Welcome, everyone. This is a presentation by June Oliver and Helen Turner on, I'm trying to find the exact title of it, but the ASPN and INSNA position statement on pain management and risks associated with SUD. Now, we have both the two speakers. So first, I'm going to talk about Helen. Dr. Helen Turner is a clinical nurse specialist with prescriptive privilege who specializes in management at, I don't know if I can say it, Dern Becker Children's Hospital, which is associated with Oregon Health and Science University. She is the director of offsite graduate learning and APRN core courses at the OHSU School of Nursing. She's a national and international consultant and lecturer on interprofessional evidence-based pain management. She's an associate professor in the schools of nursing and medicine at OHSU and is accredited with many publications on pain management ethics and health disparities. She's co-editor of the core curriculum for pain management nursing and is a fellow in the American Academy of Nursing and is also a past president of the American Society for Pain Management Nursing. Now, June has 23 years of experience in pain management as an advanced practice nurse. She manages both outpatients with chronic pain and inpatients with acute and chronic pain conditions from postoperative pain, as well as a variety of medical conditions, including patients with pain and substance use disorders. This management includes pharmacological and non-pharmacologic approaches through understanding of the risks and benefits of each medication added to a patient's overall plan. Now, I do want to say one more thing. To obtain the CE for this presentation, you will be sent a link to an evaluation after the presentation, and you have to complete the evaluation. If you complete the evaluation, the CE will be mailed to you. And then also, the slides, a copy of the slides is posted on the PCSS webpage, and that information will be on a slide later in their presentation. So at this point in time, I'd like to turn it over to Dr. Helen Turner. Thanks, Kathy, for that introduction. And as she said, we'll be talking about the Joint Position Statement on Pain Management and the Risks Associated with Substance Use Disorder that was published by the American Society for Pain Management Nursing and the International Societies for Addiction. So PCSS, I'd like to thank the group for allowing us to do this presentation. It is a collaborative effort led by the American Academy of Addiction Psychiatry in partnership with all these renowned organizations and has been around for many years with success in providing education. Overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the treatment of substance use disorders. We have no conflicts of interest to disclose. And with that, we'll get right into our presentation. Our objectives for today are to review the position statement as the foundation for formulating appropriate care and assessing for risk of SUD. We're going to discuss the impact of stigmatization on treatment of pain in persons with SUD, identify available tools to use in an integrated, holistic, multidimensional approach to assessment and treatment, and we'll present some practice recommendations for clinicians, healthcare systems, and policymakers, legislator-type folks. We always want to know the why. And the why for this is we know that assessing and managing pain while evaluating risks associated with substance use or misuse continues to be a challenge faced by healthcare clinicians. You know, both pain and substance use disorder have been around forever. So this isn't something new, but we continue to try to do better. Evidence-based clinical recommendations are needed to understand and manage patients with pain and at risk for or with SUD. So the joint position statement, as I mentioned, was published in collaborative. We had authors from both American Society for Pain Management Nursing as well as the International Nursing Society on Addiction. And our position statement is the core of that statement is that persons with co-occurring pain and substance use disorder have the right to be treated with dignity and respect and to receive evidence-based, high-quality assessment and management for both conditions while using an integrated, holistic, and multidimensional approach. So the position statements, again, this is just a screenshot of the two journals. And then there was also a full-length manuscript published in Pain Management Nursing that really provided the bulk of the evidence for the position statement. And again, folks on this manuscript come from nursing background, addictions background, clinical practice, academics, and research, so a really well-rounded group of authors. The overview for our presentation today is that we need to affirm that there's an ongoing triple crisis of pain, substance use disorder, and overdose death. We know that this worsened during the COVID pandemic. Prevalence of co-occurring pain and opioid use disorder is there. We do need to differentiate the risk of overdose death, and the risks are different for people who have pain, people who have substance use, and people who have both conditions. Our attitudes and the regulations around this topic of opioids and substance use disorder actually play into a lot of clinical practice. And they result in decreased access to care for pain, substance use disorders, and mental health care. An example of some of the harms that have resulted is the noted rise in suicidality of our veterans. And we also want to advocate for a balanced understanding of the data on opioids and overdose death. Avoid oversimplification of these really complex issues, and acknowledge the impact of federal pain guidelines. The first thing we're going to talk about is the impact of stigma. And stigma is huge for this population. And we know the main impact is that it really dehumanizes or objectifies patients with pain, patients with substance use disorders, and patients who have both conditions. Stigma also reinforces misperceptions and incorrect assumptions. It interferes with evidence-based assessment. Also, it interferes with management of both conditions. And often it results in a lack of patient disclosure because they're afraid of being judged. And once they've had that sense of being judged, they carry that with them for a very long time and from each encounter to the next. And so we know that stigma really hinders therapeutic relationship between patients and the providers caring for them. One thing we can do is really think about the words we use when we're working with with folks who have these conditions and when we're working with our colleagues. We need to role model nonjudgmental language. This is important enough that NIDA actually created a table and it's called Words Matter. And it lists, this is just an example of some of the terms to avoid and the terms to use instead, and the reason why. A lot of times it's easier for us to change our language if we understand what's behind that. So, for example, rather than using addict or former addict, we could say a person with substance use disorder or a person in recovery. And what this really shows is that the person has a problem rather than that the person is the problem. And so I would encourage you to look at this. This table is also in that full length manuscript if you get that. So, out of the manuscript, we really went into a detailed list and review of the literature, as well as how to put forth some recommendations. And those are highlighted in the position statement, but really the details are in that full length manuscript. But the big thing is to do some holistic information gathering. So, really evaluate the impact of pain and SUD on the person's life and or their ability to function day to day. We want to recognize that persistent pain and SUD often co-occur and that they can add or reinforce each other. We know that patients with pain, about 65% of them have anxiety and 83% have depression. So, there's a lot of comorbidity going on. Patients with substance use disorder, again, have high comorbidity with these disorders. And with pain catastrophizing, which is a repetitive negative thought process, not being recognized as a mood disorder, we know it has significant impact. So, we really need to pay attention to the whole person and not just get bits and pieces when we're doing that information gathering and doing our screening and assessment. So, screening is asking the questions before their signs and symptoms. And assessment is actually really doing the thorough evaluation and potentially diagnosing disease and conditions or risks. So, when we look at that holistic information gathering, we want to talk about pain. We all know that it's not just a number. This has to include an assessment of function. Also, we want to get information around mental, emotional, and spiritual health because we know how tied together the psychosocial, spiritual aspect is with the physical experience. We also need to look at and assess for risk of substance use disorder. We really need to be clear, again, about the words we use and the terminology so that we don't get misinformation or don't misdiagnose, if you will. Call people the wrong thing, identify a behavior in the wrong way, those kinds of things. But we really want to be clear if there's harmful drug use versus misuse versus substance use disorder versus opioid disorder. And it's really important to understand the distinction of those. Also, a positive screen for a substance use disorder is not a diagnosis of substance use disorder. It's a positive screen and that's all it is. The diagnosis has to meet the DSM-5 criteria. We also want to monitor opioid use. And in that, we are looking at opioid misuse being a manner in which the opioid was not prescribed. And just being really clear about what that is, whether that's being used for reasons other than pain or whether pain is poorly controlled and the patient is taking more than is actually prescribed. Misuse is not automatically a substance use disorder or opioid use disorder. Most misuse is because the person is seeking pain relief. And often that responds to education and just, if needed, an adjustment in the prescription. There is a small percentage of folks with opioid misuse that may be at risk for substance use disorder, opioid use disorder. And also when we're doing all of this, we need to be thoughtful about substance withdrawal, whether that substance is opioids, alcohol, benzodiazepines, or some other substance. So there's a lot of different tools out there and it's really important to know what a tool does and what it does not do. Many opioid screening tools look at problematic opioid use behaviors, such as the current opioid misuse measure or the COM. But only the opioid risk tool for opioid use disorder measures opioid use disorder risk as opposed to misuse. So there's a lot of tools out there, like I said, for all these different aspects of holistic information gathering. And you're really encouraged to select the tools that work well for you, the practice you're in, the patients you care for. Add those to your toolbox so that they're readily available and that you get really comfortable using them. The more you use them, the more efficient you can be with using them. And you also can start to see the nuances in how they work. So this is a list that obviously you can't read because I can't even read it and I'm looking at the slide. But in the full-length manuscript, this table is there and it really identifies the tools for the various categories. So pain talks about what's important there, the tools that are available. Sorry, my computer's decided to do its own thing. There's tools to look at spirituality, anxiety, depression, suicide, and mental health. There are tools to assess for screenings, assess for risk of substance use disorder, opioid use, withdrawals, and then also diagnosing. So again, another nice resource that's available to you to really pull together the holistic information gathering. The opioid risk tool for opioid use disorder that I mentioned is really a very straightforward and easy tool. You can see it here, a score of zero to two indicates there's low risk for future opioid use disorder. A score three or above indicates that there's a high risk. And so having that information can help you really plan and work with the patient to have a plan in order to be able to safely monitor and prescribe opioids if needed. And now I'll turn it over to June. Thank you, Helen. Thanks for getting us going. And we're going to continue and dig into some of the recommendations that are in the full length manuscript. Excuse me. So this is a slide showing the overview of what actually is addressed in the manuscript, and we'll look in more detail at each of these. But for the bird's eye view, we do look at all patients receiving opioid treatment with 12 recommendations, including treatment plans. And if you go to the document, the full length manuscript, you can look at the figures and the tables that give you details about such things as treatment plans. And we're looking at patients with acute pain at risk for or with opioid use disorder. For or with substance use disorder, three recommendations. Specifically, there's Helen already showed you the carve out picture for the opioid risk tool for OUD. And there's another figure that shows resources for testing and monitoring urine toxicology. Also, recommendations for patients with persistent pain who are at risk, again, for SUD, eight recommendations. And there's a table looking specifically at medications used to treat opioid use disorder in the setting of persistent pain. And what do we do with those? And for patients with acute and persistent pain who are actually receiving the medications for opioid use disorder, and what do we do with that when they're experiencing acute pain episodes, or if they're having persistent pain? And then there is an addressing of tapering opioids with an overview of four recommendations. Next. So in looking at the details of the recommendations for all patients receiving opioid therapy, whether they have an SUD known risk or not, these would apply to everyone. So one, reassure that their report of pain will be addressed and will be taken seriously. So you don't have to wrestle with, you know, gosh, is it true or is it not true? Are they telling the truth? We're going to take it seriously. We're going to address it. But as Helen said, pain is not just a number. It's a holistic assessment, including function as well as safety. But we reassure the patient that we are taking this seriously. Two, use formal assessment tools and standard procedures to guide individualized care. They are not absolute rules or restrictions. They are there to help you. And again, finding your toolbox and knowing what that tool measures and doesn't measure is going to be very useful. And three, ensure accurate diagnosis of pain etiology. This is basic for any pain intervention. We need to treat, of course, the underlying etiology whenever we can. But this is foundational for pain practice with and without substance use disorders. Sometimes patients with substance use disorders are dismissed. They're like, ah, they're making it up. No, we need to take it seriously and look as aggressively for the pain etiology with that patient population as we would without. And four, conduct a screening for pain, SUD and mood disorders. Screening again is asking questions. So not just pain, but are we screening for these other concurrent conditions that may or may not exist. And five, document a mutually agreed upon treatment plan. And there's a table in the document that goes into specifics of what to include, but it's addressing the risks and the benefits of the treatment plan, including opioids and beyond, as well as boundaries and responsibilities of both patient as well as provider. And of course, maximize multimodal pharmacology approaches and non-pharm analgesia. That goes for standard care for all of our pain patients, but don't forget it with the patients that have special needs. And seven, continual evaluation of pain function, adverse events, opioid use and progress. Not recommended to change treatment plan based on pain intensity alone. It's a much more holistic evaluation. There's an interesting quote from someone who I can't remember who to attribute it to, but evaluating pain on intensity alone is like evaluating music on volume alone. That is a completely inadequate assessment. So we need to be more holistic in evaluating and get appropriate intervention based on that. Eight, individualized adherence monitoring. How well are they using the treatment plan as prescribed? Pill counts, urine drug tests, prescription monitoring programs can all be helpful. And then nine, monitor for signs and symptoms of opioid use disorder as well as other SUDs. Could be alcohol or other substances, but always keep a therapeutic relationship. And if you are finding concerns or actual evidence of an opioid use disorder, refer and treat, but keep that therapeutic relationship. This is not a punitive action, it is a care response. 10, consider tapering opioids if continued unsafe behavior that you're noticing, or if there's treatment refusal, then you need to look into tapering resources, which we have listed for you also in the manuscript. 11, document all interactions, goes without saying, but besides a medical legal obligation, you can use your documentation for education and for rationale when you're changing a treatment plan or when you're feeling that tapering is necessary. You can go back to those notes and share them with the patient. This is where you were, this is where we were, this is the assessment, this was the plan. So it can be useful in many ways. And then prescribe naloxone with education. Of course, the significant other's family need to be involved in that because the patient cannot give it to themselves if they actually need it. Next. Additional recommendations for pain and substance use disorder risk with acute pain. So we would prefer short-acting opioids at least initially. You can make a case for long-acting, but to begin with, short-acting opioids are safer and preferred in this setting. When they're in an institution, in the hospital, it could be outpatient, but with acute pain, controlling the pain is one issue, which can be challenging, but usually can be accomplished. Well, what is the discharge plan? If this patient has substance use or high risk for it, what are we gonna do when they go home? So we need to be finding a detailed discharge plan for monitoring of both pain, adherence to treatment, problematic behaviors, substance use risk. And if this is acute pain, are we expecting it to resolve? What is the tapering plan? Can you send them home with tapering doses? And referral to mental health and substance use recovery support. What support are they getting as they're going home? Remember that uncontrolled pain can also be a trigger for relapse. So we need to have a plan with a holistic support surrounding them. Next. How about persistent pain? Well, this can go for acute pain as well, but these patients may need higher doses of opioids to control the pain. If they have tolerance, if they have an opioid use disorder, we're expecting that they're going to have the need for higher dose of opioids. When they no longer need opioid for the pain problem, they're probably gonna need a slow taper if they've had significant tolerance issues. If they are in recovery, you need to ask questions that would assess the duration and stability of recovery. How long have they been sober? How many relapses have they had? What's their support system? What are their triggers? What do they do when they're triggered? And these are discussions that you need to have with the patient. Who can they confide in? Who do they go to? Open communication with the patient with their significant other and the nurses and well as the staff involved in their care with concerns regarding the treatment plan, especially medications that they may go home with. It's not a secret. It's not a shaming discussion. It's an open discussion about what's safe and what kind of supports are needed. And then substance use disorder is a relapsing condition. It's a chronic condition. It can relapse. Anticipated and do not automatically terminate pain care if there's a relapse. Make a plan for how you're going to intensify recovery efforts and still be safe. That doesn't mean everything medication-wise continues the same, but we are not dismissing the patient because there's a relapse. We may be changing the plan of care in intensifying recovery efforts. Next. Okay, so if the patient is having medications for opioid use disorder, also referred to as MOUD, what is the goal? Obviously adequate pain control and lowering the risk of relapse. So adequate pain control for people who are on medications for opioid use disorder can include opioids. Sometimes there's misunderstandings and fears when people come into the hospital with a significant pain issue and they're on methadone or they're on buprenorphine and they're like, oh, we can't give them opioids. If it's appropriate for their condition, yes, it can be part of the plan. It should not be automatically ruled out. Now the full-length manuscript does have special notes and we'll look at some of those for buprenorphine, methadone, and naltrexone. What do we do with patients coming with that? But for all patients with medications for opioid use disorder, the basic principles are the same. Maximize your non-opioids, your non-steroidals, acetaminophen, the AEDs, maximize what you can. Use regional anesthesia whenever possible in the operating room and even after that with some ongoing infusion. Try to use the immediate release opioids if they're still on their long-acting medications for MOUD. They're gonna need higher doses and if the team in charge of this patient is not comfortable doing those higher doses, please consult your pain and addiction specialist to help with this. Next. Okay, specifically looking at buprenorphine. Now, we have to differentiate between the milligram preparations and the microgram. The microgram preparations are labeled for pain and those can be continued at the same dose that they've been on prior to whatever pain incident they're having now. No changes in the microgram dosing, things like Belbuca, Butrans. If you're having buprenorphine that's dosed in milligrams specifically labeled for substance use disorder, although parentheses here, some prescribers do use it off-label for pain, but if they're on milligram dosing, you may need to reduce that. There is no uniform accepted level at which to reduce it, but there are resources listed and in the literature, many sources will say somewhere between eight and 12 micrograms per day is what they would reduce it to in order to concurrently use other opioids to control pain. The other things you can do with buprenorphine, you can consider dividing that daily dose into either a Q8 or a Q12 hour dosing to get a little bit more even coverage and you may get some better analgesia out of that approach. If the pain is significant and the buprenorphine seems to be interfering with the pain control with the regular mu opioids, you can consider a rotation to methadone and PRN mu opioids. And I will just insert here, we didn't go into an explanation here in this slide, but you likely know that the buprenorphine has a tight affinity to the opioid receptor and can compete with the regular mu opioids and block them from working. But there is a level with the buprenorphine coming down where a number of opioid receptors open up and you can use them as opposed to the higher doses of the milligram prescription. So that's the foundation of why we have some concerns about buprenorphine. If the buprenorphine is stopped, which is not recommended, reduce is often recommended, stopping is not recommended, but if that's what happens, the recommendation is to restart buprenorphine before they're discharged from the hospital because they need this medication to prevent relapse and consider putting them back on their full home dosing at the time of discharge. And do coordinate with the buprenorphine prescriber, especially if you feel like there's additional mu opioids needed after discharge. Do they wanna stay on a lower dose of the buprenorphine and have PRN opioids? Who's gonna monitor that, et cetera? So that would be a collaborative discussion. Next. What about our patients with methadone for substance use and for opioid use disorder? Remember, the daily dose of the methadone they come in with does not, underlined not, provide analgesia. They are going to need additional doses of mu opioid medication for significant pain that you cannot rely on that methadone. They have built tolerance to that. It is not going to cover new pain. For safety, we need to verify the dose that they are on for their MOUD by contacting the clinic that dispenses it. If you are unable, the recommendation is no more than 40 milligrams a day to start until you can get that recommendation. Also, they come in in the evening, those clinics are not open. Some providers will take half of the dose that's reported and give it to them in the evening with the idea that they're going to confirm in the morning. So you have to verify the dose and then make some adjustments if you're in the dark for a period of time. Now, continue the verified dose during hospitalization. It should be given in the same dose. You can consider dividing that dose even into every four hours or eight hours or sometimes every 12-hour dosing, again, to get a little steadier coverage of that medication that may support the other analgesia that you're using on top of it rather than one large dose early in the morning. If they're NPO, IV methadone is an option. Talk with your pharmacist in terms of converting your eco-analgesic doses. Often it's a 50% number. Only hold the methadone oral or IV if you have medical instability. Otherwise, it should be given. They can be given as a continuous IV infusion with the daily dose converted to parenteral and given hourly. Now, you can consider extra methadone doses if the benefits outweigh the risks. That's always a catch-all phrase. Just so you're going to have to have a discussion about that. If you're going to give extra methadone doses, is that an occasional IV methadone dose? Daily dose, if there really is a daily change that you feel is beneficial for the patient, you have to communicate with that methadone program before the patient's discharged or there's going to be danger as well as some chaos. If we've decreased the methadone dose due to medical problems and they're discharged without communication, then of course they risk overdose going back on their higher dose without the program knowing what had happened in the hospital and vice versa. If there's an increase, we need to communicate that and get the agreement of that methadone program so they know how to appropriately care for the patient. Next. Naltrexone is a potent opioid antagonist, long acting. If there's elective surgery, DC at 72 hours prior, there is also a monthly injection that gives a depot of drug and that should be discontinued one month prior to surgery. Otherwise the opioids will not work at all. If there's an acute event, then of course that's challenging. Just know that the opioids used in the presence of active naltrexone often have to be 10 to 20 times higher than the usual dose to overcome that naltrexone blockade. So that's a powerful blockade. That's a high dose. Not too many providers feel really comfortable with that, but that is the data that we have. However, having said that, it's also hazardous when we're actually dealing with a patient with severe pain on naltrexone because that naltrexone will dissociate slowly unless it's the depot, that's gonna take a little longer. And as it dissociates over that 72 hours, it can cause receptor super sensitivity. So this super high dose that was necessary immediately while the naltrexone was fully active, then becomes too much. So you've got to monitor them very closely, naloxone available, and of course, use all of your other tools in terms of regional anesthesia whenever possible for these patients. Also avoid hepatotoxic medications, at least potentially toxic, such as acetaminophen, monitor LFTs because there can be liver side effects with this. And then consult with that prescriber for the restart of naltrexone. If the patient was in the hospital and this was stopped, how are we going to restart it? Do they still need opioids? Is there an alternative approach for their substance use? So again, a collaborative discussion. Next. How do we taper opioids? Why and when? Well, there's a number of concerns that may raise that possibility. Safety concerns. If the way they are using what's prescribed or not prescribed is raising safety concerns, then we have to think about tapering. Uncontrolled side effects with the opioids that are really interfering with quality of life. Concurrent medications that raise opioid overdose risk, benzodiazepines being one of the top ones, prescribed and unprescribed can be a concern. No improvement in pain or function or worsening mental health with opioid therapy means this is probably not the right plan for them. So we can't just stop it, usually unless it's been a very, very small dose. We need to taper. And we're looking at things like tapering speed. How are we going to manage withdrawal symptoms if they arise? And what kind of interdisciplinary care is available for the anxiety that's often provoked with tapering, as well as either risk for substance use disorder here? So of course, we're back to maximizing multimodal. You can never go wrong with that. Monitor these physical, mental, spiritual symptoms, because this can be a stressor that can cause mental health as well as substance use issues. And what kind of support systems do they have to go through this taper? There's not good research. There's certainly no consensus about how to type taper. There are wide variations from days to years. So if the safety concern is not imminent or the uncontrolled side effects are not overwhelming, you can take your time, but it can be done more rapidly as needed. In the manuscript, there are some listing of resources for specifics. These are opinions, recommendations from specific organizations, the VA, as well as the government, HHS tools for helping you decide how to taper. Next. And for all clinicians now into more broad recommendations, how do we optimize the care of this patient population with pain and substance use disorder? The first thing is to continue a self-appraisal of knowledge deficits. There is no shame in not knowing. And to be comfortable saying, I don't know, but I'd like to learn, or I'll find out, is really to be applauded. And so be comfortable with that, with yourself, and applaud it in others. If they admit that they don't know, but they'd like to know. We need to reinforce that kind of freedom to learn and that transparency. Advocate for best practices and policies based on much of what we have talked about, finding tools in your organization that can be adopted and maybe implemented into electronic medical record that's gonna help make care the best that it can be. And of course, stay informed of current knowledge, which kind of goes with saying that I don't know some things, but I'd like to know. Attend conferences, read the journals, take your professional initiative to educate yourself. And consider becoming certified in things like pain management and addictions. There are professional organizations. The ones listed there, of course, that we collaborated together with to write this, but ASPMN and NSNA can help you with study guides as well as certification. And if you are an APRN, consider prescribing buprenorphine for opioid use disorder. You used to need an X waiver. Now that is not required, so there is not that barrier. So you can consider that option that's open to you to help your patients that you feel that have opioid use disorder and perhaps pain issues as well because buprenorphine can help with both. A role model non-stigmatizing language and behaviors. There was a nice chart that Helen showed us. There's more detail in the manuscript as well as at the NIDA site. We're not trying to shame or blame people, but we're trying to role model and even suggest. If we hear somebody using language, you say, by the way, did you know that the recommendation is this language versus that language? We can share that information. And seek support, expert consultation as needed. Understand opioid tolerance. It's not that these people are giving you a hard time. If they have tolerance and they have a new painful condition, it's going to be challenging for patient as well as providers. So get the experts on your team. Support patient education, shared decision-making with patients. Do involve them. Learn how to have conversations with your patients, not just about the pain, but their substance use history and perhaps current activity in a nonjudgmental way so that we can actually share decision-making to say how are we going to address this condition and this discharge plan that's safe and effective and is giving the appropriate attention to all of your conditions, including pain and possibly substance use. And participate in research projects, improving care for pain and SUD. If you hear about them online or in your institution, join in, give your support. And then remember to differentiate the use of buprenorphine and methadone for pain versus substance use disorder. Sometimes thinking gets muddled and people jump to a conclusion, we'll have a chronic pain patient on methadone and people will jump to the conclusions, oh, they have an addiction. Not necessarily so. Buprenorphine is also used for pain as well as substance use disorder. And the rules and regulations are different when we use them for pain versus substance use disorder. So make sure you understand the difference and investigate when you see a patient on either of those medications. Next. Okay, what do we do to optimize care for healthcare systems? You might say, well, I'm not a healthcare system, but we're all, most of us are part of it. And we can have conversations with people that are making policies and try to include patients. What's the patient perspective in this policy? And engage the stakeholders in your institution or beyond in terms of government policy. Convene clinical practice committees. If there's a difficult patient that raises issues about pain, substance use, have a review of that and perhaps get a practice committee to look into how could we do better for the patient as well as supporting clinicians. Don't forget your pharmacist, use them. They're very helpful in terms of medication, dosing, medication options, side effects, interactions, especially in complicated patients, call them up and just say, I have a question. What can you help me with this? Ensure ongoing quality review and improvement. Again, as I said, if you have a difficult situation, don't just go, they're gone, I'm glad. Capitalize on it, talk about it, have a review, find out how we can improve. And promote nurse-driven research and translation into care. If you're in an academic setting, that's terrific, but there are opportunities in institutions as well to support nurse-driven research. And ensure institutional opioid stewardship to balance the pain and the safety. A lot of opioid stewardship committees have cropped up in the last few years and stewardship is probably a good word. It's not getting rid of the opioids and it's not just over promoting the opioids. We really need that balance. How do we balance effective pain control, effective attention to substance use disorder and the risk thereof in a way that's benefiting the patient and workable for the staff? So we need voices on those committees that can really embrace and advocate for that balance of both of those. Next. And for policymakers, legislators, which you may feel very far removed from, but they do have addresses. Those are public, that's public information. So don't write off contacting them with situations that you find problematic that do have policy implications they may be able to help with. So we wanna advocate for equal education for all prescribers of medication used for opioid use disorder. And we have seen some progress with that with the X waiver that was revoked that was previously required for prescribing buprenorphine for SUD and support MOUD prescribing for all APPs, APRNs, PAs. And again, we did see progress with that. We wanna make sure it stays that way because legislation comes, it goes. So we wanna make sure that that's continued to be supported. Actable reimbursement for evidence-based non-pharm modalities. That is a big issue all around. Certainly we see this in pain management as well as substance use issues. And I think our legislators do need to hear from us. They want, there's a big push, of course, to use less opioid, use opioid alternatives, which is great when it's appropriate and effective, but there's not always reimbursement for our patients to use those, to get the mental health care that they need, to use things like acupuncture or massage, or even join a health club. They don't have the expendable income for it. So we need support to do those recommendations. And evidence-based care regulation needs to be equal for substance use disorder clinicians and centers as for all healthcare settings. One example, we need to be able to share that information. If they're on methadone, we cannot, for substance use, we do not get that information off of prescription monitoring programs. We have to reach that clinic, which isn't always easy. So there are some barriers in terms of equal transmission of information. Next. So in summary, persons with co-occurring pain and substance use disorder have the right to be treated with dignity and respect and receive evidence-based high quality assessment and management for both conditions using an integrated, holistic, multidimensional approach. That's a mouthful, but it is our goal. We don't have to be perfect to make progress. So embracing the goal and taking steps towards it is really what we're advocating for today. And the position statements and manuscripts are resources. Use them for clinical guidance, for collaborative discussions with patients and coworkers. Next. Here are our references. You can note those when the slides, you have a set of slides. And to remind you that our sponsor PCSS also has something called a mentoring program. It's designed to offer information to clinicians about evidence-based clinical practices, prescribing medications, particularly for opioid use disorder. So this is a national network of providers with expertise in things like addictions, pain, evidence-based treatment in the MOUD. There's a three-tiered approach that allows every mentor and mentee relationship to be unique, and it is no cost to you. There is an address there that you can access information to enroll in that mentor-mentee relationship. Great way to learn. Next. And if you have a clinical question, there's also a discussion forum from PCSS. It's a simple and direct way to get an answer to medications, particularly for opioid use disorder. And again, there's a web address at the bottom. You can submit a question, get an expert to answer you. Again, a wonderful resource to know about and take note of. Next. So educate, train, and mentor is what PCSS is about, and it's what we're about too. We hope we have educated you. We hope you've actually raised some questions that you're going to look into further in this manuscript, as well as other resources. Share that with other people, help train people in what you already know, and mentor for your patient's benefit and for your professional growth. And I think that is our end, and I will turn it back over to Kathy. Yes, hello. Right now, I don't have any questions in the question and answer box, but I think that's kind of my fault. I forgot to announce that. You can see a little QA box down below, and you can type in your questions and we will go through them. In the meantime, I want to remind you again about how to get the CE for this. You will be sent a link for an evaluation. And once you complete the evaluation, the certificate, the CE certificate will be emailed to you. And then also, in order for you to see a copy of these slides, it is at www.pcssnownow.org. So, all I see right now is some... Congratulations. Thank you, and great presentation, June and Helen. Are there any other questions? Oh, here. Where can one obtain MA unscripted mentioned? Manuscript, I think, mentioned. Oh, manuscript. It's listed in the references, right? Helen, isn't that in our reference list? It is in the references. I'm the first author toward the end of the bottom, Turner, and it's been published in 2015. It's well worth your read, if I do say so myself, because there's more in that manuscript than what we can present in 50 minutes, because the individual subjects themselves, you know, require quite a bit of explanation, if you're going to go into detail. Yeah, and then this one is just a statement. Much of rural America has no MOUs, Yeah, and then this one is just a statement. Much of rural America has no MOUD coverage and little cooperation from existing healthcare structures. Here, here. I would agree with that. I'm sorry, Helen. No, just rural America has so much disparity in so many aspects of healthcare, and this just being one of them. Here's a good question. Tennessee is the only state not allowing buprenorphine for pain, as legislators fear diversion. Any thoughts on how to reverse this policy? I am not aware of that policy in Tennessee, and I have to say I don't understand it, because if something is labeled through the FDA, I thought that was... States could actually set their own restrictions, and the only way to turn that around is get a lot of people to really contact the legislators that are currently in session, educate, educate, educate, and really help them understand why it's not a good idea and see if you can get the legislation overturned or rewritten or other modifications. I'm assuming that when you're talking about the buprenorphine in Tennessee not being used for pain, they're talking about the milligram dosing as opposed to the microgram dosing, the Belbucas, the Butrans, that are labeled for pain. That's what they're labeled for. Anyway, it sounds like a legislative letter that needs to be... Or a letter to the legislators that needs to be raised. You mentioned that the OUD tools are screening only. Are APRNs accountable at that point to refer to psych or counseling after a positive screen? I would say that depends on your state board of nursing requirements, but I think good practice would say if you have concerns and don't feel comfortable managing and continuing to monitor that, a referral is indicated. Yeah. And many of the tools have numbers that are totaled up and they will tell you what their conclusion is that ORT OUD has that, and when you get a positive response when you're numbering up your responses, then yes, you should refer. I mean, medical legal liability would say yes, what's the best practice? If it's problematic behaviors, again, you have to know what your tool is measuring. If it's problematic behavior that you're measuring, really the first intervention is education. Why are these problematic behaviors or the misuse happening? Is it an education thing? And then you monitor their response. Did it improve? If it didn't, then we may need referral after that. Okay. Here's another one that just says, great talk, thank you. You mentioned to give Suboxone twice or three times a day, but also say to reduce the dose when giving opioids for acute pain. Can you explain, please? Yes. So, again, there is no professional-wide consensus on what the reduced dose is, but let me just say that we're going to reduce it to eight milligrams per day. So I may do four milligrams in the morning and four milligrams at night. Perhaps they came in on 16 milligrams a day, and then we did a dose reduction. And then when we do four and four, we get a more even coverage of the buprenorphine. That may give us a little bit of analgesia, but not interfere totally with the other mu opioids that we feel they need. Okay. This one's kind of for me. They want the link again for the slides. So it's www.pcss.org. And then there's a link on the top. It says webinars, and you can either search by a topic. I'm not sure if they're in there chronologically or not. I think you have to search by a topic. And then it says, you did such a good job, there's not much room for questions. Comment on recent data suggesting buprenorphine doses 24 to 32 milligrams for pain and the underdosing of buprenorphine. You know, I can't really comment on that. I'll let Helen take a stab at it too when I'm done. The focus of this paper was really not on how to use buprenorphine for pain. We're recognizing it as microgram dosing labeled for pain and then milligram dosing for substance use disorder that may be problematic when we have acute pain on top of it. So I'm sorry, I can't comment much beyond that. Helen, do you have anything? I don't have anything specific. I haven't seen that data. But I would say that, as June mentioned, there is off-label use of the milligram dosing of buprenorphine for pain. And so I think my guess would be that it's at best confusing for folks. Unless they're doing buprenorphine prescribing all the time, it's like, okay, am I using microgram? Am I using milligram? If I'm using milligram, am I dosing too much? Am I not dosing enough? Or do I think I'm using milligram but I'm using microgram, so I'm doing underdosing? So, yeah, I have concerns of what we're seeing based on the fact that we have two different formulations with two different indications, and we're using it kind of back and forth, if you will. So, yeah, that's my only thought about it. Sorry I don't have more information. Okay, and then just a couple of pointers. Somebody else says Science Direct has the PDF of that article. And then somebody else says Harvard protocol for MOUD and acute pain. Harvard must have their own protocol. And we're kind of running out of time here. How to manage pain in patients who have received sub-blockade? I don't know what. I'm an addiction fellow and had similar patient, and we were able to control pain with extremely high oxycodone plus oxycodone, 1,700 milligrams daily and no respiratory issue. That dose made my heart do a little skip, but totally can appreciate that that might have been necessary for somebody who's getting a blocking agent. And I think that's, you know, to June's point, if you've got a complex patient like that and you're seeing those kinds of doses, then you need to get the experts involved. And you are the expert. So, you know, that tells us sometimes we're out of, we're out of our own comfort zone as an addiction fellow. June, do you have other thoughts? Yeah, I haven't seen the sub-blockade, but it's a long acting buprenorphine. I mean, it's given, I'm just looking at Hippocrates, 100 milligrams sub-Q every month. So again, you're not going to be able to go, oh, well, you know, they take this pill every day. We're going to reduce the dose. You're kind of challenged to yes, overcome it. And so high dose opioids would be what you would have to do with close monitoring. Good for you. Congratulations. Whoever did that. And then somebody had an announcement that HRSA announced nearly 9 million to increase SUD clinicians and underserved in rural communities. All right. Applause. Yeah. I think that's probably about it. Okay. So thank you, Helen and June. This was wonderful. And I think everybody on this. All right. Thank you for attending and remember to fill out your evaluation form to get your CE. Thank you. Bye-bye everybody. Thank you.

June Oliver

Helen Turner

ASPN

INSNA

position statement

pain management

risks

SUD

co-occurring pain

substance use disorder