Pain Control in Heroin Addicts

1. Pain Control in Heroin Addicts Sheila Modi Best Practices Conference May 16, 2012

2. (Real) Case 1 • R.C., a 44 yo M with active IVDU (heroin) admitted with R hand abscesses and severe cellulitis, s/p I&D, on IV antibiotics. • PMHx: • HCV, poorly controlled DM2, sciatica with chronic low back pain, neuropraxia LUE s/p fall in 2003, chronic LE ulcer, multiple skin abscesses • Patient requests transfer of physicians because he feels his pain is not being adequately controlled and he feels stigmatized due to his IVDU.

3. Case 1 (cont’d) • Subjective: • Pt c/o R hand pain, but more concerning to him is his lower back pain/sciatica with pain going all the way from R neck down to R buttocks to just above his R ankle. He says this is worse than previously. He also c/o chronic liver pain. • He denies current heroin withdrawal symptoms, denies diarrhea, diffuse muscle aches. He does report some yawning and anxiety/irritability. He feels the opiates he is getting have been sufficient to prevent withdrawal symptoms. • He says that in the past, he has taken up to 300 mg morphine per day which did not control his pain as well as IV dilaudid; he is requesting dilaudid 2 mg IV q4 hours scheduled. He says he knows that dose is sufficient to control his pain. • He is not interested in quitting heroin; the first thing he will do upon discharge is go use heroin. He states he will not use heroin as an inpatient because he understands the risks for overdose when combined with narcotic pain medications. He understands he will not be discharged with any pain medications.

4. Case 1 (cont’d) • Current pain control regimen: • Acetaminophen 650 mg po q4 hours PRN pain • Methocarbamol 1000 mg po q6 hours PRN pain • Oxycodone 5-10 mg po q4 hours PRN pain • Morphine 2-4 mg IV q2 hours PRN pain • New pain control regimen: • Dilaudid 2 mg IV q4 hours scheduled • Acetaminophen PRN pain, max 2 grams/day • Patient counseled that this dose will not be escalated

5. Case 1 (cont’d) • Follow-up: The patient did well on this dose: he was happy, cooperative, felt his pain was reasonably well controlled, and we never escalated dose, he was not discharged with any pain meds. • Reactions from other physicians (not exact quotations): • From the transferring physician: What is wrong with you: why are you giving a heroin addict IV dilaudid? • From the physician I handed off care to: What is wrong with you: why are you giving a heroin addict IV dilaudid? • My reaction: I think I’ll do a best practice talk on this topic-- we see this all the time, and we all handle it differently.

6. Objectives • Increase our basic understanding of pain and its relationship to opioid addiction • Identify our own misconceptions that may prevent us from adequately treating pain in this population • Provide general recommendations on how to approach pain management in these patients

7. Definition of Pain • Pain = an unpleasant sensory and emotional experience, associated with actual or threatened tissue damage, or described in terms of such. • International Association for the Study of Pain (IASP) • What this means: • Pain is subjective • Has both sensory and affective components • Influenced by genetics, sociocultural expectations, gender, co-occurring medical or psychiatric conditions, and other factors. • Can exist in the absence of actual tissue pathology

8. Acute vs. Chronic Pain Acute Pain Chronic Pain • Abrupt onset • Usually associated with an acute physical condition • Self-limited, resolves as underlying cause resolves • Associated with sympathetic responses: increased BP and pulse, sweating, blanching of skin, hyperventilation; pts appear distressed • Pain may persist for variety of reasons • Chronic pain causes secondary problems: sleep disturbance; anxiety; depression; loss of normal function in work, social, recreational areas; increased stress due to these losses • Effective treatment for chronic pain should be multifactorial • No sympathetic arousal; pts may not appear distressed

10. Pain in heroin addicts • Pain and addiction reinforce each other • Current opioid addicts have been shown to be less tolerant of pain5,7 • Both in threshhold (when pain is reported) and tolerance (how long can withstand pain) • Pain experience is exacerbated by subtle withdrawal symptoms, sleep disturbance, and affective changes. • Pain is more difficult to treat due to: • Tolerance and cross-tolerance • Opioid-induced hyperalgesia • Multifactorial etiology • Most pain complaints are driven by real distress4 • Patients with co-occurring pain and addiction may have difficulty knowing where pain ends and cravings for opioids begins

12. Drug-seeking behavior • “Drug-seeking behavior” is a widely-used but poorly defined term, may be explained by: • Pseudo-addiction • Pseudo-opioid resistance • Patients with a h/o substance abuse have experienced immediate distress-reduction; commonly-used long-acting opioids will not provide this  different expectations between physicians and patients  frustration by both parties • Patient’s fears of being stigmatized may lead them to hide their substance abuse history for fear that needed pain medication may be withdrawn • Source: Rowley D, et. al. Review of cancer pain management in patients receiving methadone maintenance therapy. AM J HOSP PALLIAT CARE 2011 28: 183

13. Opioid-induced hyperalgesia • Caused by up-regulation of NMDA receptors which cause an increased sensitivity to pain and reduce the analgesic efficacy of opioids • Current opioid-dependent subjects are less pain tolerant than controls in the cold-pressor test • Another study showed that negative affect heightens OIH in heroin addicts2 • Sources: 1. Ho A, et. al. Pain response in heroin users: personality, abstinence, and modulation by benzodiazepines. Addictive Behaviors. 2011 36:1361-1364. 2. Carcoba LM, et. al. Negative affect heightens opioid- withdrawal induced hyperalgesia in heroin dependent individuals. J Addict Dis. 2011 Jul-Sept 30(3):258-70.

14. Common misconceptions of health providers that result in the under-treatment of acute pain • The maintenance opioid agonist (methadone or buprenorphine) provides analgesia • Use of opioids for analgesia may result in addiction relapse • Relapse prevention theories state that the stress associated with unrelieved pain is more likely to trigger a relapse than adequate analgesia • Concern for respiratory and central nervous system (CNS) depression • The pain complaint may be a manipulation to obtain opioid medications, or drug-seeking, because of opioid addiction Source: Alford DP, et. al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Int Med 2006 Jan 17; 144(2):127-134.

15. Doctors provide less pain control for heroin addicts • A study of 516 HIV patients with cancer pain showed: • Pts with a h/o substance misuse were less likely to be prescribed strong analgesics than those with no such history and thus reported more uncontrolled symptoms and more psychiatric distress than other patients • Source: Rowley D, et. al. Review of cancer pain management in patients receiving methadone maintenance therapy. AM J HOSP PALLIAT CARE 2011 28: 183

16. Ethics • Untreated pain can cause psychiatric and medical morbidity: affective and anxiety disorders, adverse immune system changes, central neurologic changes such as spinal cord sensitization (violates “do no harm”) • Offering opioid treatment to these patients utilizes principles of beneficence and justice.

17. Recommendations

18. Key principles in acute pain management in opioid dependent patients • For patients on chronic opioid therapy (either methadone or other opioids), the established daily dose will not provide analgesia for acute pain • Pts will have tolerance and will require higher doses at more frequent intervals • Prescribing scheduled, long-acting, or continuous opioids will avoid compelling the patient to request opioids frequently, which may be misinterpreted as drug-seeking • Use PRN for dose-titration only • For individuals in recovery, an intensification of recovery activities may reduce the risk that medical challenges and opioid therapy will trigger relapse • In periods of medical challenge (e.g. illness, surgery, trauma), pts with active addiction may be especially amenable to entering addiction treatment

19. Patients on Methadone Maintenance Therapy • Continue methadone at same dosage and use a different medication for acute pain • Use opioids • Adequate pain control will generally necessitate higher doses of opioid analgesic administered at shorter intervals. • Analgesic dosing should be continuous or scheduled, rather than as needed. Allowing pain to reemerge before administering the next dose causes unnecessary suffering and anxiety and increases tension between the patient and the treatment team. • Also use other analgesics (e.g. acetaminophen) and adjuvants (e.g. TCAs) Source: Alford DP, et. al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Int Med 2006 Jan 17; 144(2):127-134.

20. Pain control in cancer patients on MMT • 12 patients: • 80% had difficult to control pain • All patients required adjuvants in addition to opioids (e.g. paracetamol, NSAIDs, neuropathic agents) • Multiple analgesic agents required in 70% of patients • 2 patients (17%) documented as having drug-seeking behavior (1 for benzos, 1 for opioids) • Source: Rowley D, et. al. Review of cancer pain management in patients receiving methadone maintenance therapy. AM J HOSP PALLIAT CARE 2011 28: 183

21. Patients on Buprenorphine Maintenance • Buprenorphine is a partial agonist which binds avidly to mu opioid receptors and will block action of other opioids • Possible strategies: • Discontinue buprenorphine (but there will be prolonged effect) and aggressively titrate opioids to sufficiently high doses to overcome the blockade. Recommend IV fentanyl which also binds avidly to mu opioid receptors. • This should be done by an experienced clinician, with naloxone on hand, and close monitoring • Take their maintenance daily dose, increase it, and give it q6 hours. • However, doses of 16-32 mg per day will saturate the mu receptors (and only partially activate them) so there is a ceiling to buprenorphine’s analgesic effect.

22. Patients who are active heroin users

23. Equivalent doses • Dilaudid 1 mg IV = 20 mg po morphine • Dilaudid 2 mg IV q4 hours = 240 mg po morphine per day • What is the equivalent dose of heroin?

24. Heroin dosing • Heroin 5 mg IV = methadone 20 mg po = morphine 30 mg po1 • Average “hit”= 20-25 mg IV heroin3 (~600 mg po morphine) • Varies depending on tolerance and purity • 1 gram street heroin DOES NOT EQUAL 1 gram pure heroin so these calculations are merely approximations • Average user 466 mg/day IV heroin = 2,796 mg morphine po/day2 • Other sources quoted slightly lower doses, e.g. 300 mg heroin/day = 1800 mg morphine po3. • No one knows for sure…. • Sources: • Anderson IB and Kearney TE. Medicine cabinet: use of methadone. West J Med 2000 January; 172(1):43-46. • Perneger TV, et. al. Patterns of opiate use in a heroin maintenance programme. Psychopharmacology 2000 July; 152: 7-13. • http://www.justiceforkurt.com/investigation/dmdpt/table3.shtml

25. Recommendations for pain control in heroin addicts • Give patients complaining of pain the benefit of the doubt • Up-titrate opioids until pain control achieved • Schedule dosing of opioids (use PRN only for up-titration) • Switch to long-acting preparations early • Switch from IV to po early • Do not also use benzos • Closely monitor (and re-assess after visitors)

26. Sources • Anderson IB and Kearney TE. Medicine cabinet: use of methadone. West J Med 2000 January; 172(1):43-46. • Perneger TV, et. al. Patterns of opiate use in a heroin maintenance programme. Psychopharmacology 2000 July; 152: 7-13. • http://www.justiceforkurt.com/investigation/dmdpt/table3.shtml • Savage SR, et. al. Challenges in using opioids to treat pain in persons with substance use disorders. Addiction Science & Clinical Practice. 2008 June: 4-25. • Alford DP, et. al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Int Med. 2006 January 17; 144(2): 127-134. • Rowley D, et. al. Review of cancer pain management in patients receiving methadone maintenance therapy. Am J Hosp Palliat Care 2011 28: 183. • Ada Man Choi Ho, et. al. Pain response in heroin users: Personality, abstinence, and modulation by benzodiazepines. Addictive Behaviors 36 (2011) 1361-1364. • Cohen MJM, et. al. Ethical perspectives: Opioid treatment of chronic pain in the context of addiction. The Clinical Journal of Pain 2002; 18:S99-S107. • Basu S, et. al. Pharmacological pain control for HIV-infected adults with a history of drug dependence. J Subst Abuse Treat. 2007 June; 32(4):399-409. • Ballantyne JC, et, al. Review: opioid dependence and addiction during opioid treatment of chronic pain. Pain 2007. 129; 235-255. • http://www.emcdda.europa.eu/attachements.cfm/att_35646_EN_COWS.pdf