Hello, everyone. My name is Laila Khalid. And my name is Michelle DeNora. Welcome to today's activity titled Treating Pain in People with Opioid Use Disorder. This event is brought to you by the Providers Clinical Support System, Medications for Opioid Use Disorder Project. Support some housekeeping content and discussions during this event are prohibited from promoting or selling products or services that serve professional or financial interests of any kind. The overarching goal of PCSS MOUD is to increase healthcare professionals' knowledge, skills, and confidence in providing evidence-based practices in the prevention, treatment, recovery, and harm reduction of OUD. We have no disclosures. Our objectives for today are, hopefully, at the conclusion of this activity, participants should be able to describe challenges and principles of treating pain in people with OUD, identify three strategies to improve inpatient acute pain treatment for people with OUD, discuss postoperative pain treatment considerations in people prescribed methadone or buprenorphine for OUD, and lastly, identify three strategies to improve outpatient chronic pain treatment for people with OUD. So, Dr. Benora, can you describe how common is pain in people with OUD? Quite common, in fact. Clinically, treating pain in people with OUD is a challenging yet surprisingly common scenario we encounter. A recently conducted systematic review and meta-analysis found that the pooled prevalence of current pain among people with OUD seeking treatment or taking an MOUD or medication for OUD, such as methadone or buprenorphine, was 60%. And the pooled prevalence of chronic pain was 44%. Additionally, studies have shown an estimated 36% of hospitalizations among people with OUD are due to acutely painful diagnoses, such as injection-related infections, endocarditis, cellulitis, abscesses, or trauma, burn, fracture, sprain, in addition to painful conditions common among all adults. Lastly, it's worth noting that un- or undertreated pain likely contributes to patterns of opioid use. Pain is a commonly reported motivating factor for use, and untreated acute pain has been found to be associated with increased risk for returning to use among people previously stable on MOUD. There are a few notable challenges to consider when treating pain in the setting of an underlying OUD. First is that pain-related sequelae from long-term exposure to opioids, such as in the case of OUD, can include opioid tolerance when higher doses of opioids are required to achieve the same analgesic effect over time. And opioid-induced hyperalgesia, a central sensitization that occurs from prolonged exposure to opioids, leading to worsened pain with higher doses of opioids. Second is that pain and withdrawal frequently co-occur, and certain symptoms can be difficult to distinguish between the two. And then lastly, the pharmacologic profiles of medications for OUD, again, being methadone, buprenorphine, and naltrexone, which are full, partial, and antagonists at the MU opioid receptor, respectively, can affect the activity of pain medications. Additionally, when considering the challenge of treating acute pain in people with OUD, it's important to consider the patient perspective and how the care they receive impacts their overall well-being. Qualitative data tells us that people with OUD consistently report experiencing stigma and a perceived minimization of their pain in acute care settings, and will often avoid seeking medical care altogether for fear of mistreatment, being judged or labeled, and or untreated withdrawal in pain. This is a quote from a qualitative study conducted among people with OUD who were seen in the emergency room for buprenorphine initiation. One study participant said, I've had emergency room doctors tell me that I should be ashamed of myself, and just shamed and belittled and made to feel, you know, as though my pain is not real. So let's go through our first case. 34-year-old woman with severe OUD, active non-prescribed opioid use, approximately one gram of IV heroin daily, is admitted 24 hours ago for a large abscess on forearm, and is endorsing severe pain and anxiety. Exam is notable for tachycardia, hypertension, diaphoresis, and anxiety. Patient is rubbing their joints and rocking back and forth. She's requesting IV full agonist opioid medications. The expected discharge is 48 hours. So Dr. Bhanora, how would you approach this patient? This is a great question. Many of us who treat patients in hospital settings will come across a scenario like this at least once in our practice. I think it's first important to note that empirical data as it relates to treating acute pain in OUD is significantly lacking, the specifics of which we'll get into a little bit later. However, expert opinion and some guidance does indeed exist. So here we've included some common principles to guide how you might approach acute pain in someone who has an opioid use disorder. So first, consider that opioid withdrawal worsens other painful conditions, and because of how opioid withdrawal presents, it can often be difficult to distinguish symptoms between the two. However, in my experience, symptoms often improve when pain and withdrawal are treated together. Second, consider that treating opioid withdrawal, even with a full or partial opioid agonist, is unlikely to sufficiently treat acute pain with a separate pain generator in addition to the withdrawal-mediated pain, and then last, consider that giving a full agonist opioid medication in an acute setting is unlikely to worsen a pre-existing opioid use disorder, and those who have had exposure to opioids, particularly high-potency synthetic ones, are highly tolerant to the effects of full agonist opioid medications. Many of you have likely seen this before, but this is the clinical opioid withdrawal scale, or COWS, which we use to assess the severity of opioid withdrawal. It can be easily looked up online or from your favorite medical app. Scores calculated using the criteria here can correlate to mild, with scores 5 to 12, moderate, scores 13 to 24, or severe, with scores greater than 36, withdrawal, and it's worth noting that when you're evaluating for withdrawal severity using this criteria, it includes an assessment for pain symptoms. On the left-hand side, you can see bone or joint aches. There's also some other symptoms here that you might also see in someone who's in pain, and this is a visual I really appreciate that we're using with permission from Dr. Melissa Weimer illustrating that in someone with a baseline opioid tolerance that is either met through non-prescribed opioid use or through a medication for opioid use disorder that's taken chronically, which is illustrated all the way on the left, and then you add acute pain on top of the baseline opioid tolerance, you need to provide enough agonist activity to cover both the baseline tolerance as well as the acute insult in order to adequately cover their acute need. When there's an opioid debt, which often occurs when someone's admitted to the hospital and is presented in the center of your screen, you can see that both withdrawal and pain symptoms can co-occur and exacerbate one another. This is often when we as clinicians come into the picture. So when you're making treatment decisions, it's important to both consider the baseline opioid tolerance in addition to the acutely painful insult in order to adequately treat the patient that you're seeing. So let's circle back to our patient. So we didn't perform the cows in a formal sense here, but given the presence of tachycardia, diaphoresis, and anxiety, in addition to restlessness and pain from the abscess, I'd say our patient likely meets criteria for moderate, if not severe, opioid withdrawal in addition to having pain from the abscess she presented with. And there are a few ways to think about approaching care for this patient. First, you need to treat the opioid debt, right, and more specifically, withdrawal, if on your assessment someone is indeed in withdrawal on presentation. You can do this with an MOUD, such as methadone or buprenorphine, in addition to other supportive medications. Secondly, you need to treat the acute pain. And so for this, multimodal treatment is gold standard with a maximization of non-opioid pharmacologic options, which we'll go into more detail as we go on in this talk. Lastly, it's important to recognize that because of the high prevalence of opioid tolerance among people with OUD, you may need to prescribe higher doses of full agonist opioids compared to those without OUD. This holds true regardless of whether someone is taking an MOUD or not. And just a quick note here, for someone who's taking buprenorphine in particular, you may need to prescribe a full agonist opioid with a sufficiently high affinity for the mu opioid receptor in order to compete with buprenorphine and provide analgesia. This is also something we'll explain in a little bit more detail as we go on. And so, Dr. Khalid, you may be wondering, how do we treat opioid withdrawal in the hospital setting? Awesome. That's a great question. And like Dr. Benora mentioned, methadone and buprenorphine are good choices to treat opioid withdrawal, but we also have help from other supportive medications. And I have some examples listed on the slide. So for example, clonidine can be used, especially in patients who have anxiety. Hydroxyzine can also be used in patients who have anxiety and agitation. We can use NSAIDs and acetaminophen if a patient is experiencing muscle cramps and pain. Loperamide, if patient has diarrhea or loose stools. Dicyclamine for abdominal cramps. Ondincetron, also known as Zofran for nausea. Trazodone for insomnia. And fluids. I tend to avoid benzodiazepines unless otherwise indicated. We've also included a website at the bottom of this slide for further details. Now, in addition to managing the withdrawal, we also have to manage the acute pain. And some of the acute pain treatment options are listed on this slide. I like to use ice and heat packs as a starter and approach acute pain management almost like a stepwise or a ladder. So you can schedule acetaminophen or NSAIDs. There are also options for muscle relaxants. So we have cyclobenzaprine, tizanidine, baclofen, gabapentinoids. Ketamine can also be used under certain settings, mostly monitored settings. We also have lidocaine patches, clonidine. And then if the pain is not controlled, we can opt for regional anesthesia such as blocks. And then full agonist opioid medications in the oral, subcutaneous, or intravenous forms. There's also an option for patient-controlled analgesia in which the patient can control how much or how frequently the opioids are delivered to the patient through an IV mechanism. So two things that I really want to stress while you're treating acute pain is assessment and escalation. So let's say you tried a treatment option. It is really important to assess the patient's response to that treatment. And if the response is not adequate and the patient is still having acute pain, to escalate it to an additional treatment, increase the dose, or add further medications. So Dr. Benora, can you tell us more about what evidence exists regarding specific pain medications for people with OUD? This is a great question and something actually the two of us have spent a significant amount of time looking into as we recently finished conducting a systematic review on acute pain and treatments for people with OUD specifically. You can look out for that in the coming months. In doing so, we've learned that the majority of available evidence on this topic is observational and the conclusions we can draw at this point are limited. Much more work needs to be done in this area. However, I will briefly touch on the available evidence that exists regarding a few interventions that might be of interest. So first, as it relates to PO and IV full agonist opioids, observational studies have consistently shown that higher doses are often used to treat acute pain in people with OUD compared to those without OUD. However, due to heterogeneity in the specific study populations, settings, and medications administered, evidence is insufficient to inform specific medications or doses. So we recommend that clinical decision-making should always be guided by patient and condition-specific factors. As it relates to ketamine, there are a small number of studies suggesting it may lower pain severity in the short term, i.e. up to 24 hours. However, it may also be associated with more adverse effects such as diplopia, nystagmus, hallucinations, nausea, vomiting, et cetera. With this in mind, the clinical scenarios in which benefits of ketamine outweigh the risks for people with OUD and acute pain are currently unclear. And lastly, there are a small number of interventions that have shown promise in single studies conducted in people with OUD, but overall remain largely understudied. And so, for example, there's been a single trial looking at oral clonidine for use in the emergency room for people with OUD who present with an acute orthopedic fracture, and that it may lower pain severity up to an hour compared to placebo. Additionally, IV lidocaine administered during general anesthesia may lower postoperative pain severity in opioid analgesic use compared to IV ketamine or placebo. Again, this is based off of a single low-risk-of-bias randomized clinical trial conducted among adults with OUD and postoperative pain. But as you can see, largely, you know, there are many gaps in the literature as far as specific interventions. When using full agonist opioid medications to treat acute pain, one thing to consider is the route of administration. What we're looking at here is a visual representation of plasma concentration on the Y-axis, time on the X-axis, and each color line represents a different route of administration for full agonists. As you can see, different routes of administration have different onsets or time to maximum plasma concentration and durations of action. So, for example, IV hydromorphone has an onset of action that's somewhere around five minutes and a duration between three and four hours. Poxicodone, on the other hand, has an onset of action closer to 15 to 30 minutes and a duration somewhere between three and six hours. Given its oral route of administration as opposed to IV, it achieves a lower plasma concentration of the full agonist opioid but for a longer period of time. And so, with this in mind, it may be reasonable to consider an oral opioid before IV if the patient's pain can be tolerable after an oral dose. There might be benefits to this approach. The schedule of administration is also relevant to think about. So, here we're looking at the same visual representation with plasma concentration on the Y-axis and time on the X-axis. Each color line now represents a different schedule of administration. As you can see, a long-acting medication, represented in green, achieves a lower plasma concentration over a much longer period of time compared to intermittent bolus or patient-controlled analgesia administration options. And intermittent IV bolus administrations, represented by the red line, will come with a much higher plasma concentration compared to the patient-controlled analgesia or PCA, which is represented by the yellow line, where the dosing is much more frequent but the bolus administered per dose is much lower. So, to circle back to our case one more time, here I've listed out two example treatment regimens for our patient with opioid use disorder, who we assess to be in withdrawal, in addition to having acute pain secondary to her abscess. So, first, we can give her methadone to cover the opioid debt or withdrawal. Now, methadone or a liquid generally is understood to provide four to six hours of analgesia only, and so it's primarily used in this setting for treatment of withdrawal. In accordance with current guidelines, we'd start with 30 milligrams for a first dose, followed by up to two additional doses of 10 milligrams as needed for ongoing symptoms, with a maximum total day one dose of 50. In addition, for her multimodal pain regimen, we could start as, using a stepwise fashion, we could start with ice and heat, schedule to see the menophin, Ketorolac, say 60 IM, and then if needed, escalate to full agonist opioids. In this case, we could consider oxycodone, 15 to 20 milligrams every four hours as needed. This would probably be fine with the methadone. A second option could be to initiate buprenorphine for treatment of the opioid withdrawal or debt. Now, it's a little bit outside the scope of our lecture today. There are various types of induction strategies for initiating buprenorphine in hospital settings, and for this patient, I might consider it a standard or a high-dose induction, since she's actively in withdrawal, with a maximum daily dose of 24 to 32 milligrams. In addition, a multimodal pain regimen could include, in the same stepwise fashion than before, so starting with ice and heat, schedule to see the menophin, Ketorolac, and then, if needed, a high affinity full agonist opioid medication, in this case, in order to sufficiently compete with the bupendorphine at the mu-opioid receptor. So in this case, IV hydromorphone via PCA or IV intermittent bolus I think would both be reasonable. And so let's continue our case. So let's say our patient chooses to start methadone and stables on a multimodal pain treatment with an NSAID, acetaminophen, and IV hydromorphone PCA. She goes on to develop severe sepsis from acute native valve aortic endocarditis and ends up needing an emergent valve replacement. She's now endorsing severe postoperative pain. So Dr. Khalid, what would you do to help this patient? That's a really great question. So it's really important to start off by getting a pre-op anesthesia consult. In addition, the medicine anesthesia and surgery teams should be in a closed loop communication so that everyone is on the same page from the pre-operative period, the perioperative period, and the postoperative period as far as pain management is concerned. Recommendations should definitely include what to do about the MOUD. And ideally, methadone should be continued. Some things that we can suggest regarding the methadone is to increase the frequency of the methadone dose. So for example, if somebody was using methadone, 90 milligrams once a day, that dose can be split into three and the patient can get 30 milligrams DID dosing. The other option is to temporarily increase the dose. So for example, if a patient came in with a 90 total daily dose of methadone, that could be increased to 100 or 110 depending on the patient's requirement. One thing that I do want to stress is, like Dr. Benora mentioned, methadone helps with pain relief for a period of four to six hours. So that's something to keep in mind. While it helps treat opioid withdrawal symptoms for a much longer time, and that's why it's dosed daily for treatment of opioid withdrawal. Another important point to note is that in many opioid treatment programs, the methadone is dosed daily. So if you do decide with input from the patient to split the methadone dose, the patient should be educated that on discharge, the patient will have to go back to the once daily dosing that they were getting from an opioid treatment program. In addition to continuing the MOUD and making changes in the MOUD, it's very important to come up with a multi-modal pain treatment plan. And this may include, I have some examples on the slide for post-op interventions, scheduling acetaminophen, NSAIDs, gabapentin, using ketamine or dexmedomidine. And this would involve input from our anesthesia colleagues, IV full agonist opioids, intraoperatively using nerve blocks, your axial blocks, intrathecal or IV, dexmedomidine, which is also Presodex or ketamine. These are specialized medications that are given to a patient in a monitored setting. And would require input from our anesthesia and pain colleagues. So there is a debate about, what about methadone split dosing? So if the methadone dose is being split, it's really important, patients should be involved in the decision-making because many patients feel strongly if their dose should be given as a once daily dosing or should be split into multiple doses through the course of the day. That's right. And so here we've just pulled in, as you can see a number of guidelines recommend the practice of split dosing. However, it is worth noting that empirical data is generally lacking in this area. To my knowledge, there have really only ever been one observational study and one case series looking into this exact practice. The observational study was conducted among hospitalized people with OUD taking methadone prior to administration with an average dose of 82 milligrams daily. And they found that premature hospital discharge was more common among participants who did not have their methadone dose increased or split compared to those who did. However, authors did not assess for any other pain or OUD related outcomes associated with the practice. And then the case series was describing six people taking methadone for OUD who then developed acute or subacute cancer related pain and experienced improved pain control with either an increased dose or frequency of their methadone. No other studies have reported on pain or OUD related outcomes associated with the practice of methadone split dosing or temporary dose adjustments during periods of acute pain. And I'll just add that in my practice, I've had the same experience as Dr. Khalid that a lot of times patients will know. They'll know what works for them and what doesn't work for them, especially if a patient's been taking methadone for many, many years. And so I'd strongly recommend talking about this with your patients before making a decision. So let us switch gears now. Dr. Benora, can you tell us how we would approach people with OUD on buprenorphine who are planning to get surgery? And we have a perfect case for this. So let me go over the case with you. 27 year old man with OUD and sarcoma of the left thigh will be undergoing resection of the tumor in the next week, has been taking buprenorphine eight milligrams once a day for six months and is afraid to stop. So what are we gonna do in this case? This patient is on bup and is gonna undergo surgery. Yeah, this again is an increasingly common clinical scenario as more and more people are prescribed buprenorphine and will need surgery. So let's start with some background. Buprenorphine is an opioid agonist medication that acts as a partial agonist at the mu-opioid receptor. It is a high receptor binding affinity and a slower dissociation creating a longer half-life, approximately 32 hours at the mu-opioid receptor compared to most full agonist opioids. And given this partial agonism, it's thought to have somewhat of a plateau effect and comes with lower risk of respiratory depression compared to other opioid medications. Generally, it provides four to six hours of analgesia. And I'm sure as most everyone by now is aware, it's office-based prescribing is available. The X waiver is no longer required and so anyone can prescribe. And so for any patients taking buprenorphine who need to undergo surgery, there are some general principles we recommend and you'll see this looks very similar to what we recommend for our patients taking methadone. So first and most importantly, we recommend obtaining a pre-op anesthesia consult and engaging in frequent closed loop communication with the patient's surgical team, anesthesiology team, in addition to the primary and or addiction medicine teams, depending what's available at the hospital. As it relates to buprenorphine, contemporary evidence currently supports the practice of continuing buprenorphine perioperatively at the hospital in which we practice. This recommendation holds true regardless of a patient's baseline buprenorphine dose. You may also consider adjustments to the baseline dose in order to maximize the analgesic properties of the medication, such as more frequent dosing or a temporary increase in dose. Secondly, there are a number of intra or post-operative interventions that you may consider, many of which we've listed here. Just briefly, those include similar to what we've been talking about prior, scheduled acetaminophen, NSAIDs, isenheat, gabapentinoids, muscle relaxants, topical lidocaine. These are all available. You might also consider talking to anesthesia about ketamine or lidocaine, nerve blocks or regional anesthesia, and then if needed, full agonist opioid medications, either through IV or spinal anesthesia. It's generally advised to avoid benzodiazepines unless otherwise indicated. Here are some pain treatment considerations recently published in the New England Journal of Medicine just in 2024, divided into the preoperative, immediate post-operative, and more prolonged post-operative periods. The last one being on discharge. The authors here generally follow the same approach that we're recommending, including to continue a patient's baseline MOUD while initiating a multimodal pain regimen that maximizes the use of non-opioid analgesia before adding additional full agonist opioid medications when needed. Amal, you're welcome to read through these recommendations in detail on your own. There are just two points I wanna highlight. So first is that the authors here note that patients taking buprenorphine at doses greater than 16 milligrams per day may have difficulty achieving adequate pain control during periods of acute pain. This concern has created some debate in the field as to whether higher doses of buprenorphine should be continued perioperatively. However, it has been the case in our practice and it is increasingly understood that even patients taking these higher doses, 16 milligrams or more of buprenorphine, do well when they continue their baseline medication at the same dose. And then the second point I'd like to highlight is that given buprenorphine's high affinity for the mu-opioid receptor, if additional full agonist opioid medications are needed to control acute pain, we need to intentionally select for an opioid medication with a similar binding affinity at the mu-opioid receptor. So for example, hydromorphone and fentanyl both have relatively similar binding affinities to buprenorphine and will competitively compete for it at the receptor. And here are just some more recommendations, ASAM National Practice Guidelines for the Treatment of Opioid Use Disorder on their focused update from 2020 also recommends continuing buprenorphine perioperatively. All right, so let's circle back to our case. So we decided to continue our patient's baseline buprenorphine but to split it into four milligram BID rather than eight milligram daily dosing. We obtained a pre-op anesthesia consult and initiated a multimodal pain regimen that included standing acetaminophen and gabapentin in addition to ice and heat. Anesthesia gave our patient an epidural and post-operatively he received IV hydromorphone via intermittent bolus with close monitoring for respiratory depression or other signs of sedation. And now we move on to our third case. So we have a 58-year-old woman with type 2 diabetes, COPD, opioid use disorder and chronic hepatitis C who's admitted for hypoxia, states that they are treated at an opioid treatment program and takes 120 milligrams of methadone daily with three take-home doses per week. So Dr. Khalid, what dose of methadone should we prescribe and why? Yeah, that's a great question. The first thing that is very important we should do is to confirm the dose of methadone from the opioid treatment program. And as you all know, methadone doses are not present in the prescription drug monitoring program. So usually many OTPs have someone on call who can give you this information when you call the OTP. Other ways of getting this information is asking the patient to bring a card that some OTPs provide the patient and that card has the dose of the methadone and the last date of dispensing on that card. Another strategy is to bring an empty bottle of methadone which also has similar information. Usually I do not recommend reducing the dose of methadone. We should continue whatever dose of methadone the patient is receiving in an opioid treatment program. But some reasons to reduce the dose are hypoxia, QTC is more than 500 milliseconds, benzodiazepine co-use or somnolence. And in some cases, if the patient has not gone to an OTP for weeks and so you don't know if the patient has been getting daily methadone. Dose reductions of 10 to 20% are usually well tolerated. Do not prescribe methadone at discharge. We cannot do that. But according to the new federal regulations, we can dispense from the hospital for up to 72 hours. However, just a word of caution that depending on the state that you're in, the implementation of the federal regulations may vary. And always prescribe naloxone at discharge. Some other general principles. If needed, let's say the patient needed acute pain management requiring full agonist opioids during hospitalization, you can provide a short supply of opioids as discharge. Avoid benzos during and after hospitalization unless there was, you know, some extenuating circumstances and consider possible risks of your opioid prescriptions. So meaning patient education, making sure that they know when to not take an opioid, for example, sedation. It is very important to communicate with the primary care physician as well as the opioid treatment program. If a patient was given opioids, full agonist opioids during hospitalization or at discharge, reason being, depending on the opioid treatment program, they may have different policies about what they find in a urine drug screen. So you want to inform them that, you know, this patient, for example, got morphine in the hospital, or I'm prescribing a few pills of oxycodone at discharge to the hospital. So it is essential information that needs to be communicated to the opioid treatment program. So Dr. Benora, but what if your patient's urine was positive for morphine or fentanyl on admission? What do you do? That is a great question. So the first thing I would recommend doing is to double check the timing of the test. Make sure the urine was collected prior to administration of any pain medications in the hospital. This is a surprisingly common mistake that we see. Then if the urine were indeed positive for morphine, ongoing non-prescribed opioid use is possible. You might consider, with the patient's consent, discussing this with the outpatient opioid treatment program. The patient may need a higher baseline methadone dose to adequately control their cravings. Split dosing may also be possible. It's also important to continue to treat this patient's acute pain. Consider that in this case, opioid withdrawal could still be contributing to the patient's pain, even if you're continuing their home dose of methadone because of this potential ongoing use. And as always, we recommend that you prescribe naloxone at discharge, explain to the patient that they will likely have reduced opioid tolerance in the period immediately following hospital discharge, and therefore be at an increased risk for unintentional overdose. And just a quick note on naltrexone. We do not present a case on this today. However, you may encounter a patient taking naltrexone, an opioid receptor antagonist who's in acute pain. And so a few notes to consider. First, it's important to note that empirical evidence to guide practice for our patients taking naltrexone in acute pain is severely limited. This is an important evidence gap. However, some options you may consider we've listed here and are based on expert opinion as well as in our practice. These include maximizing non-opioid pain medications whenever possible for mild and severe pain. In the case of severe pain, you may consider regional anesthesia, conscious sedation, or general anesthesia if needed. As it relates to elective surgery, the timing from the last dose of naltrexone should be considered when scheduling the procedure. Consider waiting 72 hours from the most recent oral naltrexone dose or four weeks from the most recent injection with extended release naltrexone before undergoing elective surgery. You may need to cover the patient with an oral product for a few days between injections. And now we move on to our second to last case of this session. So here, I'll talk us through the case. So here we have a 62-year-old man with a history of hypertension, chronic pain secondary to bilateral knee osteoarthritis, opioid use disorder, taking methadone at a daily dose of 80 milligrams, who recently underwent a left total knee replacement and was discharged from the hospital on a short course of full agonist opioid medications, oxycodone 30 milligrams every six hours as needed for seven days. Six months have now passed by since the operation and it appears that the patient continues to have pain that he attributes to the surgery. Your patient tells you that postoperatively, oxycodone provided him significant relief and he asks, can we reconsider? So Dr. Khalid, what do we tell our patient? No, that's great. I just wanna talk briefly about the transition from acute and chronic pain. So the transition from acute to chronic pain is common and some risk factors for developing chronic pain, post-surgical pain include patient factors, for example, younger age, female gender, preoperative psychosocial factors, such as anxiety, depression, pain, catastrophization, certain operative factors, for example, ischemic pain, nerve injury during the surgery, post-op factors include uncontrolled high intensity pain, longer duration of postoperative pain and that's why it's really important, as you can see, that if patient has had surgery or is having acute pain, it's important to treat acute pain aggressively. We should look at chronic pain management through three intersecting frameworks. One is the biopsychosocial pain-centered pain assessment, patient education, and multimodal treatment plan. Education of patients should be provided around the chronicity of pain, and that complete relief of pain is not likely, but the goal of the plan, the management plan, is that people have pain relief so that they can achieve their functional goals. A multimodal pain strategy should be emphasized. There's no single treatment that can relieve pain, but different treatments in synergy can provide better pain relief. So our general approach should include a comprehensive standardized assessment. So all our patients should be assessed in the same way. And as I discussed in the previous slide, educating the patient, making sure you identify their functional goals, and identifying the connection to stress and withdrawal is important. During this session, I also teach or go through coping skills for many of our patients that don't know what coping skills exist for some of their pain. Reset or clear expectations are set. Pain will not go away completely, but emphasis is on functional goals. We should also assess for pain facilitators, which we're going to discuss in the next slide. Manage OUD and assess for opioid withdrawal. Maybe the dose of MOUD is not enough. Maybe you need to adjust that. Maybe you need to adjust the frequency. And MOUD can also be used for analgesia, for example, split or increased dosing, especially for buprenorphine. Multimodal individualized pain treatment is gold standard. So I like to say that no two of my patients have the same management plan. They all have separate plans, which is catered to their situation or their nuances of life and pain. Both non-pharmacological and non-opioid pharmacological treatments should be emphasized. So again, no magic pill, but different treatments will come together to provide adequate pain relief. And of course, with every plan, the patient should be engaged, and there should be shared decision making. So what are some of the pain facilitators? Sometimes we don't think about this in, you know, like a typical pain visit, but these are all things that can contribute and exacerbate a patient's pain. So for example, mental health disorders, anxiety, PTSD, insomnia, I always ask my patients about their sleep, you know, how much sleep they're getting, how good the sleep quality is, and even discussing sleep hygiene during some of my sessions. Substance withdrawal, are they using any substances that is, and they're experiencing withdrawal that is sort of experienced as worsening pain. Depression, functional losses, and also learning and reward, and how those interact with their pain. One other thing that is not listed on this slide is also weight. Many of my patients who have a high BMI, I also discuss how an increased BMI can worsen their pain, and for example, especially for knee pain or back pain, and how I can help them, you know, lose weight. And we also discuss strategies around that. So this is a nice diagram of what are some of the multimodal treatment options available. And I just want to sort of like take you through it. I divide multimodal treatment options into two main buckets. One is pharmacotherapy, and the other is non-pharmacotherapy. So under pharmacotherapy, we have non-opioids, opioids, we also have medical cannabis as a way of treating pain. But non-pharmacotherapy is equally important, and I like to emphasize it in my patient visits. Some of them are listed here. For example, behavioral treatment, going through cognitive behavioral therapy, coping skills, like I mentioned, teaching them some brief mindfulness-based stress reduction exercises. Physical activation, I refer many patients to rehab and physical therapy, but it's also important to teach our patients on how to be physically active daily, or how to incorporate exercise in their daily living. Some examples also include yoga, tai chi, aqua therapy. And then, of course, if pain is not relieved by these mechanisms, that's where the interventions come in. So for example, both injections and stimulators, but also acupuncture, massages, chiropractor use in the appropriate setting. So Dr. Bernora, what about full agonist opioids for chronic pain? Is there any evidence? It's a great question. I'm sure most people are aware at this point that opioid medications are generally not considered evidence-based treatment for non-malignant chronic pain, and can lead to sequelae such as tolerance, withdrawal, opioid-induced hyperalgesia, some of which we've mentioned previously. In terms of the evidence guiding this, the Cochrane Collaboration published a systematic review back in 2010, examining the efficacy of long-term opioid therapy in a variety of pain conditions, concluding that evidence regarding the effectiveness of chronic non-cancer pain is too sparse to draw firm conclusions. And importantly, they noted that no long-term studies, at least as of yet, had included functional outcomes in their assessments. In 2015, Wodrachow and others published a systematic review looking not only at treatment effectiveness, but now also harms. And they found that the benefit of opioids in general was modest or absent, while data suggested that harms were mounting, including fractures, hypogonadism, cardiovascular events, et cetera. In 2018, a team led by Aaron Krebs conducted the first ever pragmatic trial of opioid versus non-opioid management of chronic pain, and reported that while the opioid group did no better in terms of pain-related functional interference, they did experience double the side effects of the non-opioid group. So for these reasons, when treating patients with chronic pain, with or without opioid use disorder, and who are not already taking an opioid medication chronically for pain, emphasis should be placed on non-pharmacologic and non-opioid pharmacologic treatment options, with frequent reassessment of ongoing symptomatology and monitoring for progress toward each patient's specific functional goal. However, we also recognize that treatments are not a one-size-fit-all. And particularly for patients already taking opioid medications to manage their pain, we recommend using a risk-benefit framework. With my patients, I avoid asking questions such as, is this patient good or bad? Does this patient deserve opioid medications? Or should I trust them? I prefer asking questions along the lines of, do the benefits of opioid treatment outweigh the risks for this patient? And I'll even add, at this time. So here we've just pulled in the most up-to-date treatment guidelines and recommendations as they relate to opioid prescribing for patients with opioid use disorder and chronic pain. So first, the CDC, as of 2022, recommends that clinicians use non-pharmacologic and non-opioid pharmacologic pain treatments as appropriate to provide optimal pain management for patients with co-occurring pain and substance use disorders. They also note that patients with pain who have an active opioid use disorder that's not in treatment, that clinicians should consider buprenorphine or methadone treatment for OUD, which may also help with concurrent management of pain. And next, here are some recommendations from ASAM as of 2020, split by MOUD, methadone, or buprenorphine. And for patients already taking methadone, they note that temporarily increasing the methadone dose or dosing frequency may be effective for managing pain, and that the addition of short-acting full agonist opioids can be considered for moderate to severe acute pain. For patients taking buprenorphine, they note split dosing of buprenorphine, Q6 to 8 hours, may be adequate for chronic pain management, and that patients experiencing substantial chronic pain on high doses of full agonist opioids experience improved pain management when they're transitioned to buprenorphine. And finally, we arrive at our last case. This time, our patient is a 43-year-old woman with a long history of migraine headaches, depression, anxiety. She's currently taking hydrocodone, acetaminophen BID, and nortriptyline. This patient has not been diagnosed with OUD and is not taking an MOUD. She continues to have daily debilitating migraines, finds that she needs higher doses of her pain medication to get the same relief. And on your assessment, you note opioid cravings, multiple unsuccessful attempts to cut back on opioid use, increased depression symptoms when she stops her opioids. She occasionally obtains extra opioids from friends. Her husband is concerned about her use, and she's noticed a decrease in function. She spends most of her day in the bed these days. So Dr. Khalid, how would you make sense of this clinical scenario? What about patients already taking long-term opioid therapy? I think this is a great case, and let's talk about this. I see a lot of patients with similar presentations. So it is very important to start off by assessing for OUD using DSM-5 criteria. Because we know undiagnosed OUD can lead to ineffective pain management. If OUD diagnosis is made, the first step should be to offer evidence-based treatment for OUD. Consider transition from long-term opioid therapy to buprenorphine for concurrent management of pain and OUD. So what this statement basically means is, for example, in this patient, I would offer buprenorphine to her. First of all, she's on long-term opioid therapy and has uncontrolled pain, has poor functioning. Again, like we stressed, the function is our goal. And in the previous slide, it was mentioned that her functioning is poor. And buprenorphine, why do I offer buprenorphine? Buprenorphine allows me to dose her frequently. And so I would expect her to use buprenorphine multiple times a day to help with pain relief. But buprenorphine is, again, not a magic medicine, especially for pain. It should be used in the context of developing a multimodal treatment plan. And in synergy with other treatments, I found it to be effective. So maximize non-pharmacological, other non-pharmacological treatments, and other non-opioid pharmacological treatments in addition to buprenorphine. Patients often endorse satisfaction with buprenorphine. This is what we have found in patients who have come off full agonist opioids onto buprenorphine. And the analgesia from buprenorphine is sort of similar to full agonist opioids. And anecdotally, I can also tell you that some of my patients also feel less anxious on buprenorphine as compared to full agonist opioids. But this cannot happen, the transition cannot happen, without effective patient-clinician communication. Expecting that transition in the first visit is, you know, unlikely. I think of it as a journey. So communicating with the patient, having the patient say, share decision-making, and then sort of like journeying through this process, that transition to buprenorphine would be helpful, can be helpful. And black patients report challenges in accessing pain care, highlighting need to avoid worsening disparities in pain management on the basis of race. So we should be aware of that as well. Any plan that we make for pain, we should be aware that things may change, symptoms may change. So we should always assess any changes in symptomatology and revisit our plans. So for example, if this patient was on full agonist treatment and was not willing to transition to buprenorphine, I might add on other multimodal treatment plans and sort of like reassess, make frequent visits. Patients who have chronic pain actually benefit from frequent visits even more than my other patients. And then sort of like using motivational interviewing to see or explore if the transition to buprenorphine, she's willing to transition to buprenorphine. And then stay on message, using positive reinforcement, using your motivational skills. These together can be successful in helping convince the patient to transition to buprenorphine. So I already discussed some of the things in this. We have to be honest and transparent. I tell my patients that we are going to try this strategy. This is not going to be the only medicine that you'll be taking. And emphasizing multimodal treatment plan. And it may or may not work. For some patients, buprenorphine does not work. And I make that clear as well from the very get-go. I also ask for feedback on how they're feeling once I transition them. So for example, if they are, if their pain is not relieved by whatever dose of buprenorphine they're on, I might change the frequency of the dosing. I might increase the dose of the buprenorphine. And so I'm in constant touch with them in this transition process. So while I'm transitioning or I'm discussing the transition process, I'm meeting with my patient very frequently. And so we appreciate everyone who's made it with us to the conclusion of this lecture. We know it's been a long one. There's been a lot discussed. A few take-home messages we want to leave you with. So first, it's often helpful to address pain and OUD in patients who have both simultaneously, when appropriate, treat acute withdrawal and pain concurrently. Second, pay attention to the multidimensional experience of pain. For both acute and chronic pain, multimodal care is gold standard. Whenever appropriate, offer medications for opioid use disorder. For patients already taking a medication for opioid use disorder, consider their implications on pain treatment options. And lastly, discussions regarding opioid medications should always be based on clinical judgment using a risk-benefit framework, shared decision-making, and frequent reassessments. Is there anything you'd like to add, Dr. Khalid, from your clinical experiences that you want to leave our listeners with? Yeah. I would like to add two points that I have experienced in treating patients with chronic pain. I think the first is listening, reflecting, and validating the patient experience of pain. I feel like this is the most essential thing you can do to develop a relationship. And without a relationship, all these treatments, I feel, are ineffective, or the patient is not even willing to try these treatments without that relationship. And the second point that I want to make is stressing multimodal treatment plan for our patient. So emphasizing not one medication, but multiple other medications, lifestyle changes, non-pharmacological treatments together are helping the patient achieve their functional goals. Yeah. I've also found two things to be helpful just from my practice. So first is everyone's an expert in their own experience. And particularly, our patients with opioid use disorder have a ton of experience. So don't be afraid when you don't know or when you're unsure to involve the patient in the decisions about their own health. And then lastly, frequent reassessments and non-abandonment are critical. Like, don't be too proud or afraid to mix it up when things aren't working. And try to continue to work with your patient to find the regimen that works for them. All right. So here are just some references used to compile today's presentation. There are a lot of them. I'd also like to make you aware of two resources offered through the PCSS MOUD that may be of interest to you. First, the PCSS MOUD mentor program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address clinical questions. You have the option of requesting a mentor from our mentor directory, or we're happy to pair you with one. To find out more information, please visit our website using the web link noted on this slide. Second, PCSS MOUD offers a discussion forum that is comprised of our PCSS MOUD mentors and other experts in the field who help provide prompt responses to clinical cases and questions. We also have a mentor on call each month. This person is available to address any submitted questions through the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. These next two slides simply note the consortium of organizations that are part of the PCSS MOUD project. And finally, please reference this slide for our contact information, website, Twitter, and Facebook handles to find out more about our resource and educational offerings. Thank you very much. Thank you.

substance use screening

primary care

screening tools

TAPS tool

implementation guidance

US Preventive Services Task Force

electronic health records

screening barriers

referral and treatment

opioid use disorder

pain management

Laila Khalid

Michelle DeNora

MOUD project

stigma

methadone

buprenorphine

multimodal approach

chronic pain

opioid tolerance

perioperative care

non-opioid treatments

healthcare providers

evidence-based practices

harm reduction

multimodal strategies

clinician-patient communication