A Smooth Landing

A Smooth Landing vs. “Crash and Burn”: The Exit Strategy for Chronic Pain Patients

An ASAM presentation by Herbert Malinoff, MD

Pain & Addiction: Common Threads XI             April 16, 2010

Reviewed by Franklin Perry, M.D., Ph.D.

· Dr. Malinoff, the Medical Director of Pain Recovery Solutions and Clinical Faculty at the U of Michigan Medical Center presented this masterful and thought-provoking talk at the recent ASAM meetings in San Francisco about the exceptionally challenging topic of how to manage the situation in which a person is taking high doses of opioids and still experiencing significant pain.

· Objectives included learning diagnostic approaches to chronic pain, chemical dependency, opioid hyperalgesia, and other co-morbidities; identifying failure of opioid therapy in chronic pain patients; and investigating clinical strategies.

· Typical physician’s strategy for treating non-malignant pain progresses from ibuprofen to hydrocodone (“Vicodin”) to something stronger to more to even more to discharging the patient.

· What is pain? A simple clinical definition (attributed to Scott Fishman, MD): “Whatever the patient states it is unless proven otherwise by poor adherence to the agreed upon medical regimen.”

· Chronic pain syndrome = “central” pain syndrome. Neuroplasticity (rewiring or reconnecting of neurons in the brain and spinal cord) is influenced by excitotoxicity, central sensitization, genetic predisposition, possible trauma/abuse, addiction/psychiatric co-morbidities, and neurohormonal derangements.

· Pain is the most highly modulated sensory experience. Pain (noxious) signals coming toward the brain are subject to inhibitory and/or facillatory processes in the spinal cord and brain. Opioid analgesics enhance inhibition initially, but may facilitate later in the course (hyperalgesia). Addictive illness facilitates.

· Many with chronic pain have co-morbidities including 4 overlapping domains: chronic pain, psychiatric illness, medical co-morbidities, and addiction.

· Dependence ≠ addiction: tolerance and withdrawal are universal with prolonged opioid treatment; aberrant behavior is required to diagnose addiction.

· Diagnosing addiction? The first and easiest question is: “Do you smoke?” The second is: Have you ever smoked? An affirmative answer to the first question indicates ongoing addiction. An affirmative answer to the second question indicates addiction that may be in remission.

· Medical co-morbidities that are common and significant include sleep apnea, deficiency states (Vitamin D, testosterone), acute pain, chronic painful conditions (rheumatologic, neurologic, statins), and brain injury.

· Psychiatric co-morbidities include mood disorders, PTSD, anxiety disorders, thought disorders, personality disorders, OCD

· Consider these needs!! Need to address all 4 areas of co-morbidity for success AND the need to avoid “crosstalk” (when one doctor’s treatment undoes another’s)

· Why use opioids? TO IMPROVE FUNCTION!! (and relieve pain). This is the position now taken by the American Pain Society among others.

· The trouble with opioids: tolerance and withdrawal, addiction potential, hyperalgesia (central sensitization), adverse effects, regulatory fears

· Opioid hyperalgesia: “If any man wants to learn sympathetic charity, let him keep pain subdued for six months by morphia, and then make the experiment of giving up the drug. By this time he will have become irritable, nervous and cowardly. The nerves, muffled, so to speak, by narcotics, will have grown to be not less sensitive, but acutely, abnormally capable of feeling pain and of feeling as pain a multitude of things not usually competent to cause it.” S. W. Mitchell, MD (Civil War surgeon in U.S. Army).

· Patients maintained on long-term opioids develop diminished pain tolerance as demonstrated in many studies.

· Opioids should be stopped if and when: they are not clearly beneficial, like any other medication.

· Medical withdrawal from high doses of opioids: can be done safely with inpatient management, even with patients with significant co-morbidity. Needed: hospital, nurses, patient-controlled analgesia (PCA) with hydromorphone (Dilaudid), and buprenorphine (Suboxone).

· Buprenorphine (Suboxone or Subutex): a synthetic opioid that functions as a partial agonist at the µ opioid receptor (only partially activates, thus safer regarding respiratory depression), high affinity for the µ receptor (binds more tightly than other opioids), dissociates slowly from the receptor (therefore milder withdrawal), and functions as an antagonist at the κ receptor (may be responsible for effects on chronic pain).

· Admitting diagnoses: intractable pain (338.2) and medication toxicity (995.2); must document need for inpatient care (e.g. nursing observation of unstable patient & need for parenteral meds).

· Buprenorphine induction recipe: Stop all opioids on admission; start PCA and allow 3-5 half-lives of the patient’s opioids; address sedatives; get appropriate consultations; stop PCA; wait for opioid withdrawal (6-8 hours); give buprenorphine SL or IM q6h x 4; discharge patient home on SL meds; office follow up in 7-10 days.

· Methadone detox (for pain): follow methadone blood levels; use PCA until methadone level falls below 30 mg/ml (may be 5-7 days); proceed with buprenorphine induction.

· Sedatives (benzodiazepines, muscle relaxers, Soma, Ambien, etc.) in chronic pain patients: do not use, because they cause cognitive dysfunction.

· Medical withdrawal from sedatives: consult with prescribing MD, stop sedatives and start oral phenobarbital at 30 – 60 mg TID/QID; titrate to symptoms; aim for sub-therapeutic blood levels (< 15 ng/ml); taper slowly over 6-12 months; consider gabapentin, oxcarbazine, pregabalin as adjuncts/alternatives.

· Outcomes: (see Malinoff, H., Weiner, M., Michaels, E., et al. 2010). 57% of patients reported significant improvement in pain control; 64% reported significant improvement in functional capacity 9 months later.

· Adverse effects: GI/GU symptoms, headache, sweating, NO DEATHS.

· “They don’t make pills for your problem!”

· Recovery from chronic pain:

o Physical health and function: manage underlying medical issues; improve physical strength and endurance; decrease pain and suffering.

o Neuropsychiatric healing: stabilize brain chemistry and functioning; improve cognitive ability, memory, and physical coordination; decrease perceived pain.

o Emotional well-being: decrease anxiety, depression, sleep disturbances; restore self-esteem; reduce pain-related suffering.

o Spiritual growth: Reconnect with family, friends, and peers; re-establish life direction and purpose; gain peace of mind and serenity. Volunteer work!

· Summary: Chronic pain, addiction, and psychopathology are common, related, and interdependent brain illnesses. Attempting to manage one without the others leads to failure and futility in all. Hyperalgesia and sedation complicate the management of chronic pain patients and lead to adverse outcomes. Medical withdrawal from high doses of opioids and sedatives can be accomplished safely and comfortably in the inpatient setting.

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