Managing Patients with Chronic Pain and Opioid Addiction

122 Pages·2015·0.93 MB·English

by  Donald R Taylor (auth.)

Donald R Taylor
Managing Patients
with Chronic
Pain and Opioid
Addiction
Donald R Taylor, MD
Managing Patients
with Chronic Pain and
Opioid Addiction
Donald R Taylor, MD
Managing Patients
with Chronic Pain and
Opioid Addiction
Donald R Taylor, MD
Comprehensive Pain Care, PC
Taylor Research, LLC
Marietta, Georgia
ISBN 978-3-319-08110-6 ISBN 978-3-319-08111-3 (eBook)
DOI 10.1007/978-3-319-08111-3
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2015
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole
or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed. Exempted from this
legal reservation are brief excerpts in connection with reviews or scholarly analysis or material
supplied specifically for the purpose of being entered and executed on a computer system,
for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof
is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its
current version, and permission for use must always be obtained from Springer. Permissions for
use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable
to prosecution under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the
date of publication, neither the authors nor the editors nor the publisher can accept any legal
responsibility for any errors or omissions that may be made. The publisher makes no warranty,
express or implied, with respect to the material contained herein.
Printed on acid-free paper
Adis is a brand of Springer
Springer is part of Springer Science+Business Media (www.springer.com)
Contents
Author biography vii
Abbreviations ix
1 Introduction 1
References 2
2 Introduction to chronic pain 3
Definitions of chronic pain 3
Prevalence of chronic pain 3
Effect of chronic pain 4
Introduction to management: managing expectations of patients 5
with chronic pain
The importance of continual care 16
References 16
3 Monitoring patients with chronic pain and addiction 19
Definitions 19
Prevalence of chronic pain and addiction 20
Monitoring patients with chronic pain and/or addiction 21
on opioid therapy
Monitoring compliance 30
Risk Evaluation and Mitigation Strategy (REMS) Access program 36
References 37
4 Managing patients with chronic pain and 39
opioid addiction
Buprenorphine 40
References 64
V
VI • CONTENTS
5 Special population: Pregnancy, pain and addiction 69
General management recommendations 69
Acetaminophen 70
Nonsteroidal anti-inflammatory drugs 71
Antidepressants 71
Antiepileptic drugs 73
Opioids 74
Conclusions 78
References 78
6 Approaches to the management of patients 83
with chronic pain and addiction
Patient with chronic pain who develops addiction 83
Patients with a managed addiction who developed chronic pain 91
Pregnant patient with addiction and chronic pain 98
References 104
Conclusion 107
Appendix 109
Opioid Risk Tool 109
Sample informed consent document 110
Sample treatment agreement 113
Clinical Opiate Withdrawal Scale 115
References 117
Author biography
Donald R Taylor, MD, is the medical director at Comprehensive Pain
Care, PC, and the principal investigator for Taylor Research, LLC. He
graduated from the Medical College of Georgia in Augusta, GA in 1984.
He then completed a residency in anesthesiology and critical care medi-
cine at Johns Hopkins Hospital in Baltimore, MD. After this, he stayed at
Johns Hopkins Hospital for a fellowship in Regional Anesthesia and Pain
Management. During his fellowship he established the use of patient-
controlled analgesia and epidural analgesia for postoperative pain at
Johns Hopkins Hospital. After his fellowship was completed, he remained
on the faculty for a year in the division of regional anesthesia and pain
management, providing services in the operating room and in the pain
clinic. In 1990, he left Johns Hopkins Hospital and returned to his native
Georgia where he entered the private practice of anesthesiology and
pain medicine. He has spent nearly a quarter of a century practicing
pain medicine and conducting phase II and III clinical trials for pain
management medications and devices.
His interest in the treatment of opioid addiction arose from his obser-
vations of the development of addiction in his own patients with chronic
pain, and his recognition of the fact that few pain specialists knew how
to manage this group of patients. After buprenorphine/naloxone became
available for the office-based management of opioid addiction, Dr Taylor
became certified in its use and began to use this medication to treat his
patients with comorbid pain and addiction. After early success with this
approach, he expanded his practice to accept referrals of patients with
pain and addiction from other physicians. Currently, Dr Taylor divides his
practice between treating patients with chronic pain without addiction,
patients with chronic pain with addiction, and patients without pain but
with drug addiction. He is a Diplomate of the American Board of Addiction
Medicine and a Diplomate of the American Board of Anesthesiology, with
added qualifications in Pain Medicine.
VII
Abbreviations
AED antiepileptic drugs
BEMA BioErodible MucoAdhesive drug-delivery
technology
CBT cognitive behavioral therapy
COT chronic opioid therapy
CP chronic, noncancer, pain
FDA US Food and Drug Administration
LAO long-acting opioid
LC/MS liquid chromatography/tandem mass spectrometry
MRI magnetic resonance imaging
NSAID nonsteroidal anti-inflammatory drugs
ORT Opioid Risk Tool
SAO short-acting opioid
SNRI serotonin norepinephrine reuptake inhibitor
SSRI serotonin specific reuptake inhibitor
TIRF REMS Transmucosal Immediate Release Fentanyl Risk
Evaluation and Mitigation Strategy
Ix
Chapter 1
Introduction
Chronic, noncancer, pain (CP) is a significant problem. On October 11,
2004, the World Health Organization cosponsored the first Global Day
Against Pain in order to draw worldwide attention to the urgent need
for better pain relief [1]. A review of the literature by the International
Association for the Study of Pain suggested that in North America, Europe,
and Australia the prevalence of CP ranges between 10.1–55.2% [2].
In 2011, the American Institute of Medicine estimated that CP affects
approximately 100 million Americans each year [3]. Furthermore, the
American Institute of Medicine noted that: “effective pain management is
a moral imperative, a professional responsibility, and the duty of people
in the healing professions” [3]. As opioids have historically been part of
the pain management pharmacopeia, and given the prevalence of CP, it
is understandable that prescriptions for opioids have increased [4]. Along
with this increase in legitimate opioid use there has been an increase
in abuse of opioids with resultant unintentional overdose deaths [5].
However, most of the people abusing drugs do not obtain them from
physicians; only one in five people who misuse opioid analgesics get their
drugs exclusively from physicians, and 69% never obtain any of their
drugs of abuse from medical sources [6]. This is consistent with my own
opinion that the majority of the people who die from an unintentional
overdose are not patients; nevertheless, we as physicians need to be aware
that some of our patients on chronic opioid therapy (COT) may develop
addictions and some may be diverting their medications (ie, giving them
to family and friends or selling them illegally).
(cid:2)SpringerInternationalPublishingSwitzerland2015 1
D.R.Taylor,ManagingPatientswithChronicPainandOpioidAddiction,
DOI10.1007/978-3-319-08111-3_1
2 • MANAGING PATIENTS WITH CHRONIC PAIN AND OPIOID ADDICTION
Many patients will continue to benefit from COT for a lifetime without
harm [7]. Indeed, one report suggests that while analgesic abuse may
be a growing problem, the prevalence rates of abuse and addiction
among patients with CP appear to be low (0.924% in patients with CP
who are prescribed opioids) [8]. This study would seem to belie recent
declarations of an opioid abuse/addiction epidemic in patients with CP
who are treated with opioids [9]. In my experience, the majority of patients
treated for addiction did not become addicted through a prescription
but rather through illicitly obtained drugs; however, it must be remem-
bered that anyone exposed to opioids for an extended period of time is
at risk for developing the disease of addiction. In my practice, there is
a small but significant subpopulation of patients who developed their
addiction during the course of CP management. Thus, physicians and
their multidisciplinary teams need to know how to monitor for, diagnose,
and manage addiction in patients receiving COT.
This book aims to discuss COT, how COTs can be used to treat CP,
and how to manage addictions in patients with CP. Additionally, adverse
events and risks of using COTs will be discussed as well as detecting
aberrant drug-related behavior in patients using COT.
References
1 World Health Organization supports global effort to relieve chronic pain. WHO News Release
2004. WHO. www.who.int/mediacentre/news/releases/2004/pr70/en/. Updated October 11,
2004. Accessed September 18, 2014.
2 Christa Harstall. International Association for the Study of Pain, How prevalent is chronic pain?
Pain clinical updates. 2003;11:1-4.
3 Institute of Medicine (IOM). Relieving Pain in America: A Blueprint for Transforming Prevention,
Care, Education, and Research. Washington, DC: The National Academies Press; 2011.
4 Grand rounds: prescription drug overdoses—a U.S. epidemic. Centers for Disease Control and
Prevention. www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm. Updated January 13,
2012. Accessed September 18, 2014.
5 Centers for Disease Control and Prevention/National Center for Health Statistics. National Vital
Statistics System. Drug poisoning deaths in the United States 1980-2008. NCHS Data Brief. 2011:81.
6 Becker WC, Tobin DG, Fiellin DA. Nonmedical use of opioid analgesics obtained directly from
physicians: prevalence and correlates. Arch Intern Med. 2011;171:1034-1036.
7 Watson CP, Watt-Watson J, Chipman M. The long-term safety and efficacy of opioids: a survey of
84 selected patients with intractable chronic noncancer pain. Pain Res Manag. 2010;15:213-217.
8 Roland CL, Joshi AV, Mardekian J, et al. Prevalence and cost of diagnosed opioid abuse in a
privately insured population in the United States. J Opioid Manag. 2013;9:161-175.
9 Remarkably low opioid abuse in pain patients. Pain Treatment Topics, Pain-Topics News.
updates.pain-topics.org/2013/08/remarkably-low-opioid-abuse-in-pain.html. Updated
August 24, 2013. Accessed September 18, 2014.