The broadcast is now starting. All attendees are in listen-only mode. Good afternoon. I am Dr. Ann Schreier, and it is my pleasure to welcome you to ASPMN's ninth year series of webinars that focus on the use of opioid therapies for the treatment of pain, opioid dependence, and the safe use of opioids in the treatment of chronic pain. This series is one of the many resources made available by the Providers Clinical Support System, a program that is funded by the Substance Abuse and Mental Health Services Administration. It is a collaborative project led by the American Academy of Addiction Psychiatry with a number of professional organizations. On the last slide, you will find a list of these organizations. You are able to obtain Nursing Continuing Education credits for this presentation. You need to participate through the question and answer period. Detailed instructions concerning the CE credits will be given at the end of the presentation. 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And that website is www.aspmn.org. The slides will also be available through the PCSS website in the near future. That website is www.pcssnow.org. Today's presentation is Pearls for Pain Management and Traumatic Injury Populations Experience Substance Use Disorders. Our presenter today is Jason Sawyer, who is a board-certified pain management nurse working in acute care and has many years of experience. Welcome, Jason. All right, thank you, Anne. And thank you for everyone that's attending. So I call it Pearls for Pain Management, mostly by design. And I hope as the presentation goes on, it'll become clear to you why I was unable to call it Evidence-Based Review for Pain Management. I have no conflicts of interest to disclose. I worked on acute pain service as the official title for more than 20 years, but really the every pain service. I'm estimating I've looked after somewhere between 18 and 20,000 patients in my career. As the opioid epidemic washed through North America, we were seeing more and more patients. And as such, I've taken some steps to learn a little bit more about that population. So I have taken the waiver training certificates through ASIM, and I do have an opioid dependence treatment certificate program through the University of Toronto. So these will be the educational objectives here, outlining some of the unique challenges of the post-traumatic injury population, some non-opioid pharmacologic interventions, and identifying some non-analgesic factors that will improve the quality of pain management. And so this is the hospital I work at, Sunnybrook in Toronto. It's a 1300 bed facility with almost 700 acute care beds. We're also the largest trauma center in Canada and largest veteran center. And we just recently opened up a trauma patient follow-up clinic. The second half of this will be a case. And although our acute pain service is pretty well staffed now, and we now have an addiction service, at the time that I was caring for the patient in the case, we didn't yet have an addiction service, and our acute pain service was not as well staffed as it is now. And I would like to thank Dr. Whiplamba, who I met rather by chance at a round table discussion many years ago. And he's a physician in the addiction world, and he helped me immensely with some of these challenging patients. So I wanted to thank him for that. We saw about 2200 trauma patients last year, give or take. This is a breakdown of the type of patients or the injuries that brought them to the hospital. As you can see, most were motor vehicle crashes and fall from height. And when you do this long enough, you can recognize there's a seasonal element to this. And I can say that right around Christmas, we just got over the elderly gentleman falling off the roofs, putting up Christmas lights. So that's one of the annual things that we look after here, that again, it doesn't show up in statistics, but it shows up if you do it long enough. With the increased opioid use in the community, either legal or otherwise, there's been about 150% increase of hospital admissions for this. And what I kind of think outside the box a little bit, and one of the things I realized with this is there's this increase, is there's probably 150% increase in patients that often meet the exclusion criteria for randomized controlled trials. And I think those that work in the addiction world will say that there's not a ton of RCTs going on in this population, and certainly not in the select population that I'll be talking about today. But when we talk about the trauma patients just in general, there's been some good research done by Goldsmith. And in my references, I've included some other references you might find interesting as well. But basically, getting a trauma is quite traumatic, not only physically, but also mentally. And when we talked to them about, when they were asked about their pain experience, a lot of them described a big challenge transitioning from getting pain care at the hospital to pain care at home. So certainly the fact that they potentially were receiving gold standard and more invasive pain management, say nerve blocks for those, for example, in hospital, having nurses guiding the dose prescriptions, but the nurses guiding what doses they would get. And if they were kind of not feeling up to it, having the drugs brought to them to at home, maybe that the medications weren't the same as in hospital, they maybe weren't working the same, it wasn't the same dosing. And they really struggled with pain control when they got home. And in general, what they were describing as well is that the trauma experience in general, but also the pain around it was quite horrible and made them quite scared, particularly after they left the hospital. And again, this was just general trauma patients. But when we start to look at when opioids are part of the picture, this was a study that was done, and this was just patients that were admitted to a trauma service that had an opioid prescription. So it had nothing to do with illicit use or anything. And what they found is they were intended to be older. The mechanism of trauma was a fall. They were more likely to be admitted. And in fact, contrary to other populations, the lower the ISS score, the more likely they had a higher length of stay than people who did not have long-term opioid prescriptions. Moving on a little bit further, we're a different population where this paper by Tseng looked at prescription abuse, their words, not mine, illicit abuse and persistent pain use. And what they found is across these three populations, definitely increased length of stay, readmission rates, non-home discharges, and major complications. And one of the things they concluded for the least in terms of the reason for the length of stay increase was some combination of tolerance or opioid-induced hyperalgesia, which made their pain management more challenging in hospital, which again, they were speculating was one of the contributors to the increased length of stay. If they were using alcohol at the same time, there's a further increase in length of stay. So then moving more toward the population and the case I'm gonna present today, this was another study done by Titus. And what they did is they used urine drug screens to look at over an eight-year period. And then they teased out the people that tested positive. And what they found was almost half of the population tested positive for some substance and 25% were poly-drug use. And in that population, there was more mortality and more trauma team activations than people who did not have a positive urine drug screen. Another example here, again, similar, about 45% of the population. Again, similar, about a quarter of them were poly-drug use. And urine drug screen positive in multiple drugs showed an increased rate of OR interventions, length of stay and ICU stay. And what they found is that the impact varied by the drug and the number of drugs, but that alcohol was not a significant predictor of clinical outcomes in and of itself. And they were looking for the usual, I guess the usual suspects of drugs, alcohol, opiates, cannabinoids, benzodiazepines, amphetamines, and cocaine. So there's this evidence that's saying that in the seriously injured trauma population, that depending on where you live, of course, that there's a significant number of them that will be having substances in their urine. And there's several reasons why that would be important to know, and I'll cover it a little bit later. So when you have these complex patients coming in with these difficult and awful multiple injuries, we often look to guidelines to help us, help guide where we need to go with our care. And this is one that I'm sure this audience is very well familiar with. And so this came out in 2020, and I'm gonna just draw your attention to a specific section when they're talking about the special population. So special populations pain and special populations with surgery. And so they mentioned the standard multimodal analgesia, which is fairly ubiquitous in guidelines around pain. And they do mention, and I quoted, that short-acting full agonists can be effective for severe acute pain in supervised settings. And then in their special populations, they have a quote that says, the research has demonstrated the addition of full opioid agonists can be effective. And so they have two references, and I thought I would include them here. And what they are is one was a case series of five patients that were on buprenorphine for persistent pain, so not with a substance use disorder, and that the dose was highly variable, and they were adding more opioid to this group. And then the second guideline was this one, periodical considerations for patients with, if you read the whole title there, you can read it, but basically the recommendations were a facsimile of the ASAM guidelines, which was multifunnel analgesia, regional, potentially some guidelines around maybe splitting the methadone dose or the buprenorphine. But in terms of making recommendations to add a potent pure agonist, these were the reference that were there. The second guideline that I read with great interest that came out the same year was trauma, from the ACS trauma quality programs, and it was again guidelines for acute pain management trauma patients. Again, they speak multimodal, which again, everyone does. And I just want to add that the challenge with multimodal is that we still don't, in the pain world, have a really good sense of what makes a multimodal ought to happen in any individual patient. And so that makes sort of customizing the care challenging. But one of their recommendations was that an IV patient-fold analgesia is a good option. And so my experience, this is not a good analgesic option at all, but I recognize it's complicated, meaning if you work in a facility where maybe you don't have access to nerve blocks or epidurals or ketamine, you might not have much of a choice but to give opioid. But certainly in my experience, the PCA can be a double-edged sword because you have a really hard time getting the patient off the pump. And sometimes it'd be kind of blurred if you are mimicking the behavior of their drug misuse versus providing pain control. That line can get kind of blurred a little bit. And then the evidence would say they use more opioid on a patient-fold analgesia pump. So are we actually contributing to OIH in this population? So the evidence to use it is not that great. What I just told you was my experience. So again, there's not a whole lot to really guide us on this. But again, it kind of depends on what resources you have available. In terms of this guideline here though, there was just a single page. So there was one at least, but there was a page about what to do with an untreated opioid use disorder. And this would be the case I'll be discussing later. There was no real guidance on any other substances of misuse. But again, they talk about how an IV opioid via PCA or short-acting are both suitable for treating acute pain and addressing withdrawal. Adjuncts like ketamine may help pain management. And they leave a reference for this. And when you look up at the reference, it's about an outpatient methadone program. And so here's the reference here from Shanahan. So as patients admitted to a medical floor that were started on therapy, suboxone in hospital, and then followed up post-discharge. And so with these two guidelines, and if you're in the audience, I'm sure you're aware there are other resources, and there are, but essentially people look to guidelines first. And in these two highly impactful guidelines, we basically have two and a half pages of the 160 that were dedicated to this population related to what to do in the context of this substance use disorder when they're having surgery. And the evidence, as you can see, is not overly applicable. And so that, again, it really leaves you kind of struggling of what direction to go to if you're relying on these guidelines. And so again, my comment earlier about why this is called clinical pearls and not evidence-based, I hope is becoming a bit more clear. But three main issues that the evidence would say, and certainly if you have experience in this field, would also tell you, is that if you rely on opioids in this population, that they're gonna have tolerance already, so they're gonna require herculean doses. And assuming that might even get them comfortable, in many cases it does not, there's the risk of opioid-induced hyperalgesia. And the evidence isn't great, but there is some evidence that there can be relapse and misuse relying on opioids in this population. So one of the drugs that the evidence would say is a really good one to use in this population is ketamine. And the benefits of ketamine are really that, basically, the more intense the pain is, the greater the area of pain is, and the more tolerant or dependent they are, the better the outcomes in terms of analgesia there will be with ketamine. And I've got a couple of references there. And I just wanted to draw one of the conclusions from the Cochran Review. And the last point here is that with very high-quality evidence, that ketamine produced no increased risk of central nervous system side effects, hallucinations, nightmares, or double vision when you're using doses at or below one milligram per kilogram. And then I gotta be clear that I'm not saying people on ketamine won't hallucinate. What I'm saying is they have just as good a chance as someone who's not on ketamine. So, and I know that might clash with some people's anecdotal experience for sure, and also their beliefs around ketamine. But it is something to think about. This review was almost, it was over 8,000 patients. So it was, it's not huge, but it wasn't small either. Some of the other bonus benefits of ketamine, particularly in this population, is that it can mitigate the withdrawal symptoms of many substances of misuse. And all of the ones that I mentioned here except the amphetamine were in human, usually case reports. It can help with opioid withdrawal during buprenorphine induction, opioid-induced hyperalgesia. And actually, there's some evidence to show that it can remove some of the neuroplasticity that occurs in long-term drug use. And so, wondering how ketamine would do that. So just a couple of slides quickly on glutamate. And recognizing that I'm only talking about glutamate here, knowing that there's a ton of neurotransmitters involved in pain and addiction. You know, GABA, dopamine, there's countless others. But in terms of the purposes of what I'm doing today, that the interaction with glutamate and ketamine is important. And so, it's the primary excitatory neurotransmitter. And there's a lot of evidence to show that it's this significant role in a lot of the negative aspects of substance misuse, the withdrawal, the tolerance, relapse, cravings, even some of the, for me, the behaviors of the neuroadaptive level. Now, most of this work is in animal models, but there's more and more human data coming up, including human trials. And so, in terms of glutamate and persistent opioid use, as I mentioned, there is some evidence that there's neuroplasticity that happens in the glutaminergic system, which in general leads to a decrease in glutamate levels, which in order to help maintain homeostasis, there's an up-regulation and increased number of NMDA receptors and AMPA receptors. And there was this study, the last one I quote, NMDA receptors, what they found is when they actually, on cadavers, they actually were able to identify post-mortem that there were more NMDA receptor subunits in people who have drug misuse than people that do not. So basically, if you have a longstanding use of drugs and misuse, particularly opioids, you have this up-regulation of glutamate receptors and lower levels of glutamate. But then when you introduce pain, what happens is it causes a increase in glutamate levels. And you get increased synaptic glutamate, substance P and CGRP, which relate to pain. And what that then does is, particularly with the substance P, is it eventually leads to activation of the AMPA receptors, which in turn cause further engagement of the NMDA receptors. And so what we get with synopsis of this is that you get these neural adaptations in the glutaminergic system with prolonged opioid use, compensation by up-regulation and actually increased number of NMDA and AMPA receptors, tolerance, and then you get an enhanced pain response. And so you've got more NMDA receptors. Ketamine is an NMDA receptor antagonist. And so in order to be effective, this is sort of giving you some background on why you probably need higher doses for ketamine in this population. And this review that just came out late last year by Martinotti, it's just talking about potentials of ketamine in OCD, substance use disorder, and eating disorders. And I just have the substance use disorder piece here, but you can see that the doses are anywhere between, you know, usually at 0.5 milligrams per kilo and going much higher if they need to. And that's certainly higher than you use as starting doses in the postoperative population. And we use ketamine fairly ubiquitously here. And what I can tell you is that in the, you know, the non-substance use disorder post-op patient, it's incredibly rare for us to be above, you know, 0.15 or 0.2 milligrams per kilogram. But we have had trauma patients with substance use disorder that we've been as high as 1.5 milligrams per kilogram per hour. And that's awake and alert walking on the unit. So there's certainly something to this. So anyway, we'll get to the case, and hopefully I'll give you a bit of base of where I'm gonna go with the case. So this is a case, and I do have written in consent to talk about this from this person. So the day of the injury of this person, he was a gunshot wound. He ended up having an open reduction internal fixation of his right femur fracture from the bullet. He got a general anesthetic. He got just a single shot of a fascia leaca. It was done in the middle of the night, so they weren't quite able to do a nerve catheter. There was just some documentation. Again, he came into trauma. They didn't have time to do much background digging, but he was currently on methadone, and more importantly, there was no urine drug screen done. And so I got consulted to see this patient. And so he was in our main ICU. He was awake and alert. He wasn't intubated. And I've been paid several times and frantically because they didn't know what to do with this poor gentleman's pain. And I could hear him yelling across the unit, and it wasn't anger. It was anguish. And he was, why are you doing this to me? You're just doing this. You're making me suffer because I do drugs. This isn't fair. But as you can see, that he was not on insignificant medications. He was fentanyl 200 mics an hour, hydromorphone one milligram per hour, a lot of purine opioid use, and he was on a decent dose of ketamine. And so it certainly wasn't that he was being sort of abandoned, but I think that perhaps everyone's kind of got their limits and where they want to go, and they were saying, oh, he's on these herculean doses of opioids and still in severe pain, so we need some help. And so when I come and see this, I'm thinking, okay, is there OAH happening? Clearly opioids aren't the answer, but I need to get this guy comfortable. And so over a course of 45 minutes, IV push, this is what I gave him. And it wasn't, I kind of switched. The keterolac was a single dose, but the ketamine and midazolam, I was kind of rotating between the two. And at the end of that, he was settled, he was awake, he was alert, and he was very comfortable. But I took, and this is probably key, I think, in this population, is I took the time in that 45 minutes to really try and get to know this person. And so with all my patients, but more so with this population, first thing I say is I'm a nurse practitioner with a pain management team, and I will not leave the bedside until you're comfortable. And almost without exception, that calms everyone down to some degree. And of course, you can't say it if you're not gonna mean it, but I certainly intended to stay there. And then, so some of the things I ask him at that time is can I ask you some questions during this time while I'm getting you comfortable? The answers you give me will help you, help me to get you comfortable quickly and safely. And for those of you that this is kind of, I'm just scratching the surface a little bit of some motivational interviewing. And here's a slide of some of the sort of aspects of motivational interviewing. In red, I put what was probably the most salient one for this patient at this point in time, but also seeing him as a client, as a very equal partner. The evidence for using this in the addiction literature is well described. There's some certain processes to it. I won't get into a whole lot of detail, but you can see you're engaging, you're focusing, evoking, and planning. And you can kind of balance between these as you go forward. A lot of open-ended questions. And so using the motivational interviewing sort of techniques. So these are some of the questions that I asked him. So again, I didn't say, did you use fentanyl on the street? So if you'd be comfortable, tell me about your fentanyl use in the street. Can you tell me about your experiences with Suboxone? Would you like to hear about what I know about managing pain in people that use fentanyl on the street? And so I'm really asking permission to give him information, but also giving him permission to tell me as little or as much as that he wants to. And so this is some of the information that I got from this, was that he's prescribed methadone, 30 milligrams once a day as observed doses, but for at least a few weeks prior to coming to the hospital, what he was doing was just going in every second day and on his off days, he was purchasing fentanyl and using that. He had a step other that was doing it with him. So as you know, environment and people involved are supportive of the things you wanna do. And so certainly he had some support with maintaining his fentanyl use. He was shot while attempting to purchase fentanyl and that he had previously was on Suboxone, but did not like it. So he'd been using Oxypercocet for quite some time for shoulder pain, he was abruptly cut off. So he switched to fentanyl and cocaine, long-term cannabis user. And then I asked him, would you like to hear about how you could get back on Suboxone in a safe way while you're here? And what was interesting was again, I asked him what his experience was with Suboxone because in my head, of course, I'm thinking, he'd been prescribed it and for whatever reason, didn't agree with him. But when I asked him about his Suboxone and I gotta say, he's not the first person that's told me this, but that he had been introduced to Suboxone by the person he bought his drugs off the street. And of course, it precipitated a heck of a withdrawal. And I'm thinking if you're a drug dealer, that's a heck of a business plan because you're helping to ensure the patient stays addicted because you're making them to be averse to one of the treatment strategies. So it was important for me to know that his exposure to Suboxone was in that context. So it wasn't in any sort of professional or medically ascribed way. It was actually given in a very inappropriate way by someone who had a vested interest in him not being on Suboxone. And so despite his personal legacy of negative interactions with healthcare providers, there's lots of evidence to say this is sort of rife in this population. Using motivational interviewing, being supportive, actually being the one getting them comfortable, not asking just someone else to do it and leave the room. Very quickly got the trust and transparency. He felt very safe. And he's engaging in self-advocacy and agency. You know, obviously he was appreciative of that. And so I was able to talk about what we could do around pain control. And certainly, usually when we get asked, or I get asked to see these patients already being exposed to opioid. And so what I will often say to the patient is that, you know, it was not unreasonable to give you this high dose opioid to start with to get your pain under control. But if this dose isn't working, then it's a good chance higher doses won't. So we need to pivot. And the best evidence we have is that you're telling me your pain is 10 out of 10 and you're on these amounts of opioid. And I'm not saying that sort of clarification of the plan works every time, but for most patients, they're like, okay, but now what are you gonna do for me? And so for him, the big thing was gonna be ketamine and a nerve block. And certainly I think you need to have a pretty good sense of what your plan is gonna be before you see any of these patients. And so this is what we ended up doing for him. So I just stopped all of the opioid infusions in the PRN orders just right there on the spot. And he knew that, of course, he was okay with that. We did a fascia-liaca nerve block. We used an intermittent bolus with ropivacaine, 0.2%, which is our usual. He had a ketamine infusion, which we had the range there. He was 77 kilos. So he's getting about 20 to 25 milligrams an hour of ketamine. We used that 0.3% to start pre-gabalin, cellococci, and Tylenol. At the time, we don't now, but at the time we had oral ketamine available as a PRN, and we continued his methadone once a day and put him on some Nabolone to just try and minimize withdrawal from his marijuana use. And so just a point about the multimodal, at least experientially, it can be quite challenging to get this population to take Tylenol and Celebrex. They're pretty savvy with their pharmaceuticals, and they generally have used Tylenol and Celebrex, an over-the-counter anti-inflammatory, and have found them not helpful. And so they can be pretty dismissive about using it. So you need to be kind of prepared for that, but also to have a good reason why they ought to be taking that in the context of the rest of the medications, why it might be helpful. But at the same time, you could kind of make an argument that if you're using high-dose ketamine and a nerve block, and they're already on methadone, I don't know that we have some good evidence that says for sure in this population, those medications help. And I also don't necessarily recommend using the context of opioid sparing, because in his case, he spent a good part of his recent life trying to get more opioids. So using, framing a medication that will make him use less might not necessarily be the best way to approach that. So when I saw him the following day, he was in very good spirits. He was feeling really good about where we could go with this. He was in significant pain overnight. I gave him five mils of 0.4% ropevacaine, so basically I doubled his dose for the block, and then I changed the concentration to 0.4%. I think this is a key thing to remember is that you need to be flexible with what you can do multimodally on the ward. So if someone is gonna be prone to be having extreme pain, then you're likely gonna need more total dose of local anesthetic to get them comfortable. So you need to have these available, and that has to be something that kind of go on the ward as well. His ketamine was increased to 0.5, so that's a few milligrams per kilo, and he's on the nursing ward at this point in time. And we had another discussion around the suboxone, and he was really keen to transition to suboxone, and so what we did, we gave him his last dose of methadone that morning on day two. We had a good conversation about when he could participate getting withdrawals, and he certainly had been through enough withdrawals. He knew what his symptoms would be. Gave him a bit of guideline of when they might occur, and then what I did is I wrote this as the order exactly. Now, he wasn't the first person that I've done this for, so the nurses on the trauma were a bit familiar, but this is the exact order. So once he is experiencing moderate withdrawal on the SOWs, to give him his first dose of suboxone, repeat times three, to a maximum of 16 milligrams on the first, basically in the first eight hours from getting onto suboxone. Several copies of the SOWs were left at the bedside and with the RN. I went over it with the nursing and the patient several times, and what I also did was I made a photocopy of the order, and I put it in his room, so he knew exactly what was gonna happen and when I left my cell number with the RN. And so basically, what I'm trying to do is a bit of a hype. I'm taking advantage of the safety features that are built into a patient being in the hospital, so it's kind of a combination of an office observed and an unobserved home induction, whereby I'm giving the patient some autonomy to be engaged when he's gonna get his first dose, which set his mind at ease, and I'm certainly not saying every patient should have the SOWs, but for ones that it seems appropriate, that they really appreciate it, they had some ownership over when this would all happen. Here's the picture of the SOWs. The reason why I was using it is, again, there was discussions in the organization about introducing the cows, but it wasn't introduced yet, and so some education for nursing around how to use it hadn't happened, and so this was my sort of workaround to make sure that I could make sure that the patient was getting onto the Suboxone at an appropriate time and in a safe way using a good tool. And what I can tell you is, in the right patients, the SOWs is very appreciated because they know what withdrawal is like, so they are definitely, if you tell them to wait till it's an 11, they're definitely gonna wait till it's an 11 because they know all too well the consequence of withdrawal if they take the Suboxone too soon. So what ended up happening is, about 60 hours after his final dose of methadone is when he got his first dose of buprenorphine. He got all the doses we wanted on the first day, in that first eight hours, to 16. Eventually, the next day, I bupped him up to 20 milligrams. We removed the nerve block after day six. He had used seven doses of the ketamine PRN total in the six days, and it was discontinued. And as I mentioned, his buprenorphine was the 20 milligrams for once a day. He was able to walk stairs on day six. And so in terms of getting him home, he got a prescription for the buprenorphine, Suboxone, Celebrex, Pregabalin, Nopurin, Analgesia. And on day seven, he went home with, actually an appointment with one of our rapid access to addiction medicine clinics close to his discharge address. So we call them RAM clinics here. And so he was pretty happy with that. And so I think one of the things about doing this is it, so the ketamine, I think, allowed him to be comfortable from pain perspective, but it also, the evidence would say it minimized how severe his withdrawals were. So it allowed us to make a transition pretty quickly off of the methadone. So in the span of, you know, it was just over two and a half days. And so when it's the push to get people home and out of the hospital, certainly this is a strategy that can be used, you know, as a complimentary strategy to say a rapid induction, which can take several days and might, you know, either delay discharge or have to be continued after the patient goes home. So just another strategy or another way to get people onto Suboxone in a rather timely fashion while they're in hospital. And keep in mind, this is all happening in the six days after being shot. So I have a really good pain control and transition to Suboxone. About one month post-discharge, he was having some flashbacks and nightmares. He started going on to patient trauma therapy. And then I noticed that he was being transitioned to methadone and Cadian. There were no notes available, but basically he was on Suboxone for about 18 months afterwards. So I do recognize addiction as a lifelong, something to do with lifelong. And, you know, there's, you know, often people have to fail and be restarted back, but it seems like he did a good, at least 18 months. So what do I hope to take you take away from this? Well, maybe a little bit of self-reflection perhaps, just, you know, do you have the knowledge, skill and abilities to provide competent care to this population? And if you're not quite sure, how would you acquire those skills? Motivational interviewing, the evidence is there. Certainly in my practice, it was a game changer in terms of how I approach caring these patients. So I don't think it changed my care, but how I approach the care of these patients. And I did have some concerns that it might take longer to use a motivational interviewing technique, but in fact, in most patients, you get to where you need to go a whole lot quicker. You know, understand what your personal values and beliefs are around opioids, and then their use. And I think another thing is to be curious. So, and by curious, I mean, this is some information from the drug sampling service here in Toronto from July, December of last year. And basically what this slide is telling us, what the most common drugs were in the community, fentanyl being the most common one at just under 50%. But when you look at this slide here, it's how much fentanyl was in each substance. It was in each sample that they found. And if you look at the last two columns, there was like as little as 0.2% of the sample had fentanyl up to as much as 82.3%. So obviously not a lot of quality assurance happening here. But when they looked at the expected fentanyl substances and they actually looked to see what other drugs were there, you can see there's a lot of other drugs that were there and including caffeine. And so, I mean, it's something that I'm thinking about is that when someone's having a withdrawal and it seems kind of fit between, you know, it's not really fitting the cows or say any benzo or whatnot, is it maybe a caffeine withdrawal? Is this something we need to think about as well? But having this information on a urine drug screen in the hospital, it certainly, it helps to open a conversation with the patient about, you know, so you're buying fentanyl, you're doing fentanyl, but you're aware that there's all these other drugs in your fentanyl supply. It also helps to guide what the withdrawal symptoms they might be occurring, they might experience would be. So I think there's a lot of tremendous value because one, if you remember from the beginning, so with urine drug screen, that multiple sample, urine drug screens with multiple polysubstance in them tend to have longer lengths of stay and certainly knowing what's in the sample as well can lead to conversations with the patient. So, and also guide withdrawal management. So I know I just said that, but it's important that you really need to consider the value of urine drug screens in this population. Another thing is to really challenge your beliefs on the role of opioids. I think it's very unlikely a role as an analgesic, but again, I stress that if you don't have the luxury of nerve blocks or epidurals or ketamine, you might, that might be all you have, but I think you really need to be careful about how you use it and very clear strategy of how you're gonna get off it or reduce it before they leave the hospital. Certainly some opioid will be necessary to avoid withdrawal, but know that it can lead to OIH and exacerbate tolerance and so if you're gonna rely on opioids, you're straddling a lot of very fine lines here and there is some evidence to increase to relapse. So advocation at an organizational level, so I think at the level, so I think that you need to be, it's one thing to have policies around nerve blocks and ketamine, but they can't be so restrictive that you can't meet the needs of these particularly challenging patients and I know that, I know on the listserv, I see on the US that, and even in Canada, that there's a lot of places that have very low restrictions of what can be, ketamine doses can be on the wards without very onerous cardiac monitoring and whatnot, but they kind of tend to not have any limits to how much opioid people can get. I think that shift really, that sort of mindset really needs to shift. I don't know that it'll be easy to do, but it definitely needs to happen. And just for the, I know someone might ask, we do not have any cardiac monitoring on our units for ketamine because the evidence doesn't say that you should have it. In terms of the nerve blocks, again, it's one thing to have them, but we have, in our recovery room, we always have a couple of high-potency epidural solutions, but we also have the single 0.4% solution of rofibicaine for our nerve blocks that our pharmacy can make up. And again, this, so if you have that available, then nerve blocks that aren't working at 0.2 can be fixed and made to work and not just abandoned. And then you certainly need enough time while they're in hospital to make all these things happen and advocate for having motivational interviewing supports for staff to learn this. And you need some addiction specialists either to hire or create them. And I think generate some conversations around this. So the evidence for particularly these substance use disorder trauma patients is very sparse, I think that needs to change. And so is it whether it's communities of practice, case reports or conferences, we'll have to see, you know, maybe some discussion will come of this, but there's more work that needs to be done for sure. And I noticed that the Trauma Association of Canada's conference for this year, the theme is inequity of trauma care, we are not immune. And I know the inequity can be about a lot of things, but I'm certainly hoping that one of the things that it is, is about the inequity this population is getting in terms of research and access to, I guess, non-standardized, but important pain control. I think the last thing is to really need to look at the patient, any patient really, but this population more so as partners. And so motivational intervening will keep you on track at the availability of the sows, in addition to the cows. In some patients, it can be very empowering, provide agency, and this is certainly something I've noticed in my practice. If they're not engaged in the moment, that's okay, but it's important to kind of meet them where they are. And yeah, that's my presentation. Thank you for your time. Thanks, Jason, very much for that presentation. We have a bit of time for questions, so I have a number of questions in the question box, but you still have time to put some questions in. The first one, a person asked, do you use pregabulin only in patients with documented neuropathic pain? Or do you use it more in general? We used to use it fairly ubiquitously. I mean, there's some reviews that came out recently that would suggest that the benefits of the gabapentinoids were probably not as good as we thought they were in the beginning, but we still use them in this population because anything that can kind of steer us away from opioids, I think is beneficial. We are aware of the fact that the gabapentinoids can be used as a substance of misuse and in occasions potentiate the effect of opioids. We don't send people home on them, but we do use them in this population fairly regularly. Okay, and this person also wanted to know about how many patients a year do you see at your institution with pre-trauma opioid use disorders? Anything I gave would be a guess because it's not something that I'm aware that we track clearly and we don't, urine drug screens aren't sort of routinely done, so I don't have a good sense. It's not a small percentage. It's not all of them, but I don't have any hard data to tell you, unfortunately. Okay, and another person has asked about, you've worked through this patient with the protocol in the hospital, but what's the transition to the community? Who's gonna be working with them for the next 30 days or so while they're using Suboxone? Yeah, so on that slide I mentioned, so if you're not from Ontario, you won't be familiar, but the rapid access to addiction medicine. So there are clinics that are set up all across the city that are open for certain periods of the day that are staffed with some allied health, but also physicians and MPs. And so basically by connecting him with one of our RAM clinics that gets him, they then take the ball from there in terms of ongoing Suboxone or if he's on methadone, and whether it's working with the family provider or them owning it, it's very, very individual. I haven't worked at one, but basically they were set up to allow people to have sort of walk-ins if they're struggling with substance use disorder without having to get a doctor for an appointment. But it certainly allows us when discharging patients to tie them into a service that they would benefit from. And that's what I did with this gentleman. So I asked where he was going to live. So he was injured living in one spot, but he was going to recover in another. And so I looked up the address. I found the RAM clinic near him. I printed off to him the phone number, the dates and times that were open. I also, with his permission, faxed his particulars to them. So you don't need an appointment to go to these clinics, but they sometimes appreciate getting a heads up. So I did set up an appointment with him. So there is mechanisms transitioning from the hospital to the community. And certainly at the end of the day, it's up to the patient how much they want to pursue it. When the RAM clinic didn't exist, RAM clinic, sorry, it could be very challenging getting people onto therapy in the hospital, particularly if their family provider was not keen to pick up the baton after they left. Right, right, right. So you would recommend the fact that people kind of investigate around their community what the resources are ahead of time so they're kind of prepared. Yeah, I mean, what I would do before the RAM clinics, I mean, before I would do this, I would call the family provider and say, hey, this is what I'm thinking of doing. Is this something that you're comfortable with picking on after they leave? Some were, some weren't. Obviously, if you can't continue in the community, there may not be the best idea to initiate in the hospital. I can't say that I came across that problem. At least for me now, it's less of a problem because one, the RAM clinics are all over the city. And as I said, we do have an in-hospital addiction team as well, so that finding the resource, is it something that I need to pay as much attention to now as I did at the time? Okay, this is a- But it's a point, yeah. Yeah, yeah. And this person says, this could probably be a whole nother talk, but can you speak to the chronic pain patients with trauma experience? And they see a lot of patients post-trauma and they wanted to also know a bit about paraplegia and what, wondering what pain sensations people have in paraplegia. That certainly is a big, big question there. Yeah, well, so certainly for the first piece, I mean, for my practice, in terms of my approach to pain management, I approach a persistent pain patient the same as I would with someone who's a substance use disorder. Minimal opioid. I mean, the goal is to continue the opioid they're on, they come in on the prescription opioid. They might get a bit more opioid in the first 24 hours or so. And certainly the, our care isn't sort of robotic here at the organization. I mean, depending on who's looking after the patient, they'll have their strategies for pain management, but as a general rule, we're opioid sparing. So if this was a similar patient coming in and same age, and he had just fallen and broken his hip, I would have continued his opioid at home. I would have mentioned the same, adding more would probably not be beneficial, and I still would have done the ketamine and the nerve block. And so having these strategies available in your organization, but also that you can do on a regular nursing ward means that you don't have to sort of put the care for the addiction patient in general on a pedestal. It can just fold into much to what you do with the persistent pain patient that's on opioids. You're just having that extra conversation around addiction. And in terms of the paraplegia, I mean, that's a pretty complex question. It kind of depends on the extent of the paraplegia, how well they're coping in the community, what they come to the hospital on. But again, if they're on opioid in the community, the goal, opioid sparing. So again, a lot of the principles would be the same. Okay, very good. This person says, thank you, Jason, for a very good presentation. And they were wondering if your treatment would be similar if this patient came back to your organization again with another trauma and injury, because it seems like he's back to square one with the methadone plus cadian. Yeah, so I don't have any circumstance as to why he did that. That it could be a very good thing, he's why he's doing that. So I don't know. But I mean, certainly, if he were to come back, I mean, using the motivational interviewing approach would be the same. I would lead with ketamine and the nerve block again, and the multimodal as I outlined. How far engaged we go down the path of Suboxone or methadone would be dictated 100% by him, actually. Him or her. It's just- Right, right. And this, another person asks, why did the patient choose to go back to methadone? And you really probably don't know the answer to that. No, it just, you know, he, you know, I put the consent, it was like, he popped in to see me a few times, let me know he was doing well. And, you know, so he is, but I'm not, he's not getting that care at my organization, so I don't have access to any of the information. It's just a high level. I know that he got switched to methadone. The circumstance, I don't know. Yeah, I mean, I guess the take home was that, you know, he left here after six days and seems to have done well on Suboxone for 18 months, which is not a lifelong win, but it felt like a win of some sort. Yeah, yeah, at least for that period of time, yes. A person wanted you to comment on your thoughts about using CBD or marijuana for pain. Do you have any thoughts on that? Well, my thoughts are guided by the systematic reviews that say that the benefit for pain control is not, control is lacking, that there's more harm than benefit. And that's not to take away from all the anecdotal instances where marijuana has been a game changer in someone's life. I don't dispute any of those because I don't know those people or their experience, but the systematic reviews would say, at least with what we have now, there's no evidence to support using those elements for pain control. So I don't introduce them. If a patient says to me that they want to try them when they go to the community, I will give them the best information that I can. It's legal here as well. So I mean, at the end of the day, if they want to go and buy it at the store, they can. But the only time I prescribe any sort of cannabinoid is if they tell me that they're on it in the community and it's to avoid a withdrawal. Right. Here's another, thank you for your excellent presentation. As you noted, there are various competing interests to even establishing basic multimodal analgesia, basically barriers on the wards organizationally. I guess all pain services would be consulted. Any suggestions about overcoming barriers to appropriate pain addiction care? Well, I mean, it would depend on what the barriers are, but I think, so part of it is you need to know what you're asking for. Find out, like, I know almost, I know the vast majority of pharmacists in the organization, at least the ones in the units I go to, have conversations just in general, find out who you think might be aligned with what you're trying to do, and also come hard with the evidence, because you have to be ready to have an answer when someone says, well, we can't do that because, and that's sort of the extent of their response, right? So you need to know how to have those conversations. I've been at this organization for a long time, so there's certainly pros and cons to that. And so, but I think you really need to, it all starts with, I think, what are you asking for? And then, you know, have some, if you think what you're doing at your organization is really not the best, then do some data collection to show, like, you know, these patients aren't doing well, and here's where they're not doing well, and here's where the evidence says we could do better. So it's a lot of work. There's no easy ways to do it. You know, you might have to spend some capital or collateral, but yeah, it can be easy, but it often is not. So yeah. Right. Thank you, Jason. Really, our time is up for, and I thank everyone for participating in this webinar. As a reminder, we're able to provide continuing education for this session. At the end of the webinar, you will be sent an email with an evaluation form from ASPMN, and you must complete this evaluation within 10 days in order to receive your CE certificate. A link to retrieve your certificate will be on the thank you page after you've completed the evaluation. Even if you are not applying for the CEs, please take a few minutes to assess the evaluation and provide your feedback on today's session. A reminder that today's webinar was recorded and will be posted tomorrow afternoon on the ASPMN website and on the website for the Physician's Clinical Support System in the near future. The URL for the Physician's Clinical Support System is PCSSNOW.org and a calendar of upcoming events and many helpful resources are available there as well, I encourage you to go to the ASPMN website for our resources on pain management. Thank you again, and we hope you will join us for upcoming PCSS sessions. We have one next Wednesday at the same time, so I hope to see you then. Thank you again, Jason. Thank you everyone, have a good day. Thank you.

pain management

substance use disorders

opioid dependence

opioids

ketamine

non-opioid interventions

motivational interviewing

urine drug screens

transition of care

collaboration between healthcare providers