Thank you. Thank you for everyone in attendance. I'm sure more will join. Welcome to our fourth and final webinar in the series, Testimony from the Trenches. For the past four months, we've reexamined treatment norms around providing buprenorphine for opioid use disorder. In November, we reconsidered the role of urine drug testing and we discussed potential harms from reflexive urine testing in office-based treatment. In December, we discussed the low threshold buprenorphine treatment, which describes an approach that removes as many barriers as possible towards allowing a person to receive medication. Last month's webinar prompted a lively discussion afterwards when we talked about introducing buprenorphine treatment into residential treatment settings that have been historically abstinence-based. If you've not attended these prior webinars, then you've missed some lively discussions that followed, but the presentations themselves are available on the AOAAM website. We will follow the same process today. The presentation will be recorded and then available for viewing on-demand at the AOAAM website, and then we will stop the recording and we will leave ample time for discussion amongst attendees. After the presentation, we definitely want to hear from attendees about today's topic and we want to hear about how you manage pain in patients with opioid use disorder. In other words, we want your testimony from the trenches. We are very fortunate to have our next speaker to cap things off in this series. Elise Wessel is a fellowship-trained, board-certified addiction medicine physician practicing at Carl Addiction Recovery Center in Champaign, Illinois. She is board-certified in family medicine and completed a family medicine residency at Carl Foundation Hospital in Champaign. She completed medical school at A.T. Steele University. She served as a volunteer in service to America at a healthcare for the homeless clinic in Casper, Wyoming through AmeriCorps. She graduated from the University of Wisconsin-Madison Addiction Medicine Fellowship Program. She now works in outpatient, inpatient, and mobile healthcare settings providing treatment for people with substance use disorders. She serves as a clinical assistant professor of medicine at the Carl Illinois College of Medicine. She is an Illinois Society of Addiction Medicine board member and she chairs the education committee. She is dedicated to providing education for clinicians, residents, and medical students in an effort to banish stigma, inform policy, and promote evidence-based treatment for people who suffer from the disease of addiction. And I will add, we've been extremely fortunate to have her join our education committee where she's brought a lot of energy and enthusiasm and expertise. And I'm very happy to turn the presentation over to Dr. Wessel about safer pain management practices in people with opioid use disorder. Thank you for the introduction, Dr. Lefkley. I'm going to share my screen now. Good evening, everybody. Thanks for joining tonight. I'm looking forward to a lively discussion. I have no disclosures. Tonight's objectives will be to conceptualize the pain and addiction neurocircuitry, analyze the factors influencing the pain experience, develop safer opioid prescribing for patients with an opioid use disorder, decrease risk for people to develop an opioid use disorder and prevent lapses, and then also understand how to treat acute and chronic pain in patients on MOUD. We've all seen this schematic before of the neurocircuitry involving the development of addiction. So we know there are genetic, epigenetic, and environmental factors, personal experience in the development of addiction. The cause of addiction we know is a brain disease with environmental factors and stems from a dysfunction of the mesolimbic system, which goes on to affect our executive decision-making in the prefrontal cortex. And so with review of this, we will go on to now this schematic, which evolved from fMRI research of brain pathways associated with the development of chronic pain and addiction and depression. And so we know that chronic pain is a complex neuropsychiatric disorder. It's characterized by sensory, cognitive, and affective symptoms. Part of the development of chronic pain syndromes includes the dysregulation of the dopamine function in the mesolimbic system, not unlike the brain roles in the development of addiction. And so not only are addiction and chronic pain pathways interrelated, but also those of depression. I want to emphasize that addiction is not equal to tolerance or physical dependence. Tolerance and physical dependence are natural pharmacodynamic properties of many medications, including opioids. And so again, patients with tolerance typically require a higher amount of a certain medication to achieve a desired effect. Physical dependence occurs when people experience withdrawal symptoms when abruptly stopping a medication. And then misuse. Misuse is defined as a medication used in a different amount, a different frequency, route of administration, or different purpose than what the prescriber intended. Again, these factors do not necessarily equal addiction. And before I go on, there were SAMHSA, based on SAMHSA's national survey, the NSSA, in 2017, around 11 million people, 12 and older, misused prescription pain relievers in the past year. And repeated use of opioids, prescribed or non-prescribed, increases the risk of developing an opioid use disorder. So it's important to identify misuse before it becomes an opioid use disorder. And then we know that the criteria for a substance use disorder or an opioid use disorder involve behaviors associated with that person's substance use. The pharmacodynamic properties of tolerance and withdrawal are not included if it is due to a prescription medication taken as prescribed. Otherwise, they will be counted in the DSM-5 criteria. So when choosing medications for your patients who are experiencing acute or chronic pain, it's important to recognize factors influencing the management of their pain and risk factors for development of an opioid use disorder. This would be primary prevention for the development of an opioid use disorder. People are at increased risk for the development of an OUD when they have a personal family history, particularly in parents or grandparents, a personal history of SUD. If they have a low distress tolerance, pain-related anxiety, you can use the pain catastrophizing scale to further assess this out. And we'll talk about that a little bit more. There are additional biopsychosocial factors leading to the pain experience, including adverse childhood events, history of trauma, and psychiatric comorbidities. And then patients who are on opioids chronically can have hyperalgesia. And then, of course, tolerance will influence prescribing practices. So in regards to pain catastrophizing, we have now recognized the amygdala plays a role in modulating the pain experience, including this what's called pain catastrophizing. They're exaggerated and abnormal functional connectivity within the mesolimbic and executive functioning network in our brains. So the pain catastrophizing scale is a 13-question, 13-statement evaluation that is scored on a Likert scale from 0 to 4. Scores greater than 30 and indicate clinically relevant level of catastrophizing, where intervention should be warranted. The modifiers here, the HMR, H is helplessness, M is magnification, and R is rumination. Each of these factors can guide treatment. So would CBT be appropriate for the patient, ACT, which is acceptance and commitment therapy, mindful-based strategies within a multimodal paid management approach. So when you're looking at prescribing opioid agonist, so whenever I am using the term opioid agonist, I'm going to be referring to medications other than buprenorphine and methadone. So we want to remember that acute pain is treated in a similar fashion regardless of a patient's addiction history. People can tend to avoid going to hospitals with painful conditions, especially if they have a history of addiction because of stigma. Their pain may not be treated as well. They may not be given appropriate medications due to their history of addiction, and so many people actually tend to avoid going to the hospital when they need to. However, to minimize risk for unsafe opioid behaviors, whether that's preventing relapse in a person with an opioid use disorder, whether that's primary prevention to prevent the development of an opioid use disorder, there are generalized standards that we typically use, and so those are checking the PDMP for what other medications they could be on or could be prescribed, have been in the past or now. It's ideal for one provider to provide all the pain medication prescriptions, starting at the lowest most effective dose to achieve adequate response is optimal. Tolerance, of course. If they're not opioid naive, they will have a tolerance and typically require a higher dose than somebody who is not opioid naive. Weaning the medication periodically to reassess pain control, and then using non-psychotropic pain meds when possible, and of course always prescribing naloxone. Concurrent prescriptions of benzodiazepines, C-drugs, and other CNS suppressants like epipentin or pregabalin greatly increase risk for overdose when used in combination with opioids, and so always warning the patient of this or trying to avoid them if at all possible. We will get into the use of non-pharmacological therapies and non-opioid therapies to manage pain. It's important to monitor liver and kidney functioning, assess for the effectiveness of the dose. We're looking for functionality, improving somebody's daily life and quality of life with the medications, avoiding over sedation, drug liking, euphoric effect, all which can lead to lapse or addiction. If there are any legal concerns when using pain medications in people who have a history of addiction, clear documentation, indication for the medication, dosing interval, amount provided can all be helpful. Then just addressing addiction. Is the patient in sustained recovery? Is their mucous or active? What are the risks for relapse? Would it be helpful to get a family member involved to help manage medications? What is their support system like? What is their mental health like? So, when prescribing opioids for acute pain, the likeliness of continuing to use opioids increases after five days of being on the medication, of being on the opioid. And so, when, and this is in opioid naïve people, so when prescribing opioids, if prescribing them for less than seven days, ideally three or less can potentially mitigate the risk for chronic opioid use and or the development of an opioid use disorder. Additionally, many practitioners treat chronic pain with opioids despite the lack of evidence that opioids are better for treating chronic pain more effectively than non-opioid pain relievers like NSAIDs or Tylenol. And so, there is not an abundance of there is not an abundance of evidence supporting opioids for chronic pain in terms of effectiveness at managing the pain. So, if, and we all, and we know that patients on chronic opioid therapy experience many poor outcomes, including greater likelihood of hospitalization, deaths due to overdose, and other life-threatening conditions. Patients also prescribe chronic opioids face a high risk of developing opioid use disorder. And more than 25% of people on chronic opioids for chronic non-cancer pain do have features of opioid use disorder. So, again, primary prevention, avoiding it if at all possible. So, now we'll get into multimodal pain management approaches. This is going to be important for your patients who are on MOUD and then those who are not as well. And so, this can include, yeah, bentinoids, again, the CNS suppressants when used in combination with opioids can increase the risk for overdose. And then when taken together, opioids do increase the Gavapent absorption, which have led to black box warnings on the prescriptions of both of the drugs. So keep that in mind and weigh the risks versus benefits when prescribing Gavapentinoids. Again, acetaminophen NSAIDs, heat or ice, topicals, lidocaine-patched TENS units, distraction techniques, your CBT, mindfulness, nerve blocks, and OMT. So Tylenol or acetaminophen can help treat chronic low back pain. It's effective for treating osteoarthritis, migraine, and both acute and chronic pain. You know, the risk of hepatotoxicity increases above more than three to four grams a day, and people should have lower dosage. If they have chronic heavy alcohol use, they have an alcohol use disorder or liver disease. NSAIDs, they help treat localized osteoarthritis, beneficial for acute and chronic pain. You need to be careful for cardiac risks, GI bleeds, renal impairments with long-term high dosage use of NSAIDs. Your anticonvulsants like pregabalin, gabapentin, and carbamazepine are helpful for neuropathic pain. They do have abuse potential. Again, gabapentinoids are used to augment highs for people with the opioid use disorder. They can lead to sedation, respiratory depression, dizziness. And then the TCAs, SNRIs like amitriptyline, duloxetine, fentanyl vaccine, they're helpful for pain management in settings like fibromyalgia. TCAs are less desirable in elderly folks because of the anticholinergic properties. And then OMT, we should all know our local friendly osteopath to help our chronic pain patients. Again, capsaicin cream, diclofenac gel, muscle relaxers can be helpful. You have to be careful again with those CNS suppressants. Sub-dissociative dose ketamine infusions can be helpful for acute pain in hospitalized settings. TENS units, nerve blocks. Exercise therapy, very important. Yoga, swimming, which can be easier on the joints. CBT and coping skill development for dealing with or managing chronic pain and with addiction. And then support groups are helpful. And then sleep is very important. Sleep can impact all areas of our life, mood, decision-making, and the pain experience. And so one of the benefits of implementing a multimodal pain approach can allow for opioid tapering if a person is on any kind of opioids for opioid agonist or chronic non-cancer pain. And then I'm highlighting opioid tapering here because not many folks receive a lot of guidance for opioid tapering. It's one of the questions I get asked the most. And so just following a general rule of thumb, tapering opioids in patients who have taken them for less than one year. You can reduce the dose by 10% a week or those for more than one year would typically do better at a slower taper at a reduction of 10% a month. And so this is adjusted based on the patient's comfort level. It can be faster or slower depending on the individual. Close follow-up is important with limited prescriptions. If you're giving a patient a month's worth of time and asking them to reduce their total dose by 10% a week, that's likely not going to have the outcome you or the patient desires. So if you're able to have close follow-up and schedule like weekly or even monthly, if you're reducing a month at a time will be helpful, especially with patients sticking to the plan. And then provide management of any opioid withdrawal symptoms as they come up. Typically with a slow enough taper, patients won't experience a profound opioid withdrawal syndrome, but symptoms may come up. And I won't go through all of these, but having a plan in place and discussing with the patient for anything they may come up can help ease the anxiety around tapering. Okay, so when patients are on MOUD and they have comorbid pain, in the setting of chronic pain, split dosing is going to be helpful to get the most out of the opioid agonist, whether it's methadone or buprenorphine, because they do both have analgesic effects. I know that at some of the OTPs where I live and work, they do offer split dosing, which can be helpful for people with chronic pain. And then for buprenorphine, smaller, more frequent dosing will typically achieve greater analgesic effect. And so for chronic pain, split dosing to BAD to TAD, for acute pain, that should be TAD to QID dosing. And alternatively, if a person wants to maintain their buprenorphine, like taking it at eight, for example, eight milligrams in the morning, you can have, typically start at 25% of the total dose, add that for split dosing to manage the acute pain. And so these, I'm not going to go through there just for your own edification for in regards to buprenorphine, methadone, and naltrexone. Now, if somebody is on acetylalase naltrexone or Vivitrol and comes in with a traumatic accident, like a car accident with acute pain, you can override that blockade with high doses of potent opioids, such as fentanyl. In an observed setting, like a hospital, you need to watch out for respiratory depression because you're trying to override that blockade, but pain control can be achieved with opioids. And then also using a multimodal pain management approach. Right, and then when managing buprenorphine in a patient who has an upcoming surgery or procedure, if they're taking more than eight to 12 milligrams a day, it's helpful to reduce their dose to around eight milligrams a day, a day or two before surgery. And then that way they free up some of your muropoid receptors for anesthesia or acute pain control post-operatively. And again, people who are maintained that eight milligrams throughout this perioperative period will need higher doses of folate agonists to achieve pain control, again, in a multimodal pain management approach. So keeping somebody on a basal dose of buprenorphine through this perioperative period is helpful because then they will not have to go through an induction again on buprenorphine, which having a person stop their folate agonists for pain management, returning to buprenorphine can put patients at increased risk for a lapse or return to other substance use, depending on the person and the person's psychosocial environment and factors. And so this eliminates that. People find it easy to just maintain themselves on this eight milligrams a day, getting their acute pain treated as necessary. And they don't have to worry about going through withdrawal, re-inducting themselves. If they are at less than 12 milligrams or eight milligrams a day, then just continuing on their doses without changing it or needing to alter it is what's recommended. And this is from the Pain Journal, several years ago. And it's one of the buprenorphine managements we use here. Anesthesiologists and surgeons are all on board with it. It is very important though to coordinate care with the person surgeon to discuss pain management because sometimes they won't get a high enough dose of opioids if needed for acute pain postoperatively. All right. And so again, reassuring patients that their addiction history will not prevent them receiving adequate pain management can be helpful in managing the patient's anxiety related to their pain and pain experience. Again, coordinating with the patient's care team is important. And of course, pain can be a little bit trickier to treat because of a read cross tolerance, hyperalkesia, and then decreased pain threshold in some individuals. Whenever managing pain, offer clear instructions, schedule dosing orders and avoid as needed medications. And recognize that attitudes of healthcare providers towards patients with OUD and chronic pain can be stigmatizing, invalidating, shaming, and judgmental. So being empathetic, offering words of support and being an advocate for them can go a long way. And again, I talked about this earlier. Individuals with OUD often avoid going to hospitals when they need to most, and around half of people with OUD will use illicit substance while hospitalized due to undertreatment of pain. And so they know what works for them and can self-medicate. And hospitalized patients with SUD are three times more likely to leave AMA. And this is associated with doubling of all-cause mortality. So it's important to recognize inherent biases and stigma in healthcare settings to avoid these situations, which can be devastating. And then one last point, I wanted to point out the CDC guideline misapplication. So one of the issues that we are facing here in Illinois is that clinicians can be cutting people off of opioids for specifically for chronic non-cancer pain. There's no good plan for them to manage their pain. There's no tapering being offered. And so this puts people in a really, really tough space where they are doing whatever they can to manage their own pain. And that can be going to the ED over and over again. It could be doctor shopping. It could be going to street sources where the chance for overdose is extraordinarily high. And so whenever you see patients who have been on opioids at high MMEs or greater than 90, that doesn't necessarily mean they have an overdose disorder that they need to be tapered off quickly, that they need to be at a dose less than 90 MMEs a day. It may mean that that's what they're doing well on or they may need multimodal pain management. And so avoiding abrupt tapering or sudden discontinuation opioids should be avoided at all costs. And you see this time and time again, and it puts patients again in such a difficult place. So that is all I have to say about that. And I will stop sharing and open it up to discussion. We can go over a case if needed, but I imagine a lot of people will have a lot of things to say. Yeah, great. Hey, thank you for that presentation, Dr. Wessel. I will say there was one question if we could answer quick and then we'll stop the recording. The question is, it is important. Is it important to distinguish what types or causes of chronic pain will and won't respond to opioid analgesics? Is there any evidence base for this type of pain will do well or won't do well? I'm not sure if there is, or I'm not aware of one, but. Yes, so migraine pain should not be treated with opioids. It typically, it doesn't work as well as other migraine medications. Same with fibromyalgia, TCAs, SNRIs do better for patients with pain from fibromyalgia. So it is important to recognize and understand what the pain is, the source of the pain, whether that's osteoarthritis or neuropathic pain and use that to guide your treatment and your choices. Great, so thank you for that response. And I think we can go ahead and stop the recording and then we'll open it up to just more free form discussion and ask our attendees how they're managing pain in their patients with opioid use disorder.

Safer Pain Management Practices

Opioid Use Disorder

Neurocircuitry of Pain and Addiction

Safer Opioid Prescribing

Multimodal Pain Management

Medication for Opioid Use Disorder (MOUD)

Individualized Treatment Plans