Addiction As A Major Health Problem

“A new national public opinion poll commissioned by Research!America shows only 18% of respondents believe chronic pain is a major health problem, even though a majority of Americans (63%) say they know someone who experienced pain so severe that they sought prescription medicines to treat it. Chronic pain conditions affect about 100 million U.S. adults at a cost of approximately $600 billion annually in direct medical treatment costs and lost productivity.

Most Americans are concerned about the misuse of pain medication to treat chronic pain. A high percentage (82%) believes that taking prescription painkillers for long-term, chronic pain could result in addiction, which nearly 50% of Americans describe as a major health problem. An overwhelming majority (85%) are very concerned or somewhat concerned that prescription pain medication can be abused or misused. Indeed, 40% believe that prescription medication abuse and addiction is a major problem in their community.”

http://www.medicalnewstoday.com/releases/258897.php

Source: MedicalNewsToday.com – April 12, 2013

Chronic Pain in Opioid Treatment Program Patients Typically Untreated

Many patients in opioid treatment programs (OTPs) are likely to have chronic pain, but in many, that pain will not be adequately treated, in part because there are so many problems balancing the methadone they are given for opioid dependence with the types of medications needed to treat pain.

“Most physicians in an OTP have experience treating addiction and pain, I can guarantee that,” said Nicholas Reuter, MPH, senior public health analyst with the Center for Substance Abuse Treatment (CSAT) at the federal Substance Abuse and Mental Health Services Administration (SAMHSA). “I go in and inspect the programs, and I can see patients who obviously have some chronic pain issues. They’re not hard to identify—they have canes, walkers, and scars.”

But OTPs cannot be pain management clinics because of regulations, said Randy Seewald, MD, medical director of the methadone maintenance treatment program at Beth Israel Medical Center in New York City.  “If a patient comes to us and says, ‘I just want methadone once a day for pain,’ we can’t admit them,” said Dr. Seewald, who has a fellowship in pain management. Sometimes patients may say this because they don’t want to admit that they are addicted.

Methadone needs to be given multiple times each day for pain relief. And the federal regulations allow OTPs to dose only once a day, which is adequate to prevent withdrawal.

At Beth Israel, the first OTP in the country, many patients are older, noted Dr. Seewald. “In general as people age, they are more likely to develop chronic pain,” she said, adding that many Beth Israel patients have had significant illnesses, including HIV and hepatitis C. She defines chronic pain as pain lasting 6 months or more.

Study: Epidemiology of Pain in MMT Programs

“We know this is a vulnerable population of chronic pain patients,” said Lara K. Dhingra, PhD, Co-chief of the Research Division in the Department of Pain Medicine and Palliative Care at Beth Israel. “Patients who are on methadone for treatment of their addictive disorder may still require treatment for their chronic pain, and at present there aren’t any guidelines for protocols we should be following with respect to the medication regimen,” said Dr. Dhingra, who works with Dr. Seewald. “The majority of patients are likely to not have their pain treated.”

Dr. Dhingra is the lead author of “Epidemiology of pain among outpatients in methadone maintenance treatment programs,” part of a larger study funded by the National Institute on Drug Abuse (R01DA020781, R01DA020841), published in the August 27 issue of Drug and Alcohol Dependence. Her study (Dr. Seewald and Russell K. Portenoy, MD, chairman of the Department of Pain Medicine and Palliative Care, are among the co-authors) was based on sites in New York and San Francisco in which all patients had hepatitis C. Of the 489 patients in the study, 237 (48.5 percent) had clinically significant pain.

The patients treated their pain with prescribed opioids (38.8 percent of patients), non-opioids (48.9 percent) and self-management approaches, including prayer (33.8 percent), vitamins (29.5 percent), and distraction (12.7 percent). (Some patients used more than one approach.)

The same steps that are followed for people who are not opioid dependent should be followed for OTP patients with chronic pain, said Dr. Seewald. This means diagnosing and trying to treat the cause if possible, starting with non-drug therapies and nonopioid drugs, and considering opioids only if an assessment indicates that these drugs are likely to be safe and effective, and taken in a responsible way over time. In this population, opioids often are viewed as the last resort, but for many OTP patients who have hepatitis C, acetaminophen, with its liver effects, would not be appropriate, and NSAIDs have a high risk of gastrointestinal bleeding, she said.

The primary care provider (PCP) is generally in charge of pain management, said Dr. Seewald. But she noted that the OTP sees the patients much more frequently than either the pain specialist or the PCP, and the OTP is required by the Joint Commission to assess pain at every visit.

Methadone for Pain

Interestingly, methadone can be a great medication for pain in general, because it does not produce the euphoria or rush of other opioids in patients who may be predisposed to this effect, said Dr. Seewald. “Methadone is challenging to use for pain, however, and doctors who do not have experience in using it this way should obtain help before doing so.” 

Although Dr. Seewald did a fellowship in pain management—precisely because so many OTP patients have pain—she does not treat patients for pain alone, even in her private practice. “I’m also a pain specialist, but if I have someone with pain and addiction, I will work with another pain specialist,” she said. “You don’t want to be the only one involved.”

 Need for Training on Opioids and Pain

“The federal regulations don’t say anything about pain treatment,” said Mr. Reuter. “They’re really tailored toward treating dependence.” But OTPs are ideal, in many ways, for dealing with patients who need opioids. With all of the training given to OTP physicians about the pharmacology of methadone treatment, said Mr. Reuter, these physicians would be likely to have more knowledge about opioids and their risks than average physicians. “Methadone is one of the most complicated opioids there are,” he said.

Primary care physicians need to know more about medication-assisted treatment of addiction, but it works both ways—OTPs need to know more about pain, said Dr. Seewald. “I worked in drug treatment with methadone patients for 20 years before I took my pain fellowship. We were never trained to treat pain.”

Perspective: Docs Feel Pressure to Give Addicts Opioids

doctors“A push to treat chronic pain and financial disincentives for treating addiction may pressure clinicians into prescribing opioids for patients who are already addicted, a researcher suggested.

Over the past decade, there’s been a perfect storm of changing clinician attitudes toward pain treatment and patient attitudes towards suffering, combined with a lack of compensation for time-consuming clinic visits such as addiction counseling, Anna Lembke, MD, of Stanford University, wrote in a perspective in the New England Journal of Medicine.”

http://www.medpagetoday.com/Psychiatry/Addictions/35539

The full perspective can be accessed at: http://www.nejm.org/doi/full/10.1056/NEJMp1208498

Source: MedPageToday.com – October 24, 2012

3Qs: When Painkillers Kill

The U.S. Food and Drug Administration recently introduced a series of safety measures designed to reduce the risk of extended-​​release and long-​​acting opioid medications. Northeastern University news office asked drug policy expert Leo Beletsky, an assistant professor of law and health sciences at Northeastern University, to expound upon the threat posed by opioid analgesics, 22.9 million prescriptions of which were dispensed last year. The Q & A’s include:

  • Why has opioid abuse increased over the last decade?
  • How has President Barack Obama’s 2011 Prescription Drug Abuse Prevention Plan fared in curbing the abuse of prescription drugs, the second-most abused category of drugs after marijuana?
  • What would be your strategy for improving the safe use of opioids while ensuring access to prescription drugs for patients in pain?

http://www.northeastern.edu/news/2012/08/opioids/

Source: MedicalExpress.com – August 3, 2012

Vital Signs: Risk for Overdose from Methadone Used for Pain Relief — United States, 1999–2010

According to a new report from the Centers for Disease Control and Prevention (CDC) prescription painkiller overdoses were responsible for more than 15,500 deaths in 2009. While all prescription painkillers have contributed to an increase in overdose deaths over the last decade, methadone has played a central role in the epidemic. More than 30% of prescription painkiller deaths involve methadone, even though only 2% of painkiller prescriptions are for this drug. Six times as many people died of methadone overdoses in 2009 than a decade before.

The report also acknowledged that methadone has been used safely and effectively to treat drug addiction for decades. It has been prescribed increasingly as a painkiller because it is a generic drug that can provide long-lasting pain relief. But as methadone’s use for pain has increased, so has nonmedical use of the drug and the number of overdoses.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm61e0703a1.htm?s_cid=mm61e0703a1_w

http://www.cdc.gov/VitalSigns/MethadoneOverdoses/

Source: The Centers for Disease Control and Prevention - July 6, 2012

Heroin Addicts Have Higher Pain Sensitivity, Even During Treatment

Heroin addicts often have an increased sensitivity to pain, and this sensitivity does not subside over the course of treatment with methadone or other opioids, new research finds.

Researchers from the University of California-Los Angeles sought to determine how increased sensitivity to pain might change as a heroin addict moves from drug abuse to stabilization and eventually to maintenance on a pain-treatment opioid such as methadone or buprenorphine.

http://health.usnews.com/health-news/news/articles/2012/04/25/heroin-addicts-have-higher-pain-sensitivity-even-during-treatment

Source: USNews.com– April 25, 2012

Veterans of Iraq, Afghanistan Wars with Mental Health Diagnoses More Likely to Receive Prescription Opioids for Pain

Iraq and Afghanistan war veterans with mental health diagnoses, particularly posttraumatic stress disorder, are more likely to receive prescription opioid medications for pain-related conditions, have higher-risk opioid use patterns and increased adverse clinical outcomes associated with opioid use than veterans with no mental health diagnoses, according to a study in the March 7 issue of the Journal of the American Medical Association (JAMA).

Greater exposure to combat coupled with improvements in battlefield medicine and protective gear have resulted in large numbers of veterans of Iraq and Afghanistan surviving injuries that would have been fatal in prior wars. Veterans are returning home with co-existing mental and physical health problems, and posttraumatic stress disorder (PTSD) is the most prevalent mental health disorder. “Nationwide, the prescription of opioid analgesics has nearly doubled since 1994 because of a greater recognition of the importance of treating pain. At the same time, rates of prescription opioid misuse and overdose have increased sharply, and prescription opioids are now a leading cause of death in the United States. Iraq and Afghanistan veterans with pain- and PTSD-prescribed opioids may be at particularly high risk of prescription opioid misuse given the high co-occurrence of substance use disorders among veterans with PTSD,” according to background information in the article.

Karen H. Seal, MD, MPH, of the San Francisco Veterans Affairs Medical Center, and colleagues examined the association between mental health disorders and patterns of opioid prescription use, related risks, and adverse clinical outcomes, such as accidents and overdose, among a national sample of 141,029 Iraq and Afghanistan veterans. The study included veterans who received at least one non-cancer-related pain diagnosis within one year of entering the Department of Veterans Affairs (VA) health care system from October 2005 through December 2010.

Additional information on the study is available at: http://pubs.ama-assn.org/media/2012j/0306.dtl#1

Journal of the American Medical Association – March 6, 2012

SAMHSA Issues New Treatment Improvement Protocols (TIPS) on Hepatitis and Chronic Pain

TIP 53: Addressing Viral Hepatitis in People with Substance Use Disorders

This TIP was developed to assist behavioral health professionals who treat people with substance abuse problems in understanding the implications of a diagnosis of hepatitis. The TIP discusses screening, diagnosis, and referrals and explains how to evaluate a program’s hepatitis practices.

http://atforum.com/addiction-resources/documents/TIP53.pdf

TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

TIP 54 was developed to help equips clinicians with practical guidance and tools for treating chronic pain in adults with a history of substance abuse. The document discusses chronic pain management, including treatment with opioids, and offers information about substance abuse assessments and referrals.

http://www.atforum.com/addiction-resources/documents/TIP54.pdf

Source: The Substance Abuse and Mental Health Services Administration – December 2011 & January 2012

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