Hello, my name is Melissa Wymer. Today I'm going to be talking to you about managing pain in the patient with opioid use disorder inpatient management. This lecture is part of the PCSSO core pain curriculum. Our objectives today are to distinguish a substance use disorder as a chronic disease, identify ways to improve inpatient pain treatment in patients with opioid use disorders, describe how to safely use methadone for opioid withdrawal management in the hospital, recognize how to manage inpatient pain treatment in patients prescribed buprenorphine. Substance disorders, as we now know, is a disease of the brain. The outdated view is that substance use was a moral failing or a bad choice. But the modern evidence-based view is that substance use disorder is identified by genetic and environmental factors that predispose to chronic drug use. This leads to structural and functional disruption of motivation, reward, learning, and inhibitory control centers. And this can turn drug abuse into an automatic compulsive behavior known as substance use disorder. And when you talk to patients about it, this is a quote of how they may feel going through withdrawal and then their experience of substance use. And this patient says, Most of us that do it can't stand it. I hate this stuff. It is wretched. It's like damned if you do, damned if you don't. When I do it, I don't even feel good anymore. Like it takes so much just to be okay, to be normal. It's like when I use it, I just feel normal. So they don't understand that. So patients many times aren't even enjoying their substance use and they feel like they're trapped. This feeling and this thought of potentially being stigmatized by substance use can cause patients to avoid care. And really their avoidance is because they have the fear that they will be mistreated if their substance use is known. They fear that they might be judged or labeled as a drug user or drug abuser. And there's a real fear of withdrawal from the substance and that can keep them in this continual state of use. One patient describes it as this, you become crippled and sick from the withdrawal of opiates and methamphetamine. Diarrhea, sweating, vomiting, and chills. It's like the flu times 10. I would rather go through childbirth. Let's talk about a case. And for those of you who take care of patients in the hospital, these cases should, I hope, feel very familiar and some that are similar to the ones that you're encountering in your hospital setting. The first case, we're going to talk about a 34-year-old female with severe opioid use disorder. She's using approximately one gram of IV heroin per day. She was admitted 24 hours ago for a large abscess on her forearm and she's complaining of severe pain and anxiety. Her exam shows tachycardia, hypertension, diaphoresis, and anxiety. She's rubbing her joints and rocking back and forth. She's requesting IV opioids. She's expected to be discharged in the next 48 hours as you treat her abscess. If you're encountering this patient, you may be thinking, what's going on with her? Is this a sign of a more severe infection or is something else causing her symptoms? One way that you might determine whether this is opioid withdrawal or how severe her opioid withdrawal may be is an objective measure we have called the Clinical Opioid Withdrawal Scale. This is a scale that's well validated that can tell you if many of the symptoms she's having may be attributed to withdrawal from an opioid. It would be quite expected that she's going to withdraw from an opioid because she's been using heroin on a daily basis and she's now gone several hours without it. This scale goes through many of the signs and symptoms such as tachycardia, sweating, restlessness, dilated pupils, boner joint aches, runny nose, tearing, GI upset, tremor, yawning, anxiety, and goose flesh. Based on how they score here, this can tell you the severity of the withdrawal that the person may be undergoing. Some general principles about the effects that opioid withdrawal has on pain. We know that opioid withdrawal can actually worsen other painful conditions. Part of the opioid withdrawal scale was bone and joint aches. We know that people may just feel overall quite ill and quite painful. We also know that treating opioid withdrawal symptoms can improve pain management. If we attend to those symptoms, we're likely to not only have better pain management but also more engagement by the patient. Giving opioids is not going to worsen a patient's substance use disorder, so giving a few opioids in the hospital is not going to make that person more addicted or less addicted. Patients who use heroin or other very high-dose opioids are highly tolerant to opioids. Finally, it's important to determine if the patient coming in is currently potentially receiving a medication-assisted treatment such as methadone, buprenorphine, or naltrexone because this is really going to determine how you may treat their condition. The general approach for a patient who is coming in highly dependent on opioids would be doing a urine drug test to determine what opioids the person is using. They may not be forthcoming with that information. Next is to treat the opioid debt. The patient is in withdrawal from the opioid and their body is going through withdrawal because they're no longer receiving that same dose of the opioid. This is going to require that you're using some adjuvant treatments that we'll go over. You may consider, as we're going to go over, treating that debt or that withdrawal with a highly effective medicine that we are able to use in the hospital, and that's methadone. You can also use known effective pain treatments. What do we know actually treats pain, acute pain, in the hospital? Using other modalities such as Ketorolac, acetaminophen, and opioids when indicated. Recognizing that you may need to prescribe higher doses of opioids to help a patient in this situation receive pain relief. Let's talk a little bit about how you can actually manage opioid withdrawal in the hospital. I'm going to tell you right now that I think methadone is really the best choice and probably the most effective. You can also use buprenorphine however you need special training in order to do this, but that can also be highly effective. There are lots of other medicines you can also use, and these are not controlled substances such as clonidine, which can be highly effective to treat the hyperadrenergic state that occurs. Hydroxazine, which helps with agitation and insomnia. Nonsteroidals and acetaminophen for the cramping, aching, pain. Treating the abdominal cramping, stomach cramping with dicyclamine or hycosamine. Treating the diarrhea. Zofran for any nausea. Fluids. Medications can have a lot of insensible fluid loss and that can worsen their symptoms. All of these things can be highly effective, highly useful, and safe to treat opioid withdrawal. It is important to try to avoid benzodiazepines because that can create some secondary gain issues and could potentially be unsafe because of drug interactions. Ultimately, if you're able to, methadone can be a highly effective, safe medication to use to treat the opioid withdrawal as well as provide analgesia. How you would dose this is actually for a patient. Again, this is not a patient who is on methadone maintenance. This would be a patient coming in in acute opioid withdrawal who is not on methadone maintenance treatment. You could start with a dose of 10-20 mg of methadone, considering a lower dose if the person has lower tolerance or is only using opioid pills as opposed to heroin. You'd want to reassess the patient every 2-3 hours. You could give an additional 5-10 mg until the withdrawal symptoms abate. You would not want to exceed 40 mg in the first 24 hours. That is a pretty hard and fast rule. Any time that I've seen a patient harmed by methadone in the hospital is when they received more than 40 mg in the first 24 hours. That is an important point that should not go understated and should be followed to a T. That doesn't mean that you have to give up to 40 mg, but that means that you should not exceed that amount in the first 24 hours. Certainly you would want to monitor for CNS or respiratory depression. You may want to consider doing a baseline EKG to assess for QTC prolongation. You'd want to avoid methadone if a patient has a QTC greater than 500 ms. Because we know that methadone can cause QTC prolongation and torsades, which would be a potentially fatal arrhythmia from QTC prolongation. Some other guidelines. On the following day after giving those first doses of methadone, you'd want to give the total dose from the day prior as a single dose. Generally in order to treat withdrawal, opiate withdrawal, we're able to give a single dose once a day. That is consistent with dosing in the outpatient setting as well. Your goal is to alleviate the acute opiate withdrawal symptoms. The patient may continue to crave opioids, and that's part of the disease of opioid use disorder. Patients may also continue to have pain, and really you're using the methadone primarily to treat their opiate withdrawal. You are getting some analgesic benefit from the methadone for about 4 to 6 hours, but overall your primary goal with the use of methadone is to treat the opiate withdrawal. You'd want to discuss with the patient tapering the medication prior to discharge or maintaining the patient on the daily dose and referring them for treatment. If you are able to refer directly to a substance treatment center like an opiate treatment program, we're finding that that can be very beneficial to help engaging patients in care and helping them treat their use disorder. If that is a possibility, that would be an important thing that you might want to offer the patient. Having done this for patients now in the hospital for over a year, I can say that we're seeing very good benefit, very good patient engagement, and patients really feel like they're being cared for in an important way. Again, not to understate the importance of doing this and helping treat the patient. There are some different options here. There's this maintained dose option and then there's the tapered dose option. If you're using the maintained dose option, you're giving the same dose of methadone each day including the day of discharge. Generally, if the patient is not going to be directly connected with care, they're probably not going to want to exceed 30 to 40 milligrams of methadone. What you'll be doing by keeping the patient on that same dose is allowing a 24 to 36-hour withdrawal-free period after discharge from the hospital. You would want to prescribe the patient a naloxone rescue kit at discharge and discuss how they may have reduced opioid tolerance and may be at risk for opioid overdose after their discharge if they resume use. The methadone tapered dose option, if the patient requests a taper, would be to decrease the dose by 5 milligrams per day and stop the taper if the patient requests it. You wouldn't want to prolong the hospitalization in order to complete the taper. Again, you would want to provide a naloxone kit at discharge given the potential higher risk of opioid overdose given changes in opioid tolerance. A final point is that you want to be very aware that you should not give a prescription for methadone for the treatment of opioid use disorder at discharge. You would want to refer or arrange for opioid use disorder treatment for ongoing care. For the patient we discussed who was having a lot of pain from an abscess, was using 1 gram of heroin per day, and was having a lot of anxiety and withdrawal symptoms, an option for treatment would be to prescribe her 40 milligrams of methadone oral liquid. This is going to provide her about 4 to 6 hours of analgesia. Again, we're primarily using this for the treatment of opioid withdrawal. Additionally, we would want to offer her Ketorolac or something intramuscularly, a very strong anti-inflammatory medicine which will help not only her pain as well as her opioid withdrawal symptoms. You'd want to offer her scheduled Tylenol. Many patients will refuse this or say that it's not going to do anything for them, but I still schedule, I still order it and I still offer it to patients because it can really provide some good benefit. Additionally, you could prescribe her oxycodone immediate release at a higher dose, given that she has increased opioid tolerance. So a dose you might choose is 15 to 20 milligrams every four hours as needed. You'd wanna offer other modalities that we know work for pain, including ice and heat as needed. If her pain were very, very difficult to control and she was having a lot of symptoms, despite all of these measures, you could potentially think of a PCA or a patient controlled analgesia as another option for treatment. This patient unfortunately goes on to develop severe sepsis from aortic root valve endocarditis that was found on her exam. And she ends up needing an emergent valve replacement. And as many people who have any sort of very large cardiac surgery, she's having a lot of post-operative pain. So what are some ways that we can approach this situation? Well, if you can be proactive about it, that's always helpful. So I always like to engage my anesthesia colleagues for a pre-op consult, if available, to help them be able to anticipate that this patient is going to have higher opioid needs. And we wanna be very, we wanna offer a multimodal treatment to this patient because we know that her pain may be quite difficult to treat. If there were an option for a nerve block, if she were having, say, a joint, if she developed osteomyelitis and was having a joint washout or something like that, they may be able to do a nerve block, which can be highly effective. Because she's going to be in the hospital for a while, you may also consider changing her methadone to twice a day or three times a day. Again, you're primarily treating opioid withdrawal, but you're starting to see some stabilization, particularly over time, which will also treat, effectively, her opioid use disorder. And you're getting some additional analgesic benefit by dosing the methadone more frequently. Other things that can be quite helpful for a patient in this situation is ketamine post-operatively. It's an NMDA antagonist, and again, part of the multimodal treatment is providing additional analgesia using other pain receptors other than just the opioid receptors. A PCA can be helpful in this setting, as well as preoperative and post-operative gabapentin given at doses around 600 to 900 three times a day. And then again, using scheduled acetaminophen can be quite helpful. So as you can see here, we're really using multimodal treatment. We're addressing the opioid use disorder, but we are not denying her pain treatment. Certainly opioids are indicated post-operatively. Again, you may need higher doses used. But as you can see here, we're really attending to multiple different pain receptors. We're treating all of her pain in a multimodal fashion, and when you do that, we see that patients have better outcomes. Okay, case two. So this is a 27-year-old man with opioid use disorder and sarcoma of the left thigh. He will be undergoing resection of the sarcoma in the next week. He's been taking buprenorphine naloxone 8-2 milligrams once a day for six months, and he's very afraid to go off of it. So he started this treatment, has been very, very successful in this treatment for quite a while. This cancer has come on and really taken him by surprise, and he's really afraid that he's at risk for relapse if he stops taking this therapy. So what is buprenorphine naloxone? It's a partial opioid agonist, which means that it has not only a plateau effect but also means that it only partially blinds the opioid receptor. There's more information that you can get about this medication in some of our other lectures. It has a very high opioid mu receptor binding affinity with a very slow dissociation. It tends to have less euphoric effect than other opioids. It can provide some analgesic benefit similar to methadone for about four to six hours. It is paired with an antagonism to prevent abuse through injection, and it is approved for office-based prescribing if you have a DEA waiver and have gotten some additional training. So for this patient, there are some options of how you might approach the situation. He does not want to stop the buprenorphine, so your options are to really, again, try to use as many multimodal modalities and consider this approach, which is to use preoperative gabapentin, scheduled acetaminophen, consider an epidural. He is gonna have a procedure in his thigh, so typically an epidural would be effective. You could change his buprenorphine regimen to twice a day or even three times a day to obtain more analgesic benefit. Another alternative would be to increase his buprenorphine dose to see if that provides some additional analgesic benefit. And really, you're continuing this medication. We're gonna talk about another approach in a moment. Possible adjunctive opioids you can use, hydromorphone or fentanyl will competitively bind in a patient who's prescribed buprenorphine, so you can use them together. You would need to use potentially higher doses in order to have beneficial effect. You would certainly wanna have close monitoring because you are prescribing two opioids, and that can be a dangerous situation. But like I was saying, both fentanyl and hydromorphone have binding affinities that will competitively compete with buprenorphine at the opioid receptor, so you can get additional analgesia from their co-prescription. There is a lack of evidence to know what is the most optimal management strategy in this situation, but in this situation, for a patient who is very much wanting to continue buprenorphine, this is an option. If you're able to talk to the patient and the patient said that he wanted to stop buprenorphine, you could consider doing that as well, utilizing these adjunctive approaches, and then restarting the buprenorphine in the future. But for this patient who's clearly stated he does not want to stop the medication, this is a way that you could approach that situation. And for this particular patient, he ended up doing very, very well with his combination of medication and was very happy that he was able to continue staying on buprenorphine. Case three, so this is a 45-year-old female with persistent neck pain who has prescribed high-dose opioids for the last 10 years. She is admitted for nausea, vomiting, and abdominal pain. So general principles for this patient who's prescribed prescription opioids. It's important to know that the existing opioid prescription will not likely cover the acute pain that she's having. It's unlikely, or excuse me, unlike the patient who's using heroin, this patient may have already tried many existing pain treatments, so they may not be as successful, or she may have sort of some pre-existing expectation of whether they will work or not. The multimodal approach continues to be the most successful, however. Next, it's important to be aware that there could be secondary gain issues in order to determine whether these could be going on. You'd want to check the Prescription Drug Monitoring Program to confirm the dose that the patient describes and her prescriber. You would want to check a urine drug test to confirm that she's actually been adherent to her opioid regimen, confirm that she has an agreement with her PCP, and you may want to discuss with family what's been going on and consider that maybe opioid withdrawal could potentially be a cause of her symptoms. If she's been overtaking her medication, running out early, or other things, diverting, something like that. Your general approach is going to rule out medication harm, so do you feel that the benefits of this medication outweigh the risk and the harm? You are going to want to maintain her existing opioid regimen if it is safe for her. You're going to probably need to provide some short-acting opioid for acute pain, and you'd want to treat any opioid side effects. So is she potentially having withdrawal-mediated cyclic vomiting? Is she having constipation? All of these things would be things that you'd want to have a conversation with her about to determine how to best address it. You probably will need to discuss her pain regimen and discharge plan with the PCP to make sure that you're not prescribing additional opioids, particularly if she has an opiate agreement with that person. And I would also discuss with the patient that she could be at risk for opiate overdose in the future because she's prescribed high-dose opioids. So going back to that case a little bit, in general, that particular case was a case of a patient of mine who was actually admitted to the hospital multiple times for what we determined was ongoing withdrawal-mediated symptoms. And for that patient, the treatment was tapering her off of opioids and finding other modalities of treatment. So it's important to, sometimes this can take time to determine what's actually going on, but ultimately you're determining what the risk versus benefits of ongoing treatment. Case four, a 58-year-old woman with COPD, opioid use disorder, diabetes, and hepatitis C, admitted for hypoxia with oxygen saturation around 85%. She states she is treated at a methadone program and takes 120 milligrams of methadone daily with three takeouts a week. So what dose of methadone should you prescribe and why? So let's talk about a few methadone basics for patients who are currently being treated in an opioid treatment program. For these patients, you would always want to confirm the dose with the methadone program. Many of the clinics may not open until very early in the morning, but many may also have 24-hour call coverage and you may be able to call and ask to confirm the dose with a nurse on call. Reasons that you would consider reducing the methadone dose would be situations such as hypoxia, dangerous hypoxia, QTC prolongation greater than 500 milliseconds, concomitant benzodiazepine use, somnolence, or severe constipation. Typically reductions of 10 to 20% are usually very well tolerated. You wouldn't want to start splitting the dose of the methadone without discussing it with the opioid treatment program because most of these programs are single dose only unless there is specific approval by the treatment program to split the dose. You would not want to prescribe methadone at discharge for a patient involved in a methadone maintenance program. You would just want to instruct them to seek care at their methadone program. And if the patient's coming in with concerning hypoxia, you would want to talk to them about the risk of opioid overdose and prescribe a Narcan kit. Another point I would like to make is that this particular patient has three takeouts. So another thing to know is that if a patient has takeouts, that means that they have been successful in their program and that they're likely doing quite well. So you can have some reassurance that the patient has had success in her program. If the patient were having pain, what some points about prescribing other opioids. If needed, you would only prescribe a short supply of immediate release opioids at discharge. You would want to avoid benzodiazepines due to the concomitant risk of, or excuse me, because of the risk of concomitant prescription. You'd want to avoid those benzos during and after hospitalization. You'd want to consider possible risks of your opioid prescription, so not prescribing many or a high dose. You'd want to communicate with the primary care provider and the opioid treatment program about your plan for the patient. So what if this patient comes in and her urine drug test is positive for morphine, which would make you think that she may have been using heroin? So this would, if the urine is positive for morphine, this would make you suspect that there could be ongoing heroin use. You'd want to discuss this case with her permission with the opioid treatment program. You would want to continue to treat her pain as needed and recognize that she may have opioid withdrawal that is contributing to some of the pain she's having. Additionally, you'd want to recognize that she is at risk of unintentional overdose and you'd want to prescribe a naloxone overdose kit at discharge, as well as educate her loved ones about how to administer this. So in summary, pain can be well treated in patients with substance use disorders. Multimodal treatment is the most effective pain treatment. Treat opioid withdrawal effectively for improved pain outcomes for these patients and be mindful of opioid risk at discharge and prescribe naloxone to prevent opioid overdose or treat opioid overdose. Here are the references listed here, as well as some information about PCSO Colleague Support Program and ListServ and some information about PCSSO. Thank you so much for your attention. Thank you.

management of pain

opioid use disorder

inpatient setting

substance use disorder

opioid withdrawal

methadone treatment

multimodal pain treatment