INTRODUCTION: MANAGEMENT OF PATIENTS WITH HIGH DOSE OPIOID

Patients with high dose opioid usage present a medical problem.  If the patient is addicted, further administration of opioids is illegal. If addiction is suspected, how are the doses decreased? Fast reduction in a patient with cardiac, hypertension, psychiatric or other medical problems may in itself present new problems. If the person is a pain patient with addiction, what is then done? At this time we do not have all of the answers, but we hope to give you some information with which to start with in addressing this community crises.

Patients on high doses of narcotics may represent one of three groups or a mixture. These are addiction, diversion and pain patients. Physicians have a bias of seeing many as pain patients, whereas in this group in Vancouver, addiction and diversion may account for over 50% by DEA estimates. Addiction is treatable but diversion is not. Unfortunately, they often come hand in hand.

When the patient is in your office you have four choices: detox, office based treatment with Suboxone, methadone treatment in a licensed facility (not in your office) or dose reduction and continued pain treatment at lower doses. 

DETOX
Most physicians are concerned with the acute withdraw, the first week or so, with nausea, diarrhea and tremors. This is however only a small part of the problem. Opioid administration, whether by prescription or street, will produce profound changes in the nucleus accumbens and ventral tegmentum (VTA) dopaminergic cell bodies which persists, following the acute withdraw. These changes may last 6-9 months and represent a clinical condition referred to as Post Acute Withdraw Syndrome (PAWS).

Unfortunately, for some individuals, this is irreversible, giving reason to the caution in opioid administration. In this PAWS time period, relapse is the norm without other means of treatment. Detox alone is not the answer. Detox alone only has a chance of working if it combined with an intensive followup program. This is best done by a community resource such as Columbia River Mental Health and Northstar, where intensive follow up treatment is available. This is not to say it cannot be done in the physician's office with outpatient counseling, but the success rate is very low and the pain for the provider and patient may be high.

MEDICAL TREATMENT
The traditional model has been the licensed methadone clinic where the patient goes daily for their medication.  In Vancouver we have two: Northstar Clinic of Columbia River Mental Health, and a private facility, Vancouver Treatment Solutions.

Suboxone is a new office based program used by family physicians, pain physicians and others in the treatment of addiction. Dr. Nora Volkow, NIDA Director, noted "It allows physicians to treat patients for this disease in the same manner that other people are treated for such other chronic illnesses as diabetes or high blood pressure."

SUBOXONE
Suboxone is a prescription partial agonist, which is now used in the office based treatment of addiction. A patient may be switched directly from his high dose oxycodine and other narcotics to Suboxone and then slowly tapered off in the following months as part of a treatment program. Suboxone (bupernorphine) has some unusual characteristics:

• Only absorbed under the tongue. Eating and swallowing does nothing.
• Urges stop.
• Blocks other opioids. Oxycodine, morphine and others are blocked.
• Produces very little europhic high.
• If taken with other opioids in the system they get immediate withdraw.
• Administered one time daily.
• Cannot be administered IV due to the naloxone in Suboxone.
• Blocks itself over 32 mg, giving a safety overdose factor.

Patients report:

• Feeling normal: "I can think for the first time." (Bupernorphine does not metabolize into morphine as do other narcotics.)
• Urges are gone.

Below I have included three links from the NIDA database.  They are a short, quick read.

www.drugabuse.gov/newsroom/08/NR11-04.html

www.ncbi.nlm.nih.gov/pubmed/12954743

www.drugabuse.gov/Newsroom/03/NR9-03.html

It is recommended that all physicians who prescribe significant narcotics be familiar with Suboxone and become Suboxone certified.  This can be done over the web: www.buprenorphine.samhsa.gov/pls/bwns/training

Please consider becoming Suboxone certified. Addiction is now a disease that often can be treated in an office setting. Not treating addiction is to ignore our responsibilities as physicians and allow the problem to effect not only the patient, but the community. When patients are on Suboxone, they are easy to manage and a pleasure to work with.  Patients with addiction, on full agonist opioids, with unrecognized addiction, produce problems for the community, physicians and our office staffs.

If you have questions, contact Barbara Stampke, the area Suboxone clinical liaison at 503.791.3774. She is very knowledgeable. Barbara.Stampke@reckittbenckiser.com

I am also available to answer your questions and will assist you in treating your patients and getting started: John Hart, DO, 360.514.3142

The certification is done over the web. Please let Barbara know if you have completed the web training. She will contact the DEA and your approval will be put on a fast track.   The DEA is very supportive of assisting you.

MEDICAL REDUCTION
For those patients who it is felt should be on opioids, but with much lower doses, a reduction of 5% a day may be done or even much slower, as is done in methadone treatment. In extremely high doses of opioids, this may not be practical and a more aggressive reduction may be necessary. In treating pain, opioids are often increased by about 25% to get pain relief. Reduction may be may be done in a similar fashion. A common number used is a 20% or greater reduction per day, week or month depending on the situation.

It should be expected the patient will have some partial withdraw symptoms, which may be treated with clonidine  0.1 mg 1-2 q 4-6 hrs, phenergan 25 mg 1-2 q 4-6 hrs nausea and trazadone for sleep each time there is a dosage decrease. For some patients, administration of a clonidine TTS-1 patch for a few weeks or a month may be of value.  Expect sleep problems, anxiety and depression to emerge. Treat these but try to avoid benzodiazepines and Soma.

In doing medical reduction in pain patients, addiction will often come to light.  When that is felt to be true, referral to an addiction program, methadone clinic or for the office treatment of addiction with Suboxone is indicated.  

APPROACHES TO THE MEDICAL TREATMENT OF PAIN

Traditional - Long acting plus short acting
 Pro- We understand how to do this presently- Level of comfort for the physician
         Effective for many patients
 Con- Physician assumes the full responsibility of pain/comfort for the patient
Short acting overuse
Dosages tend to increase
Street value high

Modified Traditional - Long acting only  No short acting or breakthrough medications
 Pro- Patient is responsible for life modification when pain increases
         Dosages tend to stay more stable
                    No short acting overuse
 Cons-  Requires discussion to switch from short acting
            Street value high

For pain patients, consider the Modified Traditional particularly if they are higher risk.  Short acting opioid, such as breakthrough medications, tend to produce more feelings of urges to use and therefore higher long term dosages.

RISK FOR OPIOID PROBLEMS
There is much written on this subject, but keep in mind if the risk assessment requires an answer from the patient, the addicted individual will usually give the "correct" answer. 
Here are some questions which may help in sorting out patients.

1. At what age did you start smoking? Smoking at age 15 or earlier may alter the dopamine system placing them at higher risk for opioid problems (surprisingly sensitive).
2. Males: Were you hyperactive or ADD?
3. Which members of your family were the heaviest users of alcohol or pain medications?
4. Personal history of previous addiction including alcohol?

When one or more of these are positive, think addiction first and pain second.

These are a few of the behaviors that tip me off about my present patients. Often the office staff will pick them out before the physician or provider.

• They cause problems with our receptionist or staff. Demanding or rude.
• Pain behavior. Slowly walking, hand over back, grunting sounds. Think addiction first, pseudo addiction second. If you were deaf and could not hear their story, could you pick them out by observing?
• Overly kind. They want all of your office to be their good friend.  My "best" patients but just over the top. These "very, very nice patients" are possibly diverting drugs. They will give you no reason to "fire them" as it is a business.

Next week I will send out information on the pros and cons of treating axial back pain with chronic opioids.

Written by John Hart, D.O.
Reviewed by Michael Bernstein, MD

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