The broadcast is now starting. All attendees are in listen-only mode. Good afternoon. I am Anne Schreier, and it is my pleasure to welcome you to ASPMN's ninth-year series of webinars that focus on the use of opioid therapies for the treatment of pain, opioid dependence, and on the safe use of opioids in the treatment of chronic pain. This series is one of the many resources made available by the Prescribers Clinical Support System, a program that is funded by Substance Abuse and Mental Health Services Administration, which is SAMHSA. It is a collaborative project led by the American Academy of Addiction Psychiatry with a number of professional organizations. On the last slide, you will find a list of these organizations. You are able to obtain nursing continuing education credits for the presentation. You need to participate through the question-and-answer period in order to obtain these credits. Detailed instructions concerning the CE credits will be given at the end of the presentation. Now, some housekeeping. Please feel free to ask questions during the session. Please, if you're using a cell phone to view the webinar, refrain from texting unless submitting a question. In the upper right-hand side of your screen, you will see a control panel. In the lower portion of the panel, participants can type in a question or comment and submit it to the webinar organizers. You can do this at any time during the presentation. We will reserve about 10 minutes at the end of the presentation for questions and answers. If we are unable to get to all of your questions, the presenter has agreed to respond to them in writing. The slides were sent to you by an email earlier today. The webinar presentation slides and questions and answers will be posted on the ASPMN website sometime tomorrow afternoon. And when you go to that website, which is www.aspmn.org, click on professional development, then on education, and then finally on PCSS webinars. The slides will be available through the PCSS website in the near future. That website is www.pcssnow.org. Today's presentation is acute pain management in the individual with opioid use disorder. Our speaker today is Kathleen Broglia. Kathleen is an associate professor of medicine at Geisel School of Medicine at Dartmouth College and a nurse practitioner in palliative medicine at the Dartmouth-Hitchcock Medical Center. She has conducted research on the prevalence of opioid misuse risk in oncology, cannabis use in palliative medicine, implementation of opioid management guidelines in the palliative care setting, and interprofessional palliative care education. Kathleen's clinical care focus on complex pain and symptom management and treatment of substance use disorder for patients with serious illnesses. She mentors colleagues, lectures, and has published on the treatment of pain in the setting of risk for substance use disorder. Her expertise includes acute and chronic pain management and acute ambulatory and home-based palliative care. She received her bachelor's in economics from the University of Maryland, her bachelor of nursing from University of Hawaii, a master's in nursing from University of Washington, and a doctorate in nursing practice from New York University. She completed a palliative care fellowship at Beth Israel Medical Center in New York. Welcome, Kathleen. Thank you very much and thank you to both the American Society for Pain Management Nursing and the provider's clinical support system for allowing me to talk with you today about acute pain management in individuals with opioid use disorder. I don't have any financial disclosures to report and remember this overarching goal of PCSS is to really train healthcare professionals to use evidence-based practices for the prevention and treatment of opioid use disorder. My hope is that after this presentation today, for those of you on the call that are prescribers that may not have yet obtained your buprenorphine waiver, I would hope that you will go on to PCSS and find more information and help with that. At the conclusion of this activity, I hope that we can discuss more what are the pain management strategies that we use for people that have active substance use that come into our inpatient or acute care setting. Talking about the medications that we use for opioid use disorder, which previously was called MAT, medication-assisted treatment, but it's more appropriately called medications for opioid use disorder because this is not an assisted treatment. This is a primary treatment for opioid use disorders, and that you'll be able to develop treatment strategies to treat acute pain for people with substance or opioid use disorders, and what are the safe discharge strategies for individuals with acute pain and comorbid substance use or opioid use disorder. When we work with people with substance use or opioid use disorder, it's a balancing act. Clinicians face fears when treating patients with substance use or opioid use disorder, and it could be just because of lack of knowledge, lack of confidence, worry about their own legal liability, and then there's individual fears. How many patients have we taken care of that may have histories of substance use disorder that may not even want to disclose it, even if it's a distant history, for fear of being stigmatized, for fear of not being treated, and in reality have been undertreated for their pain, and so we want to think about what are the general considerations when we take care of people with substance use disorder, which can include opioid use disorder. I'm using the general term substance use disorder because I think this lecture really does encompass what do we do when we have people that come in the hospital that do have a substance use disorder. I think we can advocate for safe, appropriate pain management. More importantly, how do we start incorporating into our own practices if we're not already doing so a harm reduction approach, maximizing the use of multimodal analgesia, which many may already be doing if you're on this call and you work in the acute care setting, and then consideration for treatment for mental health issues because we know there's a lot of overlap between substance use disorder and mental health issues, and then obviously collaboration with the prescriber if this patient is receiving medications for opioid use disorder. So, you know, language matters, and then we see this more and more, and I wanted to put this up because language is a source of stigma. I think all of us have come across charting in the medical record where we see this person is an addict, this person is a junkie, this person is drug seeking, and one note by one clinician using this type of language can actually mark a patient for life if someone sees that. So, we need to start really using person-centered language. In fact, I was just on a lecture before this and people were saying end-stage liver disease patient, and I kept saying no, it's a patient with end-stage liver disease. That person is not the disease. So, in the same way, you know, we look at substance use disorder as a disease. That person is not, that person may self-refer to themselves as an addict, but we should be using the appropriate person with substance use disorder, a person who uses drugs, not the alcoholic or not the alcoholic cirrhotic in room 330, but the person with alcohol use disorder or a person who misuses alcohol or a person with risky use. You know, the person who injects drugs, you know, again, medications for opioid use disorder has become the preferred term because we don't say that someone with insulin-dependent diabetes is using medication-assisted treatment when we say they're using insulin. That is the primary treatment. The same way in terms of medications for opioid use disorder, this is the primary treatment for opioid use disorder. One term that I have a hard time having to change my vernacular was like, you know, instead of relapse, return to use, use or recurrence of use, you know, person, a recovering addict, a person in long-term recovery, you know, instead of saying a dirty urine or failing a drug test, testing on positive drug screening. And I think that we need to actually help our colleagues that may not be using this terminology to change terminology because words do matter. And then we want to think about how do we adopt a harm reduction strategy? And this is something that I'm slowly just getting my own hands around. I've noticed that over the years, like how am I really doing harm reduction with my patient? And when we have a harm reduction strategy, we accept that drug use is a reality, you know, but we don't minimize the reality of the harm. I mean, I have a patient that was leaving the hospital against medical advice last week, had been actively using substances prior to coming into the hospital, did not want to be on buprenorphine treatment because still was using about a bag of fentanyl a day. So we don't want to minimize the reality of harm. We want to make sure that we sent him out with naloxone, but that we just understand that, you know, that substance use disorder goes along a continuum from, you know, occasional risky use to more frequent use to uncontrolled use to when you get to someone who has substance use disorder at the end of the continuum where we think, oh, wow, you know, they just are chasing that next high, but really that person is not. That person is in a cycle where they're actually trying to minimize the pain of going through withdrawal. So that, you know, reaching for that next use is really to minimize the negative consequences of withdrawal. And then if we're doing a harm reduction approach that we're collaborating versus coercing and we're really recognizing that we want to give voice to the patient. I mean, I think sometimes one of my colleagues, I had dinner the other night and we were talking about he was on a COVID unit, a unit where patients were being taken care of for COVID and a young girl that was 14 had just delivered a baby and she'd been using injection drugs every day. And he overheard the nurses talking about, you know, oh my God, look at this woman's addicted and now this baby's addicted. And, you know, he had to go to them and says, do you think that this young girl grew up saying, I just want to grow up and become an addict? You know, I mean, I think that we need to recognize that, you know, anyone you talk to and spend the time talking to, they're not going to say, listen, all I wanted to do was, you know, grow up and end up with a substance use disorder. And we not, and we need to recognize and the inequalities and bias. We know that people of color have been stigmatized against, they get less treatment for pain, but they also may have more criminalization of having drug use. We know that in neighborhoods where they're predominantly of color, there may be less people that prescribe buprenorphine and more reliance on having to use methadone as a maintenance. So all, and recognizing this is what's happening. These type of strategies are not harm reduction saying to someone all or nothing, you know, I mean, you know, okay, if you don't want to accept what I'm taking, then forget it, you know, coercive. If you don't do this, I'm not going to treat you. Or on the other hand, ignoring use, which I see sometimes happening in palliative medicine. Well, we know they're going to die anyway of their cancer. So maybe we should just, you know, not to pay attention to the use and, and, or ignore the dangers or harms of use. I mean, like I told one of my colleagues today, I said, this patient who's having a recurrence of drug use now has their leukemia that's in remission. His serious illness is his substance use disorder, because that is going to be what potentially will cause his death, not his leukemia. And we can't, and we, and not harm reduction is ignoring that there are inequalities, there are vulnerabilities, or just having a fatalistic approach, like, you know, I really can't do anything, because this person is just going to overdose, there's always something we can do, we might not get the desired outcome, in terms of the patient, eliminating all use, but there's always something we can try to do. I think you'll probably see this a couple times throughout the lecture, you always want to make sure in the acute care setting that that patient leaves the hospital with naloxone in hand. And this is anyone who is diagnosed with a substance use or opioid use disorder, whether they have active use, whether they're on medications for opioid use disorder, or whether they're in remission, and they're not on any medications for opioid use disorder. CDC has recommended anyone who's receiving greater than 50 milligrams of morphine equivalent daily, or those that are at risk for overdose, frail, organ dysfunction, or are there safety risks in the home, their children. Now, this is actually a picture of one of my patients who really got worried, saying, well, why am I keeping my naloxone in the safe at home if something happens when I'm out? So, he found this little thing, probably on our favorite website that people order from all the time, and would carry his naloxone around with him. And I'd say have it in hand because it's been very discouraging for me to find out that my patients can obtain all the high-dose opioids that I prescribe with a $1 copay, and then they call me and they tell me that there's a $100 copay for their naloxone. So, just being aware of that, that's why I say they should have it in hand versus go pick it up at the pharmacy. So, when we take care of patients, it's a balancing act. How do we do risk mitigation strategies? Picking a safer opioid for opioid overdose and diversion, such as buprenorphine, you know, maybe picking a long-acting or extended-release opioid, you know, as monotherapy versus prescribing a lot of immediate release, you know. You know, doing short fills, you know, being aware of our own stigma, being aware of our own bias, you know. And again, how do we, you know, engage in harm reduction strategies? And it could be that if your patient isn't willing to stop using, are we talking to the patient about safer injection practices, not using alone, making sure they know where syringe exchange programs are, you know. Can we talk to them about, you know, using, you know, other methods other than injection, you know. And how can we, if it's alcohol, how do we reduce the use of alcohol? So, all of this, you're thinking, wait a minute, I came to this lecture and we're supposed to be talking about acute pain management for an opioid use disorder. So, we're going to get to that, but this is really should be the basis of your practice, whether you're in the acute or the ambulatory or home care setting. So, let's talk about a patient that I took care of, 58-year-old woman. She was admitted to the intensive care unit with respiratory distress, and at that time, she found out she had small cell lung cancer with extensive osteous metastasis. She was intubated, and palliative care was actually originally consulted for goals of care and potentially withdrawal of life-sustaining treatment. But she started to get chemotherapy in the intensive care unit, and like a lot of people with small cell lung cancer, had a dramatic response. She was an active injection drug user. It was heroin at that time. If it would have been today, probably fentanyl, because no one I'm looking at, you're in drug screens now, has fentanyl. It's usually, I mean, has heroin or the metabolites of heroin, which would be morphine or 6-monocytomorphine, but it's fentanyl. She used occasional methamphetamine. She had chronic back pain secondary to a lumbar access, for which she had a laminectomy. She lived in a boarding house. She had twin daughters with active injection drug use, and one was hospitalized at the same time with endocarditis. During the hospital course, as usual, she was started on methadone to prevent withdrawal in the hospital setting for the treatment of her substance use disorder and pain. Due to her perceived intolerance to methadone, the hospitalists rotated her to oxycodone extended release and immediate release, discharged her with a month's supply, and scheduled her to follow up with palliative medicine to manage pain. The patient calls the hospital two days after discharge, calls the clinic and says, I'm out of meds. So how could we have better managed pain in the inpatient setting? And some of you might be thinking like, why in the world would this hospitalist put someone who was active injection drug use on, you know, full mu-agonist opioids and immediate? She had a diagnosis of cancer. So sometimes that takes everything out the window. We don't have to worry about injection drug use. We'll just put that on. I'm not going to tell you what my response was on the outpatient setting, but it ended up with a good outcome. She ended up on suboxone, but what could we have done differently? So when we have people that come into the hospital with active substance use, the first thing is we need a medical history, you know, and what is, and we need to do a substance use assessment. And that's just being really honest. That's being nonjudgmental. Like what, what we want to know what you've been using so we can make sure that we can help treat you. You want to do a withdrawal assessment and then really assess for what kind of psychosocial supports can we put in place. So we want to use non-opioid multimodal analgesia when needed, but, and we want to consider initiating medications for opioid use disorder. Now, obviously you can do methadone or buprenorphine in the hospital, even if you have no waiver, or as long as they're not being admitted for something related to their substance use disorder. Now you're not going to start buprenorphine if they're not in withdrawal, unless you're going to start low dose initiation. You want to treat the pain though. And some people have argued, why would you give a PCA? And I would say you would have to be careful if you don't have good lockbox and, and, and, and surveillance mechanisms in place. But I think scheduled opioids are better than considering as needed opioids, because there's two things. One, you have the patient that's constantly going to potentially be in concern about when can I have my next pain medicine if I'm in uncontrolled pain. But more importantly, I worry about the nursing staff who may then use stigmatizing language of saying this person is a drug seeker, this person is clock watching. But remembering that people that are using actively may have much higher opioid dose needs because of the tolerance, especially when we think about the high dose fentanyl that people are using illicitly right now. And we want to make sure that we're treating withdrawal symptoms because even if you're treating with a full mu agonist opioid, that person still could be having withdrawal symptoms because of the high dose opioids they were using prior to admission. So obviously you want to screen for opioid withdrawal. Hopefully all of you in your inpatient acute care settings use some type of withdrawal scale. This is the clinical opioid withdrawal scale that looks at different symptoms and helps you know to score whether that person is in mild, moderate, severe, or very severe withdrawal. There's also the subjective opioid withdrawal scale as well. But again you want to gauge you know is this person what to what degree withdrawal is this person. Now this may be important if you're thinking about trying to initiate buprenorphine treatment. And so you want to you know think about what are the symptoms. I mean even if you don't have the scale you're going to see nausea, positively vomiting, diarrhea, abdominal cramping, increased joint pain. I have patients they'll say they feel like they want to tear their legs off, they just have this you know they just restless anxiety, insomnia, some hypertension, tachycardia. We have to remember people can start to go with through withdrawal from illicit fentanyl use but they may have a protracted withdrawal because fentanyl stores in the adipose tissue. So that and if we think about if people had been on methadone and using it say illicitly in the out patient arena again it may be a protracted or prolonged withdrawal. So obviously what is your withdrawal treatment is either your methadone or buprenorphine or any type of opioids can help minimize the withdrawal symptoms. We also have our alpha-2 adrenergic agonists clonidine, lofexidine. These really work to help decrease the noradrenergic activity that leads to more restlessness and anxiety. And then you obviously want to treat the symptoms like cramping, nausea, insomnia. In our own hospital setting in our buprenorphine initiation treatment protocol there are actually the medications for nausea, diarrhea, for cramping, insomnia, and making sure that we're trying to get that person to feel comfortable. We don't want to not treat the withdrawal symptoms because again this is stigmatizing and it's unnecessary treatment. But you want to think about screening for withdrawal from cannabis and you say what? Withdrawal from cannabis? There actually are cannabis withdrawal symptoms especially if someone has been utilizing cannabis daily and especially because cannabis now versus 40 years ago has a much higher THC content. You might see anxiety, irritability, anger, disturbed sleep, dreams, mood changes. Now there's no strong evidence in terms of how to treat the withdrawal. Some hospitals allow patients to bring in cannabis if they've been using cannabis for as therapeutic cannabis and have like a cannabis card. There's some limited evidence that using cannabis agonists such as dronabinol may be helpful but really there's no strong evidence. You might need to treat anxiety, need to treat insomnia and irritability in order to help with these treatments. And what about stimulant withdrawal? Oh my goodness, I mean we are seeing an uptick of stimulant use. I don't know where you're living. I know we're seeing it a lot more in the northeast. We're seeing methamphetamine being mixed with fentanyl. We're seeing methamphetamine being put into cannabis and you want to assess for the effects of intoxication and it can differ depending on the stimulant. You may come in with someone who's had polypharmacy, been using opioids and stimulants. Are you seeing tachycardia, hyperthermia, psychomotor agitation, seizures, confusion, anxiety? So really you want to treat life threatening conditions, provide a quiet environment. There's really no specific antidote. So it's not like you have your naloxone for opioids. It's not like you have your flumenazole for benzodiazepines. Long-term motivational interviewing, contingency management, which is saying if you do this, I'll give you that. Cognitive behavioral therapy, stimulant replacement therapy, question mark. There's been some case studies saying if I prescribe a stimulant such as methylphenidate or dextroamphetamine, can I potentially decrease use of illicit stimulants? I do have a patient I care for now who has attention deficit disorder that I have on dextroamphetamine, also cancer-related fatigue, but she continues to use methamphetamine. Do I hope that it may decrease her methamphetamine use? Yes, I do, but there's no really strong evidence. And what about alcohol withdrawal? Okay, we know that alcohol is the most frequently used substance. We may overlook it because it's legal, but we want to consider screening if they come in with a motor vehicle accident, if there's liver disease, hypertension, chronic pain, social problems, legal problems. Individuals may under-report use if they don't get admitted with intoxication. The treatment plans should include screening and obviously management strategies if they're in acute withdrawal. Do you need to use your thiamine replacements? Do you need to use benzodiazepines if that's indicated? But also, what are we going to do for follow-up after discharge? So, we want to make sure that we implement, no matter if this is someone with opioid use disorder, substance use disorder, or no use disorder, multimodal pain management. And this includes thinking about using our anti-inflammatory medications, our anesthetics, you know, thinking about using our alpha-2 agonist, you know, our opioids when needed for acute pain, and thinking about using tricyclic antidepressants, serotonin, norepinephrine, reach up and take inhibitors, and anticonvulsants being used off-label for neuropathic pain. And what about non-pharmacologic treatments such as biofeedback, guide imagery, distraction, if you have massage in your settings, some people use aromatherapy. There actually just was a study, I think, looking at people with heart failure and pain in the acute care setting and the use of virtual reality to help manage pain. So, are there different things that we can use to help better manage pain? And you want to advocate for a safe discharge plan, you know, who is going to prescribe after discharge if opioids are necessary. What happens if this person was started on medications for opioid use disorder in the hospital and wants to continue? We want to avoid a gap of care, you know, if they started inpatient and they have no plan, they decide, okay, I'm going to really go back to the street, I'm not ready to, I'm going to go back to my street use, I'm not ready to engage in a recovery program, then you need to discontinue that. But everyone needs to walk out with naloxone, you know, but you really want to avoid this gap of care. Even if you're not wavered, you can prescribe, I think the law says, three days of buprenorphine. You want to make sure there's someone to pick that up afterwards. And I'm pretty fanatical about emphasizing this because I've attended two MMNIs that were patients that were discharged with plans to follow up in their outpatient treatment program, and both died after discharge because the highest risk for overdose is right after discharge, depending on how long they've been in the hospital, because they may have lost risk for tolerance. And so it's absolutely so important that we don't set this person up for failure and realizing that, remember, this is a chronic disease. And I always say to someone, so are you going to send your patient out with heart failure without their cardiovascular medicines and say, we'll wait till you follow up with your cardiologist in a week? You would say, no, that's crazy. The same thing with your patient with insulin-dependent diabetes, you're going to say, well, we'll wait till you see your endocrinologist in a week or so, you know, you can just wait till then. We would never do that. And the same should happen with our patients with substance use disorder as well. So let's go on to case number two. This is another patient of mine with a history of alcohol use disorder, opioid use disorder, and that he developed after using prescription opioids for chronic abdominal pain. He has a past medical history of pancreatectomy, secondary to alcohol use disorder. He had three myocardial infarctions. He has depression with previous suicide attempts and severe peripheral artery disease. Currently he's treated with buprenorphine 16 milligrams daily in divided doses to treat both his opioid use disorder and his pain. He's coming in for a surgery secondary to his peripheral artery disease. And on one of our ambulatory care visits, he's saying, I am so afraid of going in the hospital. I'm afraid they're going to put me back on opioids. I don't want to be back on opioids. I'm doing so well. So how do we manage perioperative pain in this setting? So, you know, in this next slide, you'll see a quick graphic of your medications for opioid use disorder. There are only three that are FDA approved. Methadone, which is a full muaginist that must be administered at this point until the laws change to an opioid treatment program where a patient goes daily for observed doses or may graduate to take home doses on the weekend or have weekly pickups. But it may treat their opioid use disorder with once daily dosing. But in order to achieve analgesia, it needs to be dosed every 6 to 12 hours. There's many, many drug interactions second with methadone and it can cause QTC prolongation, which can cause to soar to pop point. And I've had two patients recently that experienced that while on methadone. So now methadone is no longer a possibility for their treatment of opioid use disorder. Buprenorphine, naloxone or buprenorphine by itself without the naloxone for those that are pregnant is a partial muaginist. It can be prescribed that anyone that's on this call that holds the ability to prescribe and has a waiver. They have actually eliminated the need for eight hours for physicians and 24 hours for nurse practitioners and physician assistants to do the training. You need to nearly apply for the waiver. I would encourage everyone when they get off this call, if you have not done so, to do so, so that you have that as a potential tool. It may provide analgesia. It will provide analgesia if given in split doses. And it was previously thought that if you had someone on buprenorphine, you could not treat with pure muaginist opioids such as your oxycodone or morphine because the mu receptor was occupied. That has been proven wrong. You just may need to use higher doses. It's got fewer drug interactions than methadone. And finally, there's naltrexone, which was actually first approved for the use of alcohol use disorder, but it blocks the effects of opioids. And it's either given intramuscularly once monthly or orally daily. And because it blocks the effects of opioids, it's not a good choice if someone has pain. But if you have someone who comes into your setting needing a surgery and has had an intramuscular injection that is once monthly, you may need to give 20 times the amount of opioids to overcome that. So buprenorphine works differently than other opioids. It's a semi-synthetic thebane derivative. It's a mu opioid receptor factor. He's got a very high affinity for the mu receptor, you know, and also it holds on to the mu receptor. So if you have someone that comes in and you decide to stop the buprenorphine and switch to full mu agonist, recognize that it could take up to 72 hours for that buprenorphine to disassociate from the receptor. And therefore, that person may be at increased risk for over sedation after the buprenorphine dissociates, you know. And it produces your typical opioid effects, euphoria, analgesia, but it may have less risk for opioid-induced respiratory depression, although that risk can increase if there's a concomitant use of benzodiazepines, for example. So this is a nice thing showing that the more mu receptor intrinsic activity with your full agonist, such as heroin or methadone, compared to your partial agonist. I think one of the things that we have to actually re-educate our patients is that it can be very effective for pain, but there are even people in addiction medicine that don't recognize how effective this can be for pain management. And if we could just get rid of the waiver process or get rid of the indication for only opioid use disorder, it could be a lot easier. It would probably be my first line in terms of how I treat pain as well. So when we manage acute pain for individuals on medications for opioid use disorder, clearly there's no absolute consensus. And if I would have given this lecture a couple years ago, I would have shown you a couple of different ways that people could do it by like weaning the buprenorphine before they come in or stopping it and then starting opioids. But the strong, strong recommendations from many professionals are saying we should not discontinue methadone or buprenorphine. It's really not recommended unless absolutely necessary. So we want to take our medical history. We want to know about their drug use. We want to make sure, are they using any other drugs that's being prescribed? Like my patient that came in that didn't want to go out on suboxone, he actually came in and had been on methadone maintenance therapy, but was still using a bag of fentanyl every day. And you want to verify the medications, but say that person's going to a methadone maintenance clinic and it's a weekend and you cannot get in touch with that prescriber. Most hospitals will have some type of policy in place. Most say that you can give up to 40 milligrams daily of methadone as replacement therapy. And again, you do not have to have a special waiver to do this in the acute care setting, especially if, I mean, if they're not being admitted for something secondary to their substance use disorder, say they're coming in for a surgery. Obviously, if they're using naltrexone and it's oral dosing, you want to discontinue this. If they've been on methadone or buprenorphine, you know, again, don't discontinue. Some people have said, well, maybe it's better to wean it down to 12 milligrams daily so that you can release some of those mu receptors. So what will you treat with as needed opioids or maybe more mu receptors open? That's still being debated. There's others that say there's no need. Again, if you have someone who's been on naltrexone, you may need to use much higher doses of opioids. Again, using multimodal non-opioid analgesia, you know, it's for the pain, you know, thinking about your NSAIDs, thinking about your regional anesthetics. And if they've had acute pain or post-operative, you want to continue your non-opioid analgesia, continue your methadone or buprenorphine. And you might need to consider increased dosing or split dosing. Now, you would need to collaborate with that outpatient treatment provider, especially if, for example, you increased, like so for this patient that came in with on 16 milligrams of buprenorphine during the hospitalization, he had increased pain. So we increased his buprenorphine to 20 milligrams daily in split doses. And I collaborated with that inpatient team so that when he went out, knowing that he could stay on that increased dose. If that person is going to a methadone maintenance clinic, again, you would need to collaborate with that outpatient provider. Unfortunately, if they're going to an outpatient treatment program, there's no ability to actually split the daily doses unless, of course, maybe they're taking take-home doses. But usually once a week, they still have to go in for observed dosing and take that dose all at once. Now, Trexone, you want to continue non-opioid analgesia. If they really need to be on some type of pain management, you may need to think about stopping that and changing to a different medication for opioid use disorder or once the pain resolves to resume now Trexone. So again, I mean, you want to restart. If you did stop the buprenorphine or the methadone, you want to resume it prior to discharge. And that's why a lot of people are saying, let's not stop that because a lot of times we're trying to get people in and out of the hospital pretty quickly. And then if the danger, if you stop buprenorphine and they've been on opioids and you have not initiated a low dose initiation for the restarting the buprenorphine, then that person is going to have to go through withdrawal. And believe me, people will tell you they will do anything not to have to go through withdrawal. And again, making sure naloxone is in the hand. So what happens if someone comes in with substance use disorder, opioid use disorder, and they're in remission or recovery, and they're not on medications for opioid use disorder? Again, you're going to use a multimodal non-pharmacologic approach, strategies, your non-opioid strategies, but you want to counsel them if opioids are necessary. There opioids are necessary. There may be a lot of people that are just absolutely not willing. They do not want to take opioids. They might be in abstinence only programs. There's still a lot of narcotics anonymous, alcohol anonymous that are abstinence only. Like my one patient that I talked about who has alcohol use disorder and opioid use disorder. He goes to AA, but he doesn't tell anyone that he's receiving treatment for his opioid use disorder because he doesn't want to face the stigma from other people in that program. Hopefully, that will change over time because we know that these medications save lives. You want to still make sure even if that person is not on any medications for opioid use disorder and has been in remission or recovery, you want to prescribe naloxone because there is a risk for recurrence of substance use, especially if they were exposed to opioids in the hospital setting. It's like a patient that I saw last week, he said, I never really had a problem, but then after I got my Stills disease and they started to put me on opioids, all of a sudden I went out of control. And this is someone who had had lymphoma as a child and was treated and probably had early exposure to opioids, but it triggered it. So again, I go back to the same thing. You know, it's really a balancing act. It becomes like know yourself, you know, know yourself and know your limits. I mean, I know that sometimes I can think for my own self, am I really doing a harm reduction approach or am I being coercive with this patient? There are times I feel that I was coercive, that I got angry with patients because I just didn't want them to overdose. I wanted them to stop using, that I was upset when they came in, they had methamphetamine yet again in their urine, but really kind of stepping back and saying, how can I be aware of my own bias? How can I be aware of my own stigma? How can I safely prescribe and minimize the risk, you know, and really help the patient? So really, obviously the take home strategy is, you know, adopt a harm reduction strategy and start thinking about it and always consider a multimodal approach to pain. And really this should include treatment for comorbid mental health issues, which can be really difficult because of the lack of ability to connect with mental health specialists. Maybe it's better, it might be better in some areas of the country that you are. I know in the area of country I am in, patients can sometimes wait five months to see an outpatient provider, but you wanna make sure that, is there some way that we co-manage? Because as primary care clinicians, if you're on the call, you have the ability to do that as well. Again, I'm sounding, feel like repeating myself about naloxone, but also really collaborating with clinicians that are treating the substance use disorder, if it's not you. And really it's essential to make sure that we actually work with the transitions between settings to minimize any risk of harm. So these are some selective references that you might find helpful. Again, the patient clinical support system is wonderful. When I first got my own waiver, which was in 2017 when nurse practitioners and physician assistants were first able to, I was able to get connected with a mentor to help me through the process because there was no one in my own palliative care program that had been doing that. So it's a wonderful mentoring program. You can actually ask a colleague through the discussion forum there. And these are all the organizations that have partnerships with the providers for the clinical support system, which includes the American Society for Pain Management Nursing, which is the co-sponsor of this program. And these are the websites. And so I actually finished on time so that if people have questions, I wanted to allow enough time for questions. My contact information was also at the beginning of the slide if people want to contact me offline afterwards. But I wanna open it up and thank you both to the American Society of Pain Management Nurses and Provider Clinical Support System for allowing me to speak. And thank you for all the people that have attended. I see that there's well over 360 that were on. Thank you, Kathleen. Yes, we do have some time for questions. So if you haven't put your question in, go ahead and do it now. And I'm gonna talk, start with, there's a question about, this person asked, can you talk about the role of Catorlac for post-op pain management? Why is it not more readily available, particularly for surgeries where only two to three days of severe post-op pain are expected? Yeah, I mean, I think that non-steroidal anti-inflammatory treatments should be absolutely part of your multimodal treatment. And I think that there are some times that there are some, I mean, I think it's really kind of going back to your surgical team and really finding out like, what is your surgical post-operative set? Are there worries about, I think one of the things we worry about like sometimes in our older population is our renal insufficiency. People sometimes worrying about the use of non-steroidal sometimes in terms of like, is there a potential like in joint replacements, like with non-union, which sometimes has been disregarded and said that this wasn't really going to be a problem, especially with short term. Oral Catorlac is definitely had some more worrisome things in terms of their renal insufficiency. But again, it really kind of goes back to, what's really meeting in your organization, like what is there, it really should be part of your multimodal pain management unless it's contraindicated. I mean, so I think it's really, it should be. Yeah, and it's interesting, another person has asked about ibuprofen for chronic pain management. And so it's kind of a very similar situation, right? Right, and so when we think about ibuprofen or any type of non-steroidal for chronic pain management, in fact, we were just discussing it in a case this morning in our clinical team with someone who has the significant osteoarthritis and joint orthopathy. Again, we have to look at, you know, the benefits versus the risk. I mean, if that person, like the person I was talking this morning is over 65 years old and may have some cardiac disease, may have a little bit of, you know, then do we worry a little bit more because if they're on antihypertensives and we're using a non-steroidal anti-inflammatory, do some of them potentially block some of the effects of the non-steroidal anti-inflammatory? And so there is, you know, increased worry about like chronic long-term use, but I think it's interselected populations. I mean, I do have people that have been chronically using it, but I worry once someone gets older and if there's other comorbidities. Right, now here's a question about methadone. As you say, methadone in the hospital for patients with an OUD is usually about 40 milligrams per day to prevent treatment and withdraw. Patients in methadone treatment programs are often on doses greater than 100 milligrams a day. Is 40 milligrams really enough for a dose of someone who's on a much higher dose normally? Yes, so perhaps I didn't state that clearly. I was only saying that, you know, when someone comes in, if they've been, if they are being treated through an opioid treatment program with methadone maintenance, then as clinicians, we need to contact that program and ask them, what is the dose that patient's on? And that's the dose we should be treating with. But say you're not able to get in contact with that opioid treatment program. Say they're not open seven days a week. Say that person comes in after an MBA on a Friday night at midnight. Most hospitals will have some type of policy in place that you can at least treat with 40 milligrams daily until you can get in touch with that program. In terms of preventing withdrawal, generally it's said, you know, in concept, that if you gave about 25% of the opioid dose, you can minimize withdrawal. When people are on those doses of 160, 200 milligrams, you know, that's really to minimize the risk of craving and recurrence of use. But that's only, so the 40 milligrams is only meant as a stopgap measure until you get in touch with that person in the treatment program. And again, you may be using that to prevent the withdrawal, but if they're having acute pain, secondary twin injury, you may be treating with scheduled, like patient-controlled analgesia on top. So you can't, because if that person comes in and it's been on methadone maintenance and you restart that, if they have an acute injury, you can't assume, like sometimes people will assume, well, they're on 160 of methadone, why should I have to give them any more for pain? Their body is tolerant to that, and now you have acute pain on top of it, they mean that person may need much more. So that one to four milligrams of morphine to four hours PRN may not be sufficient. All right, thank you. This is a different question. During a recent in-service, someone spoke of using mirtazapine, I don't know if I said that right. Mirtazapine, uh-huh. Mirtazapine, off-label, for somebody with stimulant use. What are your thoughts about this? Yeah, I mean, there's been some papers that have talked about mirtazapine. There has been a paper that's talked about bupropion, also bupropion that's used for depression and smoking cessation. So there are some papers that have come out, but there's actually no strong evidence. I mean, I can't hurt, because we don't actually have a medical treatment for stimulants, for treating stimulant use. So there's a lot of bupropion, mirtazapine, the use of like methylphenidate, dextroamphetamine. There are case reports of those. I mean, if someone's having a lot of insomnia and stuff, it probably can't hurt. And even if they're on an SSRI, like sertraline or fluoxetine, there's no interaction, because mirtazapine works by a different mechanism of action. Okay. Here's another person that asks, what tool do you recommend to assess for over sedation, the POS or the RAS and why? Tom, what a question. What a question. I think you need, I mean, I think it's just, I think you need to use... First of all, I just think the point is we need to assess. You know, we just need to assess. And so there needs to be some type of tool in your system. I mean, I know that like in many systems I've worked at, the POS was used on the general floors and the RAS tended to be used more in the intensive care unit. The whole point is to actually be able to assess. I mean, and have a tool that we can assess. And so, you know, I don't have any recommendations for one over another. It's just that we actually use a tool and we assess and we treat appropriately related to that in terms of if we're going to give naloxone. I actually had an incident with a patient of mine recently that had like an event in the hospital. She was on methadone for pain, for cancer and was in for an acute pain from a surgery, was on a PCA. She had a slight event where she passed out, but she came to, I mean, she just probably had a vagal response and she was fully awake and they gave her naloxone. And it was the most traumatizing event this patient has ever went through. She went through severe withdrawal and the nurse actually documented while fully awake, I gave naloxone. And so we need to think about like what happened there. It might've been someone afraid and it might've been a prescriber saying, give me naloxone. This person's on methadone, this person's on a PCA, but we need to remember that you can cause a lot of damage doing something like that. Right, right. Here's another, we're getting into looking at multimodal therapy. What is the role of gabapentin in this situation? So, gabapentin has been utilized as part of multimodal analgesia. There's been studies that have shown some efficacy, especially prior to joint replacements that it became part of a standard of treatment. And there were some studies that have come out that have looked at this, that it may actually help if there was like a neuropathic component, especially potentially pregabalin versus gabapentin because it has a faster onset of action. And so there are people that are using, I think people, when we think about multimodal, we're trying to think about like, where are the receptor sites that we're trying to utilize where the pain transmission. And so again, gabapentin really in thinking about trying to decrease some of that pain transmission, especially some of the neuroadrenergic output can be effective if you're anticipating that there may be some nerve related pain, especially when you start thinking about these minimally invasive techniques now being utilized for hip replacements, where they're doing the anterior cut, where you may have a little bit more nerve involvement. Okay. This person asks if a patient had severe pain and required a high dose opioid medication, how much would you have to taper in terms of the morphine equivalent doses before you resume buprenorphine? Okay, so this is the thing. So that's why I say you should never stop the buprenorphine. I mean, that's where the take home is because if they had stayed on buprenorphine and you were treating over it with morphine, you don't have to make this person to go through withdrawal. But say you work in a situation where they actually are on the morphine, and then what are you gonna do if you want to restart the buprenorphine? I didn't go into it here, but there's a lot of them. You can look it up. There's the Bernice technique. There's a lot being written now about starting low dose initiation. One of the other terms we're using is microinduction, but we're trying to move away from the word microinduction because that's also being used with psychedelics. And just think about using low dose buprenorphine at the same time when someone is on full mu-agonist opioids and actually increasing that morphine over a couple of, I mean, the buprenorphine over a couple days as you're taping the morphine. But the thing is that's why the strong recommendations are coming out like we really should try not to stop the buprenorphine. Or if you had reduced the buprenorphine, you could just basically just start increasing that buprenorphine up while you're decreasing the morphine down. Because as long as that buprenorphine's been on board while you're treating over it with agonist therapy, you're not going to push someone into severe withdrawal by using more buprenorphine. Here, we have a compliment for you. I had surgery last year and was sent home with an opioid and naloxone. I was surprised, but now I understand based on this webinar, thank you. Well, good for your prescriber, yes. Yay for your prescriber. Yeah, what do you think about ordering Tylenol and NASAs around the clock instead of PRN? I find when they're ordered, they're not given regularly. I mean, if they're ordered PRN. So I think that- Yeah, PRN versus around the clock. I mean, I think that a lot of, at least in our institution, they become part of the standardized post-surgical set, like acetaminophen, Q6 hours, and said Q8 hours around the clock. I think that makes it a lot easier because I think if they're ordered PRN, then we get into the whole thing about nurses choosing a medication. And then we get into the whole thing of the joint commission like how do, if the patient has acetaminophen PRN, ibuprofen PRN, and morphine PRN, how are you then going to write orders so they know which one to use? And that's when you get into that whole thing that I don't agree with in terms of dosing to numbers. I think that should be thrown out the window. And we know that American Society of Pain Management Nurses has a very strong position statement on it. But I think that really they need to be put around the clock and then use opioids as needed. And I know I was guiding my sister through surgery about a month ago, and she was sent home with acetaminophen, ibuprofen, and a hydrocodone acetaminophen. But all of them kind of said PRN. And I'm like, no, we're going to go through multimodal analgesia. You're going to do 12-6, 12-6 for your acetaminophen, and you're going to do 8-17-1 for your ibuprofen. And then you can do your acetaminophen, hydrocodone in between. So I really think that they really routine, they should be scheduled around the clock. Because then you also don't get into the challenges of making a nurse choose one and potentially get into regulatory issues. Well, Kathleen, I'm going to final thing with, it's not a question. This was very informative. Thank you for your approach in minimizing the stigma and utilizing patient-centered care. Thank you everybody for participation. Our time is up. As a reminder, we are able to provide continuing education for this session. At the end of the webinar, you will be sent an email with an evaluation form from ASPMN. You must complete this evaluation within 10 business days in order to receive your CE certificate. And once you complete the form, you'll receive, you'll be able to get a link that you'll be able to receive your certificate on the thank you page. Even if you are not applying for the CEs, please take a few minutes to assess the evaluation and provide your feedback on today's session. We really value that. You'll also receive a second evaluation from PCSS. Please complete this second evaluation. That is for the purposes of the SAMHSA grant. A reminder that today's webinar was recorded and will be posted tomorrow afternoon on the ASPMN website and on the website for the provider's clinical support system in the near future. And that URL is PCSSNOW.org. And you'll find a calendar there of upcoming events and helpful clinical resources are available there as well. And we have a session next week also that ASPMN is offering for this series. So look for that and register and thank you again for your participation. And I hope you join for future PCSS sessions. Thank you.

webinar

Kathleen Broglia

managing pain

opioid use disorder

harm reduction

multimodal analgesia

withdrawal symptoms

medications for opioid use disorder

naloxone

non-opioid analgesics