The broadcast is now starting. All attendees are in listen-only mode. Good afternoon. I am Anne Schreier, and it is my pleasure to welcome you to ASPMN's ninth-year series of webinars that focus on the use of opioid therapies for the treatment of pain, opioid dependence, and on the safe use of opioids in the treatment of chronic pain. This series is one of the many resources made available by the Prescriber's 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 other 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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The slides will also be available through the PCSS website in the near future. That website is www.pcssnow.org. Today's presentation is When Too Much Is Too Much, Reducing Opioid Use Through Multimodal Pain Management. Oh, I got the wrong title there. Let me do that. When it's time to come down, weaning with compassion. Our speaker is Megan Villaramo. Megan is a family nurse practitioner, has worked in pain management for the last 22 years. The first six years, she worked as a registered nurse, and the last 16 as an advanced practice nurse. She works in an outpatient private practice, New Jersey Pain Consultants, Altair Health, providing care for both acute and chronic patients. Megan holds her advanced practice pain management nursing recognition and is dual certified as an advanced practice holistic nurse and integrative health and wellness nurse coach. In addition to being an active member of ASPMN, she is also co-chair of the AANP Pain Management Specialty Practice. Welcome, Megan. Thank you so much. I'm so excited to be here with everybody. I'm passionate about pain management, and I'm passionate about patient care, and I'm excited to be here with all of you. So we'll get started. These are my disclosures. I'm on a speaker bureau for Salix Pharmaceuticals. That's for opioid-induced constipation. So that doesn't really have any bearing here. And I'm on the speaker bureau for NevroCorp, which is a neuromodulation company. So that also doesn't really apply here. And this is, you are our target audience. So if you want to know if you're in the right spot, this is just a quick little blurb on who that is. So I do want to just go through the educational objectives. At the end of this, we want to be able to explain why it may be appropriate to wean a patient from opioid therapy. We want to just have a quick differentiation between tapering and medically-assisted detox for opioid use disorder, identify appropriate pharmacologic treatment of withdrawal symptoms, and describe three strategies to support patient success and support during weaning. Basically, what we want to be able to do at the end of all this is take better care of our patients, right? And that's really why I'm here today is to hopefully give you just some tools and strategies that are supported by evidence and that I've been using in my private practice for a long time. What did I do here? Okay. So here's the problem. We inadvertently created this problem, right? Back in the late 90s, the pain as the fifth vital sign came out, right? And this came out as really an effort to aggressively treat pain. What we didn't realize is that it kind of started this whole ball rolling. And at that time, medical treatment was to titrate people to efficacy, right? For anybody who was around in the hospitals back then or in situations that involved patients in chronic pain or even acute pain, we would talk about how opioids have no ceiling effect. And as long as they're breathing and tolerating it, we can keep titrating up. And what this ultimately did is it ended us up with a lot of patients on high-dose opioids. Now, again, this was well-intentioned, but unfortunately, it created some problems. And the other part of this is back when this all started, we didn't have as many options, right? Like gabapentin was first approved in 1993. It was still brand name, which caused insurance coverage issues. Diloxetine wasn't approved until 2004. Pregabalin wasn't approved until 2004. So spinal cord stimulation was still in the early phases of therapeutic use. And so opioids seemed like the logical choice. And we started a lot of people on this, and a lot of people were trained to titrate patients to efficacy. So then what happened? Then I don't really need to tell you all the drastically terrible things that came out because of this, but we went from this attempt at efficacy to an epidemic. And those things, of course, are not the same. Opioid use disorder and pain management are not the same thing. But our patients are now in a very difficult position because of this. So in 2016, we had the CDC guidelines, which were initially developed for family, non-pain management providers, but it led to this widespread change in insurance restrictions. And so now our patients who had been on these medications for a long time couldn't get them approved. In conjunction with that, there was lack of evidence to support long-term use. And that's not to say that no patients get benefit from long-term use. It's just there's not evidence to support that the efficacy continues. And then I think we would all agree that there's adverse effects of long-term opioid use. And that includes GI issues, chronic constipation, mood disorders, hormonal imbalances, dental decay. The dental decay, especially now, I've been in this practice 20 years and we've seen these patients. And now we're seeing them with these incredible dental issues because of the years that they were on opioids. So it's just a very difficult position for these patients. And the patients are realizing this as well. It's not like this is a surprise to them that they're in a difficult situation. It's their situation. So what do we do about it? That's what we're all here to figure out what to do. So the whole point of this is talking about weaning. And I do want to differentiate that I'm not talking about here patients who are misusing their medications. I'm not talking about patients who have opioid use disorder. We're talking about pain management patients who have been on pain medication for a long time. And these are some of the reasons we would wean. No pain reduction. That seems obvious, but people remain hopeful that their medication will help them. And they're hesitant sometimes to let go of it because of that. No improvement in function. Sometimes the functional improvement was seen early on, but as time goes on, it isn't necessarily sustaining their ability to work or their ability to be active with their families. Another reason is patient request or adverse effects. So this is interesting and I will say that if there's a positive outcome or a positive side effect from the opioid epidemic is that patients are now open to the idea of weaning. A lot of patients are now kind of afraid to stay on these medications where we didn't see that 10 years ago that patients were afraid to stay on this stuff. Or they're now having adverse effects and that's the other thing that can kind of take people by surprise is that their 75 year old body is not the same as their 55 year old body and now they're having adverse side effects. Changes in medical status. This kind of goes in addition to the addition or cessation of other medications. I had a patient who was on medication and then had to, was on opioids and was put on some heavy duty medications because she had to be treated for TB. She's on immunosuppressants and the change in her medications really changed the way she was responding to her opioids. So that can happen, you know, through no fault of the patient's own they end up with something new or different and they need to come down on their medications. Non-adherence, I know I said this wasn't for people with opioid use disorder necessarily, but sometimes people just start kind of down that slippery slope of they take a little bit more or they try and manipulate it themselves and that's a good time to start leaning. I'm in New Jersey, hopefully I don't talk too fast, I get that a lot, but in New Jersey there are a bunch of surgeons now between New York and New Jersey who are requesting that the patients come off medication prior to surgery. I have all sorts of thoughts about that and whether that's appropriate or not, but you know, if a patient can't move forward with surgery without decreasing their medications, then that's another time that we might want to take some of this into account and try these strategies. So the other, the only other thing that I want to take a little mention of here is if somebody is put on a benzodiazepine. Benzodiazepines are for anxiety and plenty of people with anxiety need them for treatment of that illness, but we do need to then decide like, is it safe for them to stay on their current medications? Can we adjust something a little bit? Can we wean down a little bit? So these are some of the things that you might not initially think of when it's time to wean. So I know I said that we're not really talking about opioid use disorder, but I wanted to just put this up here, what the DSM criteria are for opioid use disorder. And I wanted to just do a slide or two about medication assisted treatment for opioid use disorder. I don't know if you, if you're on a phone, this is going to be really tiny. So I'm just going to read some of these here. The DSM criteria for opioid use disorder are opioids often taken a larger amount or over a longer period than was intended, persistent desire or unsuccessful efforts to cut down or control use, a great deal of time spent in activities necessary to obtain the opioid, craving, recurrent use, resulting in failure to fulfill major obligations at work or school. So this is substance use disorder, right? This is, so I think we can identify that this isn't necessarily who these patients are who maybe had a failed back surgery 15 years ago or a crush injury at work and are still maintained on medication. So when you're looking at these patients and when you're talking about weaning, our first thing is to establish, do they have opioid use disorder or not? If they have opioid use disorder and you're not equipped to handle that, then you should refer to somebody who is. I do pain management, I don't do addiction medicine, and I don't do detox. And I wouldn't pretend that that's my specialty, but there are people who are excellent at that. And part of the reason you want to make sure that the patients get referred out for that is so that they can have the right resources on hand, right? Now, when we're talking about medication-assisted treatment, there are three medications that fall into this, methadone, naltrexone, and buprenorphine. And what can be confusing here is we do use those medications for pain as well. Now, if you're writing them for opioid use disorder, you have to have, you have to know what your legal, your legal obligations are in your state. And we'll go into that a little bit on the next slide. But these are three of the medications that are used, and medication-assisted treatment may be short-term or may be long-term. So these are some of the patients that may be on these medications for years, or they may just be on it for a short period of time. Oh, these are the three options. And what you'll notice if you work in pain management, well, let me not assume anybody works in pain management. There's, let me clear up some of the misconceptions. Methadone, people get confused as to who can prescribe methadone. If, what it really boils down to is what are you writing it for? If you're writing methadone for detox, for opioid use disorder, you have to have an X waiver. You have to be an addiction specialist, right? Not just anybody can do that. If you're writing it for pain management, you just have to have a DEA number and a CDS number or whatever the equivalent is in your state. So anybody who can write for morphine for pain can write for methadone for pain. And nowadays the pharmacies are pretty straightforward with this, but only opioid treatment programs can dispense, so the people who go to methadone clinics, that has to be specifically for opioid use disorder. Now, naltrexone can be written with or without a federal waiver, right? Anybody who can write for any non-scheduled drug can write for naltrexone. And what's interesting is the 50 milligrams of generic naltrexone was not actually shown to be superior to placebo, but there is this injection available for opioid dependence and prevention of alcohol dependence and prevention of return of opioid dependence. Now, again, I'm not writing these because I don't do addiction medicine, but this is something that if you were in that role you could do. And then again, the buprenorphine, there can be some confusion here as well. So the four drugs that I listed there, suboxone, subutex, bropufine, and sublockade, those are medications for opioid use disorder and assistance in detox. To write those, you have to have a federal waiver. You have to have that X number on your DEA. This is where it can get confusing. So those are the medications that can be written for, those brand names can be written for opioid use disorder. But we also have two buprenorphine products that we use for pain management. We use a Butrans-Patch or Valbuca, which is a sublingual, a subucal film. And those you can just write for. So again, really it's kind of like your intention here. What's your intention? And then it shows you which ones you can write for. So those are the medication-assisted treatment options. And again, those are for people who specialize in addiction medicine and opioid use disorder. So now we're getting to the juicy stuff that I really find is most helpful for people who maybe are in primary care and the patient has lost their pain provider or their pain provider has retired. Or I know that there are parts of the country where this falls to neuro or it falls to ortho. And there's a lot of different specialties that see these patients. So these are the key components to tapering with success. And so what we're talking about is not abrupt cessation. We're talking about going down slowly and helping these people get down to lower doses. And there's not actually a lot of information on specifically for weaning pain medications. So the information from this is also borrowed from psych and from nurse coaching and goal-setting strategies. So the first one here is the psychological support. And that sounds obvious, right? Like, of course we should support these people. But once you start talking about tapering, what the patient hears is, I don't want to take care of you anymore. Or you're not going to have this. And that can be a very devastating place. And even though that's not what you're saying, that is often what the patient is hearing. So in order to be successful with tapering, these patients really need a lot of psychological support. Now, if you have access to psychiatric professionals and behavioral health professionals, obviously I think that's great. I know that now in our second year of pandemic, these providers are kind of tapped out. They are seeing boatloads of people, and there's not enough psychological providers to go around. But that doesn't mean we can't support these patients. And we may be the psychological support. And some of that is just acknowledging, like, hey, I know this is going to be tough, and I'm going to see you more frequently because of it. And it sounds awful, like, no, don't make me see them more frequently. They're going to be so unhappy. But they're actually really, the outcomes are much better if they're seen more frequently. That brings us to the second one, which is shared decision making. And so shared decision making basically means let them help you figure it out. Let them decide what's going to be best for them. And this is going to come with education and with time. And shared decision making does not mean fast decision making. And what can often be most helpful is to kind of start the discussions of this early, right? Like, if these patients have been on medications for five years or 10 years, we don't have to fix it today in one month, right? We can talk about it today and say, listen, this is kind of what we see with evidence. This is why we would want to go down on your medications. This is how other patients have done. I want you to start thinking about this and we can talk about it again next month. And it gives them some time to kind of ponder over and then decide. And we'll go into that a little bit more as well. When we get to the pharmacologic support, this is different than what we were talking about with the medication-assisted treatment. This is support for withdrawal symptoms. And that's, or whatever else we may need to be handling at that time. So if we're weaning opioids, it may not be the time to be doing 15 other things with their other medications. You know, to focus on one thing at a time and to support them with the other in treating the side effects. And then a clear outline of the treatment plan. Now, this may change, right? We don't always know exactly what we're gonna do at exactly every moment. But if we go through with them, like this is what we're kind of gonna do. We're gonna try and go down on your medications. We're gonna go down a little bit at a time. And we're gonna kind of see where that gets us. We're gonna maybe decrease the long acting first, maybe decrease the short acting first. I'm gonna treat you for all of the withdrawal symptoms and we're gonna manage that as best we can. And to just go through it. Because again, a lot of patients will equate this discussion about weaning as a cessation of care. And that's certainly not what we're doing. We're weaning them to take care of them. We're weaning them for their best outcomes. And that's gonna take some time and trust. Now, the one thing that I thought was important to note is this idea of taking pauses. Now, this is back years ago, our weaning protocol would always be 10 to 20% drop every three days. Boom, boom, boom, and it was awful. And what we found actually is that if you take pauses, if the patient is aware that they're not just necessarily gonna go down every month, this goes back to the treatment plan, right? If they need to stop at one level and stay there for a little while, that their outcomes are better. When we talk about, let me jump back up again for a minute. When we talk about the clear outline of the treatment plan, they actually did a study where they looked at giving the patient an option for continued maintenance of medication. So what that means is patients were told that they were gonna start weaning and half of them were told like, we'll get you down as far as we can. There may be some reason to keep you on some medication. And the other half of patients were told we're weaning you until you're off. They were never given the option for potentially a maintenance of treatment at some lower level. And what they found is that in the group that was given the option at some point that there may be medication maintained, in the first three weeks, only 5% of them quit the program. So most of them stayed on when they knew that they were gonna have an option to potentially stay on if they needed to. What they saw in the group that was told they're just weaning is 76% of them quit in the first three weeks. Now the tapering wasn't different. It was the idea that no matter what they were coming off. So it's just something to be aware of that the way patients are thinking about this has a tremendous effect on their success. Okay, so I wanted to give you an example. This is Pam. Pam actually came to our practice. Oh, I'm calling her Pam. But she came to our practice on fairly high dose opioids. She had a previous lumbar fusion in 2007 and initially was much better. And then in 2010 started with increasing pain. This sounds familiar, right? So over her next six years, the patient was titrated up by her previous provider to 130 milligrams daily of oxycodone in divided doses. She was also on duloxetine and Lyrica. I'm certainly not criticizing this provider for doing this. We've done this with plenty of patients. And then in 2016, what happened? The CDC guidelines came out and her provider was like, you probably should go get a spinal cord stimulator and I'm gonna let pain management do your meds now. So she was transferred to our practice, which in the long run was great for her. And she had a successful spinal cord stimulator trial and implant in 2016. Let me back up. So what we're gonna do here is I'm gonna just kind of talk about, she actually, she brought up the idea of weaning. She said, I don't wanna be on these medications. This is when the CDC guidelines came out. There was a lot of hubbub in the news about adverse effects with opioids. She had been on them a long time and she just wanted to start weaning down. And so that's where we started this discussion. Now, this is some of the options of the speed of tapering. I do wanna just pause for one second and say, if you think of a question as I'm going along, just type it in the Q and A. Like you don't have to wait to type them in because if you're like me, you'll write down three words on a piece of paper and you won't remember what your question was. And then we get to the end and then you don't get it answered. So if you have questions, just add them in as I'm talking. So there's this really nice resource that the Department of Veteran Affairs put out, this opioid taper decision tool. And I wanna say it's about 30 pages. It's free to download and it's fantastic. So if you kind of want everything in one place, it's not a bad thing to download. It's the information's at the bottom there. So this is what I was talking about before. These are the different options with speed of taper. And what's interesting is there's actually no studies comparing speed of taper. So this is us kind of figuring it out as we go. And the Department of Veterans Affairs has an incredible access to data and an incredible access to people. So they put out a lot of good information. But you can see here the different speeds of taper and I can let you read these. I don't have to read them to you. But the rapid, we don't really ever do that. It's a very aggressive weaning protocol. Generally, if you have some reason that you would be decreasing people's medication by 20 to 50% in the first dose, something is concerning you there. Often it's an appropriate referral for opioid use disorder. And even what we're finding now is what we used to consider kind of regular is a very fast wean. Patients do very well if they're weaned very slowly. And this could be five to 20% every four weeks. But if you see underneath that, this is in the slow category, you include PRN pauses. So what this might look like is that a patient gets rid of one of their short acting, let's say Percocet. They get rid of one Percocet. They go from five Percocet a day to four Percocet a day. And they do that for a month. You wouldn't necessarily say at month two, you're feeling great, let's go down again. It's gonna take them some time to kind of get their heads around this. And you might, they might be fine doing that at that point. But just having this idea of like we might decrease and then we might leave you at that for a couple months. And this can go very, very slowly. But what's important to know is that this gives time for the patient to to develop new skills, right? If you take a break and you let them stand it, it gives them a chance to kind of recalibrate. It also gives them a chance, you know, opioids have a direct effect on the reward center of your brain. So separate from their analgesic effect. So when you start decreasing, there are neuroplastic or neurobiologic changes that need to regulate as well. So that this moment of decrease reward to the brain doesn't sabotage what you're doing. So the slower we go and the more time that we give the body to kind of catch up, the brain to kind of catch up with what we're doing, the patients then can learn like, oh, look, I decreased by one pill, it didn't kill me. Actually, after that first week or two, I kind of settled in and then they get encouraged by it and they can start some positive new behaviors. And I have to say that with my patients who have been on opioids for a long time, I usually either use this slow or slowest options. If they've only been on opioids, say after a surgery, they maybe had a complicated post-surgical course and so instead of two weeks of medications, they were left on meds for three months or maybe they had to go back in for an IND and then it was six months, but they're not on for years. You might find that you can go a little bit faster with success. Okay, so what are the two major fears? I'm sure that I don't have to tell you this, but their major fears are fear of increased pain and fear of withdrawal. And that's what we wanna address so that we can find an individualized plan that's gonna help these patients the most. I would just like to stop here for a second and just do a quick, I guess it's not really an activity, we'll call it an activity even though we're all separate, but I just want you to think about something in your life that has made your life much easier, like much easier. When you compare your life before to your life after it, like it made it so much easier. And maybe you just take it for granted now and it's just part of your life. What would happen if I said to you, okay, I know that makes your life much easier, but I don't think you need it anymore. I'm gonna take it away. It's not even, you may be fine without that, but that fear of going back to where you were can be very difficult. And that's what we talk about here, that anticipatory, you're anticipating trouble. These patients are anticipating increased pain, which does not work out well. They also all have this picture of, sorry, sitting in the corner, yes, sitting in the corner, shaking and crying and sweating. That's what they have a picture of when you talk about withdrawal. So this, we have to address both of these if these patients are gonna be successful. Because the increased pain isn't, they're just not afraid of having increased pain, they're afraid of the effect that that has on their life. When I talked about what makes your life easier, they wanna know that this isn't gonna affect their ability to go out and be with their friends, or it's not gonna affect their ability to spend time with their grandchildren or sleep, right? Okay, let's address both. So, first and foremost, how do we address this with them? How do we address the fear of increased pain? What's interesting is that they found that overall, when we go down on medications, patients report improvements in function without worsening pain. And honestly, if I hadn't been through this with so many patients, I wouldn't believe it. I didn't believe it when I first started this with patients, but I've seen it time and time again, is that what happens is as we start to go down on these medications, there's always that initial maybe week or two where the anxiety is bad, right? They're very anxious about it. And I tell them, like, we just have to normalize that, right? It's normal to feel anxious about this. It's totally normal. The anxiety is gonna make it a little bit trickier for you that first week, and then it should even out and you're gonna realize you're okay. We just have to be blunt with them about that, right? But what research has shown and what my personal experience has been with my patients is that this is exactly right. Patients actually find that they improve their function because they didn't think they were sedated and they didn't think they were tired, but once you start taking stuff away, they realize they have more energy and their pain doesn't get worse. Number two, again, is consider the opiate option for a continued maintenance at lower doses. Now, I know that there are different schools of thought as to whether any dose of opioid is okay. I would like to put out there that lower dose of opioid is definitely better than higher dose of opioid. So if that's what it's gonna take to kind of help them be successful and like, think about it, what usually happens is once people kind of get on a roll, they are either more likely to talk about coming off or they can get down to much, much lower doses. Number three, I think is underutilized all the time. Brainstorm with the patient. Excuse me, what do you think will work? What do you do on a bad day? What makes you feel better? You know, I have a lot of patients who say, well, if I put my feet up and I put heat on my back, I do feel better, but I can't always do that during the day, to which I ask them, why not? Why can you not do that during the day? Now, yes, at my job at work, I can't put my feet up and put heat on my back. Well, I can put heat on my back, but I can't put my feet up. But when you say to them, like, listen, if all you had to do was do that three times a day, the same way you dose your medication and it had the same effect, would you be willing to try it? And so just getting them involved with, what else do you think would happen? What else do you think would help? And see if that gives them some benefit. Okay, I already said the other two. So let's talk about withdrawal. They need to know what to expect. I think it's important to note that opioid withdrawal is the result of the sympathetic stimulation, the increased sympathetic nervous system stimulation, because you're taking away something that's antagonizing that stimulation. So patients are feeling that fight or flight feelings in their body, which is a terrible way to feel. And the way we treat that is with the alpha, the alpha-2 adrenergic agonist. So they're listed here at the bottom. I know if anybody's been in doing this a long time, you're probably familiar with people using clonidine to help dry people out so they don't get the runny nose and the sweats and all of that. Lusamira, this Lifoxidine, is one of the newer drugs to market, and it has some good outcomes. So this is kind of where we start with some of the withdrawal symptoms. Now, these are not for opioid use disorder. Again, this is just to kind of help them get off of medications with minimizing withdrawal symptoms. Oh, what are early withdrawal symptoms? Look at this list, it's terrible. Runny nose, rapid short respirations. I mean, a runny nose doesn't sound so bad until you have it for three weeks and you can't even get through a sentence without your nose running, especially now that for all of us who are wearing masks all day, right? Fever, chills, white blood cells can go up if it's all done quickly. The thing that I really want to point out here is this hyperalgesia on the bottom left-hand corner. It's in red. What many people don't realize is that a withdrawal symptom can be increase in pain. Now, you're like, well, of course, because we're taking away their pain meds, but it's not from that. It's actually a withdrawal symptom can cause hyperalgesia, can cause hypersensitivity to pain. And that's one of the reasons why we want to go slowly. But I also think it's important to tell patients, listen, sometimes withdrawal can cause an increase in your pain. That doesn't mean that's the pain you're going to be stuck with. That doesn't mean that that's the pain that long-term you're going to have. It means that your body is trying to figure out what's going on and that will go away. And then you can see these late symptoms days to weeks. Now, the reason we want to deal with this is think about insomnia. I don't know how many of you have insomnia, but everybody at some point has had some type of insomnia or you drank coffee too late and you're up all night. What would happen, what would you do if you had insomnia for three weeks? If I don't sleep two days in a row, I'm a cranky, not so nice person. But after three weeks, you'd say, just give me back the medication that was helping me. I can't deal with the insomnia. So it's easy to understand why people have these problems. So are they watching the clock? This is the biggest issue, right? They're concerned about watching the clock. And what we can do is manage their withdrawal symptoms so they don't have to do this. So this is the information on Lifoxidine. And you can read all of this. I don't need to tell you all this. I know that you've got a copy of the slides, which is part of the reason why I put all this information on the slides is because, not because you wanted me to read it to you, but because I knew that you might want to refer back to this. What's great with Lifoxidine is in the clinical trials, you had to be on 50 morphine equivalents or higher and under 240. And what they found is that it helps significantly with insomnia, with the sweats, with all the withdrawal symptoms. Now, I will say there are patients who, the times that I use this, or the times that you might find it helpful is when patients have weaned a lot of the way down and they just can't get down that last little bit. Sometimes they'll have withdrawal symptoms, ironically, at the lower doses and not the higher doses. If patients have run out of their medications and you're like, that's it, we're no more with this nonsense. This is something that can help kind of get them over that a little bit. Or again, if they're trying to get off of it for an elective surgery and they don't have a lot of time. Sometimes people want to try a slow taper on their own and then all of a sudden they get fed up and they're like, I just need off of this stuff. And the nice thing is, this is usually given for nine to 14 days. These are some of the more, I like to call them the old school options. And obviously I wouldn't give the patients all of these. I would talk to them and find out like, what are the symptoms that they're having and kind of pick one appropriately. And this is again, why you want to see them on a regular basis. The link is at the bottom there for the Veterans Affairs document that this came from. Okay, so the problem is, is I showed you all of those different symptoms. Like of course it's difficult to wean. Like why would we need to make, why would we even want to make this more difficult for patients? And what I usually, when I start weaning patients, I usually tell them I'll see them back in a week or two, depending on how fast we're going down. If it's only a tiny, tiny pinch, if it's like a 5% and they're on high doses, I might see them out a month, but they might need something the first week for nausea. And you can kind of, this all makes sense, right? That if they're having abdominal cramping, that can last for weeks. Maybe they need liparamide, which is Imodium. Maybe they need the Pepto-Bismol. Maybe, you know, and you can kind of go through here. What you'll see with the sleep disturbance, which might, some of you might find interesting is that we don't generally recommend hypnotics, sedative hypnotics when we're trying to wean people. Trazodone is a nice thing that can be used short-term and intermittently for insomnia with withdrawal. So I think also the other thing with this is if we tell patients like, hey, listen, you might have to make some pains. You can take some Tylenol. If you're nauseous, give me a call. It just, again, shows them that you're invested and that you want them to be successful and that you're willing to help them. Because the truth is most of us are willing to help them, but if the patients don't report these symptoms, they just say, oh, I couldn't do it, and they go back on their medication. So we wanna kind of give them this as a baseline. Okay, this is an important safety concern. Tolerance can return as early as one week. This is, it's mind-blowing how this can happen. So when we go back to Pam, Pam was on 130 milligrams of oxycodone in divided doses, and we went down by five milligrams, which is 2% or 2.5% every, I don't know, two or three months. But what's funny is now that she's down on lower doses, if she takes one extra on a bad day, she really feels the effects of that. She really feels the effect of a five milligram tablet when she was on 130 before. So it's important to tell our patients that tolerance can lessen as early as one week, which means they could potentially overdose if they go back up to their previous doses. You would think that this is straightforward. Patients don't know this. We know this because we're in the medical field, but patients don't really feel like, they're like, oh, no, that's not for me. I wouldn't overdose because I was on this medicine already. And they also equate overdose to something that's intentional. So it's just an important thing to have. Everybody should have a prescription for naloxone. What I tell my patients is that naloxone is for risky drugs, not risky people. I mean, obviously it's for risky people too, but my point of giving it to my patients is for their safety because the drug is dangerous. So it's just something to kind of remember. Patients feel better when you say that. So I want to just quickly go back into the strategies for success. Number one, shared decision-making. And I think I kind of glossed over this a little bit, and I honestly just want to take a minute here and talk about this for a minute. Shared decision-making. I like to think of it as the same as when somebody needs a knee replacement. So most people who need a knee replacement don't wake up one morning and they're like, oh, my knee hurts, I should go get a knee replacement. And they go to the doctor and they say, they have advanced OA, you should get a knee replacement. And they say, okay, sign me up tomorrow. That's not how it works. Somebody deals with it for a long, long time. Then finally they're like, maybe I should get this checked out. Then they get some x-rays and they're told they probably need a knee replacement. And then they decide they don't want to do anything about that, they're not going to do that. Then they decide maybe they're willing to try some injections. Then they consider, and eventually the patient decides when they're ready to get the knee replacement. Now, obviously we want to encourage our patients based on the fact that so many patients can do so well on lower doses. Part of that shared decision-making is telling them what's worked for other patients and giving them options. So there are different schools of thoughts as to whether or not you should decrease long acting or short acting medications first. The question is, does it really matter? If a patient says, if you say, listen, we could do, we could drop your OxyContin a little bit, or maybe we could go down on the dose of your Percocet. If they pick, they're going to be more successful. If they choose what they're going to go down on. And most patients have, once you talk it through a little bit, have some idea like, oh, I'm actually sleeping most of the time through the night. So I could probably decrease my nighttime OxyContin. But, or I really feel that I need that. I'm better off decreasing one of my Percocet. Now, the other kind of trick in here to remember is that you don't have to say, for example, somebody's on OxyContin 30 milligrams, three times a day. When we think about going down on a dose, we think, well, the next dose is 20, but if I drop them to 23 times a day, that's 30% of their dose of that. And that would be tough, but keep in mind, you don't have to decrease all of the doses. Maybe you do 30 milligrams, 30 milligrams, 20 milligrams. And yes, it's to copays, but most of the time, patients will say like, they're more comfortable with that. It's a much easier idea. So the shared decision-making is really, really key. And sometimes even saying like, do you think you could drop again this month? Or do you think you could decrease it next month? Because if they've been on it 10 years, again, what's the rush? What's the rush with one more month? If in the long run, it helps them be successful. Frequent follow-up so that they know that you're gonna be there and you're gonna help them. This also allows you to deal with withdrawal symptoms as they come up so that the patient doesn't think that the only answer is to go back up on the opioid. They're gonna need our help managing withdrawal symptoms. The withdrawal, they might still have some. I mean, I think that's when we go into expectations, that's another thing to tell them. Like, we're gonna manage your withdrawal symptoms most of the way. You know, you might still feel a little queasy when you get up in the morning. Your sleep might be a little bit off for a while, but this is normal. It regulates, that all comes into the managing expectations. Okay, brainstorming other modalities. This, interestingly, sometimes people are willing to retry something they haven't tried in years. Like, again, they'll say, oh, well, I tried acupuncture. And then you find out that they tried it in 2001 and they went twice, and you're not even sure if it was an acupuncturist. And you say, well, what if, you know, a lot of my patients have benefit with acupuncture. Now some insurances are covering it. Would you be willing to try that? Patients are really willing to do stuff on their phones. I show patients how to listen to podcasts all the time. I help them download that and listen to supportive podcasts or figure out how to download the Calm app or the Headspace app. And we work through it in the office. It takes three minutes. It literally takes three minutes. And then they feel like, oh, listen, they're not just taking away my meds. She really wants me to be better and she's helping me figure out these ways of doing it. Taking a pause, I think I, I mean, how many more creative ways can I say take a pause? And just be there to answer the patient's questions as you're taking these pauses. And then the one thing that I didn't really talk about is this issue at the bottom, the address cognitive dissonance and repeat. So what is this cognitive dissonance? What this basically is, is the patients want to come off their meds and they don't want to come off their meds. It's like smokers, right? They don't want to be smoking, but they don't want to stop smoking. And it's because they're getting some benefit from it. It's an understandable place to be. And they're afraid, you know, anticipatory fear is a terrible place to be and yet they're motivated, right? It's like dieting and wanting chocolate cake. So we just have to talk about that as we go along. Like, I know, like, listen, some days it's not going to be easy and you're not going to want to do this, but you know, we're going to support you through this because in the long run, here's the benefits you get from it. You don't have to come see me every month. You're not going to have to be taking three things to manage your bowels. You're going to be able to sleep better. You're still going to be able to function because what we've now seen is that people can decrease their meds and not have adverse effects in their pain or in their function. So, I'm watching the time. Okay, so what about Pam? Where is she now? She started about four months after her stimulator trial, which put us right to the beginning of 2017. I just saw Pam last week. We've been going down a little bit at a time and she is now on five milligrams of oxycodone four times a day. So she's on 20 milligrams of oxycodone a day, down from 130. I still, every time we drop a little bit, I still have to give her something for nausea. And about every fourth time I've had to give her something for either sweats or runny nose. And what really worked for her was letting her pick what to go down on and when to go down on it with the expectation that we were just going to keep at it until she was successful and until she got to a level that she was comfortable with. Her hope is to be off of all of this medication together. But if you're doing the math with me, it's now 2022 and we started this at the beginning of 2017. I don't think it has to be as long as that. But again, we're just going down. She's had no problems with it at all. And she's learned some really great skills along the way. She's actively doing mindfulness activities multiple times a day. She is much more in tune to what she needs to do to manage her body, manage her pain and manage her mind without reaching for a pill. And we're also doing frequent reprogramming of her spinal cord stimulator when she needs it. But she's actually been stable on that for a long time too. So it's really like a home run. She's doing great. So the moral of the story is weaning does not have to mean suffering. That's really the moral of the story. It doesn't have to equate abandonment by the medical team. And it can really be the next step to health. It's not a punitive thing. It can be the next step to health if we treat the whole patient and deal with all of these issues all at once. So that brings us to the 10 minutes before the hour. I have to admit, I'm pretty proud of myself that I managed to jam that all in. Does anybody have any questions? Yes, thank you, Megan, for this presentation. We still have a bit of time for questions. So if you haven't put your questions in the question box please go ahead and do that now. I'm gonna start with something about the insomnia. This person says that has melatonin ever been considered for insomnia withdrawal? Because Trazodone, although it's used in the manage of psychosis in the past, it's concerned about its frequent use. It's not really a benign medication. So what do you think about that? Of course, listen, non-pharmacological or non-actual like drug options are better. It's when you look at Trazodone versus Ambien I would pick Trazodone, but I'm so glad that you asked about melatonin because there's actually research that shows that patients with chronic pain have been shown to have a chronic melatonin deficiency and that the level of deficiency can actually equate to the level of depressive symptoms and can equate to chronic pain. So I think melatonin is an excellent idea. I think what, there's a couple of things with melatonin. Number one, I always tell patients, well, always now that I know about this deficiency issue which I didn't actually know about last year. I now always tell them to take it regularly for a month because if something is gonna have a deficiency you're not gonna fix it in one or two doses. The other thing though that I think we do need to be cautious with melatonin is that you need to give them a dose. So in the studies, in the early studies that were done with melatonin, they were looking at around three milligrams. Later publications talk about something around 10 milligrams. If you go to the store, some of these supplements say to take 50 milligrams which can then catastrophically affect your endogenous melatonin production. So I think patients need some real guidance about melatonin. I was appalled when my teenager son came home from college and was like, yeah, this stuff works great. And then I found out he was taking like 50 milligrams and I'm like, well, of course you're sleeping because you just took way too much melatonin. But I do think that's a great thing. I also think that guided, not guided, guided imagery, I'm blanking on the other word, progressive relaxation. They've done studies that compare progressive relaxation and ambient and they've actually seen long-term much better effects with progressive relaxation. So that's another thing that I would actually, I actually show my patients how to download it even on YouTube and do a progressive relaxation before bed. So yes, thank you for pointing that out. I don't, I certainly don't want to say like, let's just give them another medication. But if it's really persistent or if they need something like once a week to make sure that they can just get one night and then continue with these other things while they learn them, trazodone might be an option as is Benadryl, but you know, we don't, that doesn't have a totally clean side effect profile either. So thank you. Yes, this person asks if you could give an example of the kind of discussion you have when you're explaining why you should taper specifically for patients who are, feel they're doing well on their opioids. Yeah, so what I usually say to them is, what I would usually say is like, listen, I know you've been on these things a long time and my main goal is to still take care of your pain. You know, I've been with my patients a long time. You know, I would never suggest something that I would think would have an adverse effect on you. But we do know the long-term side effects of opioids, even when you're doing well, they can affect your dental issues. They can affect testosterone levels, which even in women can cause significant issues. And what we're seeing now is that if we go down very slowly, that patients can actually do just as well on less medication because your body has changed, your pain has changed. You're not in the same position that you were when you started here. And they'll all agree with that, right? They agree that, oh yeah, I'm not anything like what I was. You've gotten better at learning how to deal with this. Your body has adjusted. And we should talk about trying to go down a little bit and just see how you do. And we can do that either by decreasing this medicine or this medicine. And I usually have that discussion at least a month, if not two months prior to even starting that. Give them some time to get their head around it, to ask questions. And then I usually tell them the math. Like, listen, if you're on 100 milligrams, do you think the difference in relief that you get is significant between 95 milligrams and 100 milligrams? And like, would you be able to like, just try that every other day? Maybe 100 milligrams one day and 95 the next day. Like, could we experiment with it? And we'll work it out. If that doesn't work, we'll figure out what to do next. And that's kind of the discussion that I have with them. But I do think that it's important to remind them that like, I'm here to take care of their pain. That's my goal and to take care of them as a human being. And this is kind of what we're seeing now is the next best way to take care of our patients. There's another question that someone has. Have you found any medications that are particularly helpful for hyperalgesia that occurs with the withdrawal? No, the best, no, I haven't. The best option is to go down slower. So the best option is to go down more slowly. If it's, that usually only happens in the first week or so. It's one of the short early signs. So I just tell patients like, listen, that when you drop, two things are gonna happen. You're gonna freak out thinking, oh my, I'm worse. Am I worse? Maybe I'm worse. Maybe I should have taken that. Maybe I shouldn't have taken it now. And your pain might go up a little bit because your body's trying to figure out what to do now that the level is different. That's not gonna stay that way. That's not real long-term what you're gonna feel like. So we'll do whatever we need to do to kind of keep you comfortable during that time. And some of it might be distraction and heat and massage and those other types of things. They can certainly take Tylenol. Most of my patients don't want that. And many of my patients can't tolerate anti-inflammatories. But if they're having like a lot of myalgias, a lot of just kind of aches and pains, I would definitely recommend a short course of anti-inflammatories only for those couple of days right after they decrease. And then to come back off of those and we'll use them again when they decrease. So I would say anti-inflammatories, if anything, and if they can take them, but really the best bet is to minimize that by going down slowly. Thank you. Here's somebody who also practices in the New York, New Jersey area and says, wanted to know your thoughts about medical marijuana to help with anxiety and opiate weaning, because she gets a lot of patients who are asking for weaning for certification. Okay. So that's like a whole nother talk, but I will say, so there is some evidence that supports medical marijuana for the use of pain. Now that's not necessarily for weaning, but if you use medical marijuana for pain, my experience has been is that if my patients do well with medical marijuana, their weaning is much easier for them because they don't need the opioid as much. Now that's not true across the board. What I usually do is tell people to try it in place of one of their breakthrough pain medications or try it first at night and see how they do. The problem with medical marijuana for anxiety is that the evidence is kind of dual. There's, it can help with anxiety in some cases, but it can also worsen anxiety in some cases. It has a biphasic effect. So at one dose, it may, at low doses, it may help. At high doses, it may actually make anxiety worse. So I wouldn't use medical marijuana as a weaning tool. If you want to use medical marijuana as a tool for pain management with the idea of coming off the medications, I would say that that's reasonable as long as you're clear on other potential interactions with other medications and medical marijuana. So I know that sounds like semantics, but it's, I wouldn't use it as a weaning tool. I would use it for pain. You know, we're out of time and there are lots of questions for you to answer later, but thank you so much for this informative presentation, Megan. Thank you. Thank you all. I'm sorry, I didn't scroll through. There's information here. Yeah, that's all right. As a reminder, I'm just going to do a last things about how to get the continuing education. So as a reminder, we are able to provide continuing education, only nursing. At the end of the webinar, you'll get an email with an evaluation form from ASPMN. You must complete this evaluation within 10 business days in order to receive the CE certificate. A link to retrieve your certificate will be on the thank you page after you complete the evaluation. Even if you are not applying for continuing educations, please take a few minutes to do the evaluation and provide your feedback on today's session. We really value that. You will receive a second evaluation from the PCSS organization. Please complete this second evaluation. And that's for the purposes of the SAMHSA grant. Now, a reminder, the webinar was recorded and will be posted tomorrow afternoon on the website and later on the provider's clinical support system in the near future. And that URL is PCSSNOW.org. And there's a calendar of upcoming events and very helpful clinical resources available there as well. Thank you again. And we hope that you'll join us for upcoming sessions.

opioid tapering

safe use of opioids

chronic pain

weaning patients off opioids

strategies for successful tapering

psychological support

withdrawal symptoms

medications

case study

individualized care