Navigating Perception and Managing Expectations in a

Changing Prescribing Environment: Addressing the Need for an Opioid Taper and Managing

the Patient from an Integrative Approach

Rebecca Cogwell Anderson, PhD Professor, Department of Anesthesiology, Director, Integrated Mental Health, Pain Management Center, Medical College of Wisconsin, Milwaukee, Wisconsin

August 10, 2017

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Accreditation and Credit Designation

• Accreditation:

The American Academy of Pain Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

• Credit Designation:

The American Academy of Pain Medicine designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Speaker and Planning Committee Disclosures

Speaker:

Rebecca C. Anderson, PhD

Professor, Department of Anesthesiology,

Director, Integrated Mental Health, Pain Management Center,

Medical College of Wisconsin

No relevant financial relationships

Planners:

Larry C. Driver, MD

University of Texas Distinguished

Teaching Professor,

Professor, Department of Pain Medicine,

Professor, Section of Integrated Ethics,

The University of Texas M.D. Anderson

Cancer Center

No relevant financial relationships

Jennifer Westlund, MSW

Director of Education, AAPM

No relevant financial relationships

Angela Casey

VP, Medical Director, PharmaCom Group

No relevant financial relationships

Stephanie Lee

Meetings Manager, PharmaCom Group

No relevant financial relationships

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Target Audience

• The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction

• Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators

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Educational Objectives

• At the conclusion of this activity, participants should be able to:

1. Employ a strategy to communicate with patients about the rationale for an opioid taper

2. Describe several integrated approaches to the management of pain without the use of opioids

3. Formulate a plan to utilize integrative approaches into their practices with their patients

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Navigating Perception and Managing Expectations in a

Changing Prescribing Environment: Addressing the Need for an Opioid Taper and

Managing the Patient from an Integrative Approach

• Overview

Making the case to the patient

− Expectations and options

Opioid and Alcohol and Other Drug Abuse (AODA) treatments

Behavioral approaches to pain management

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Opioid-Induced Hyperalgesia (OIH)

• Opioid therapy can cause this condition, which results in heightened sensitivity to pain

• OIH occurs when increased use of opioids (e.g., morphine, oxycodone, hydrocodone) results in a reduced tolerance for pain and an increased sensitivity to discomfort

• Chronic pain sufferers may not understand that this is happening and may seek to increase their dosage

Bottemiller S. US Pharm 2012;37:HS2-7. Yi P, Pryzbylkowski P. Pain Med 2015;16:S32-6.

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OIH

• Patients, and even some providers, still think that raising the opioid dose will manage increasing pain levels

• It is not intuitive for patients to suggest dose reduction

Explain OIH to increase understanding of the need for a taper

• Be honest with patients

Let them know that pain will likely worsen before it improves and that tapers are not easy

• Tapers may be accomplished rapidly, moderately, or slowly depending on the situation

• After the taper, most patients report that:

Pain is no worse or even better

They are able to engage in their lives and relationships again

Bottemiller S. US Pharm 2012;37:HS2-7. Yi P, Pryzbylkowski P. Pain Med 2015;16:S32-6. Matthias MS et al. J Pain 2017;doi:10.1016/j.jpain.2017.06.008. Cunningham JL et al. Pain Med 2016;17:1676-85. Frank JW et al. Pain Med 2016;17:1838-47. Berna C et al. Mayo Clin Proc 2015;90:828-42.

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Other Reasons for Opioid Tapers

• Dose is too high to be safely tolerated

• Hx or development of substance abuse issues

• Patient may be taking other medications that make opioid medication more risky, such as benzodiazepines

• Patient may be referred on high doses and provider may not be comfortable with taking over the prescribing

Frank JW et al. Pain Med 2016;17:1838-47. National Academies of Sciences, Engineering, and Medicine. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. 2017. Lovejoy T et al. J Pain 2016;17:S87-8. Dowell D et al. MMWR Recomm Rep 2016;65:1-49. VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. V3.0. 2017.

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Provider Skills

• Establishing rapport

• Listening skills

• Serving as an educator

• Providing reassurance

• Explaining the plan and helping the patient feel less vulnerable

• Understanding the patient’s fears and concerns

Frank JW et al. Pain Med 2016;17:1838-47. Haas LJ et al. Am Fam Physician 2005;72:2063-8. Matthias MS et al. J Pain 2017;doi:10.1016/j.jpain.2017.06.008. VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. V3.0. 2017.

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Talking to the Patient about OIH or a Taper

• Confusion and questions

Patients may say:

− “Why is this an issue now? I’ve been safely taking this for years.”

− “Is it the government making you do this?”

− “Are you saying that you think I’m an addict or drug seeker?”

− “How do you plan to control my pain now?”

• Emotions abound:

Anger

Tears

Fears

Frank JW et al. Pain Med 2016;17:1838-47. Matthias MS et al. J Pain 2017;doi:10.1016/j.jpain.2017.06.008.

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Setting Expectations

• Reasonable expectations

We are talking about pain management, likely not pain elimination

The patient is not alone: support will be provided

• The time element: might be worse before it is better

• Set the expectation of a new and different way to manage pain, which could include multiple options:

Other medications (NSAIDs, topical agents, TCAs, SSRIs, SNRIs, muscle relaxers, anticonvulsants, etc.)

Procedures

Integrative approaches

CBT

Devices

Self-care by patient

• Sell the ideal of a sense of internal control on the part of the patient

Berna C et al. Mayo Clin Proc 2015;90:828-42. National Academies of Sciences, Engineering, and Medicine. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. 2017.

CBT=cognitive behavioral therapy NSAID=nonsteroidal anti-inflammatory drug

SNRI=serotonin-norepinephrine reuptake inhibitor SSRI=selective serotonin reuptake inhibitor

TCA=tricyclic antidepressant

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Some Patients May Have an Addiction to Manage

AODA treatment

approaches

Inpatient detox

IOP program or PHP

After-care programs (extremely important) Individual

therapy with an AODA counselor

AA, NA, SMART

Recovery, & other support

strategies

IOP=intensive out-patient program PHP=partial hospitalization program

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Case

• 26-year-old female with fibromyalgia and Ehlers-Danlos syndrome

• Long-term opioid use (multiple opioids tried) with increasing demands to increase dose

• Social issues:

Patient is very demanding and rude to providers

Family enabled patient to calm her mood

Patient is time consuming to provider/s

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Case

• Didn’t tolerate outpatient taper well:

Was sent to inpatient detox

Took everything she had on hand before scheduled admission

• Fought the detox, but after 6-7 days was discharged on no opioids or benzodiazepines and withdrawal Sx well managed

• At 2-week follow up admitted that:

Pain was no worse than when on high-dose opioids

She had more energy and could think more clearly

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Integrative Approaches to Pain Management in the Mental Health Area

Integrative approaches

to pain management

CBT Guided

imagery, hypnosis, & mindfulness

Lifestyle enhancement

& balance

Biofeedback and use of

Apps

Nutrition & diet

Exercise & movement

Stress management

Sleep enhancement

Acupuncture, massage, & chiropractic

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Cognitive Behavior Therapy (CBT)

• A form of therapy that uses the link between thoughts and behaviors to change feelings, practices, and/or behaviors

• One of the most useful non-procedure approaches to aiding management of chronic pain

• There are variations of CBT with empirical evident to support benefit

Ehde DM et al. Am Psychol 2014;69:153-66. Jensen MP, Turk DC. Am Psychol 2014;69:105-18. Thoma N et al. Psychodyn Psychiatry 2015;43:423-61.

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Variations of CBT

• Acceptance and commitment therapy (ACT)

Makes use of CBT approaches

Teaches patient skills for coping

• Dialectic behavior therapy (DBT)

Utilizes CBT approaches

Employs skills

− Mindfulness

− Distress tolerance

− Emotional regulation

− Interpersonal effectiveness

McCracken LM, Vowles KE. Am Psychol 2014;69:178-87. Linton SJ. Scand J Pain 2010;1:50-4. Thoma N et al. Psychodyn Psychiatry 2015;43:423-61.

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Variations of CBT

• Behavioral Activation (BA)

Developed to treat depression, which is often co-morbid with pain

Treats inertia, avoidance, and is generally short term

• Motivational Interviewing (MI)

Has gained favor in the treatment of substance abuse

A therapeutic approach that attempts to move an individual away from a state of indecision or uncertainty and towards finding motivation to making positive decisions and accomplishing established goals

Allows the therapist to work with the patient in a collaborative manner and places the power with the client

Reims K et al. Brief Action Planning: A White Paper. 2013. Hope, BC, Centre for Comprehensive Motivational Interventions. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: The Guilford Press, 2013. Vong SK et al. Arch Phys Med Rehabil 2011;92:176-83.

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Biofeedback and Use of Apps

• Biofeedback

Galvanic skin response (GSR)

Thermal biofeedback

Electromyogram (EMG) biofeedback

Heart rate variability (HRV) biofeedback

• Apps

Relaxation and imagery

Exercise, yoga, and movement

Mindfulness and meditation

Apps to be used with biofeedback programs

Apps to provide reminders related to lifestyle and tracking progress

Sielski R et al. Int J Behav Med 2017;24:25-41.

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Biofeedback

• Equipment is reasonably priced and home units are available

• Biofeedback focuses on reduction of sympathetic nervous system arousal

• Very little downside and essentially no negative side effects

• A level of commitment is required from the patient

Patients who demonstrate commitment often gain a sense of control

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Clinic Biofeedback Experience

• Using a HRV biofeedback approach with chronic pain patients

• After just 3 biofeedback sessions patients consistently reported reduction in both pain and distress from the beginning to the end of the session

• After completing 3 biofeedback sessions there was a significant reduction in pain catastrophizing as measure by the Pain Catastrophizing Scale

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Guided Imagery and Hypnosis

• Generally pleasant and entertaining

• Easy to participate in for most patients

• Involves guiding patient through use of their imagination to relax and reduce pain

• An inexpensive approach to:

Reduce dependence on medication

Reduce pain levels

Increase coping

• Can be supported by:

Imagery recordings made during the session for home practice

Recordings made by provider

Recordings available for purchase

Jensen MP, Patterson DR. Am Psychol 2014;69:167-77.

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Mindfulness

• Mindfulness and meditation: a mind-body experience

Involves learning to calm the mind without judgment and being open to the experience

Involves self compassion and acceptance

Utilizes a mindful body scan that teaches how to lean gently into discomfort

− This seems counter-intuitive, however, it reduces the unwelcome sensations’ power to derail patients experiencing pain

Literature is impressive regarding efficacy in treating pain

Cherkin DC et al. JAMA 2016;315:1240-9. Zgierska AE et al. Pain Med 2016;17:1865-81. Doran NJ. Qual Health Res 2014;24:749-60.

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Lifestyle

• Breath work:

e.g., the 4-7-8 breath: breathe in for count of 4, hold for count of 7, and out for count of 8

• Sleep hygiene:

Improving sleep is a powerful way to manage pain and the fatigue associated with poor sleep

• Diet and weight control:

Lack of activity and medication side effects associated with weight gain in pain patients

A healthy diet increases energy and reduces weight gain

• Exercise and movement:

So important yet such a challenge

• Smoking cessation:

Benefits of smoking cessation extremely impressive in multiple areas

• Stress management:

Reducing stress when possible and managing the stress that can’t be changed

• Self care:

Encouraging self care gives patient a sense of control and self worth

• Pacing:

Learning to avoid overdoing it while at the same time being engaged

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Sample Integrated Approach for a Fibromyalgia Patient

• Physician to offer:

Other medication options: SNRIs, TCAs, neuromodulators, etc.

Therapies: PT, OT, hydrotherapy, etc.

Procedures

• Lifestyle:

Nutrition consult

Pacing of activities

Movement activities such as exercise, yoga, tai chi, etc.

• Mental health to offer options such as:

CBT

Stress management

Biofeedback

Motivational approaches

Mindfulness

Imagery

Pacing

OT=occupational therapy PT=physical therapy

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How to Bring up the Mental Health Referral

It’s important for you to know that the referral doesn’t mean that the pain is in your head or that your doctor doesn’t know that your

pain is very real. The psychology team will assess your current stressors and how they interact with your pain and provide

recommendations and treatments to assist you in coping and living the most productive life you can even if your pain persists. The

psychology team offers cognitive behavioral therapy approaches to help with the management of your pain. Such approaches have been

studied extensively for decades and have been found to provide significant benefit for treating pain. They will help to decrease the impact of depression, anxiety, and worry related to pain and work

with you to identify environmental, personal, relationship, financial, employment, and other factors that limit your ability to obtain the

best pain management and discuss ways to address these factors. You’ll work with them to increase motivation and remove barriers so that you can improve function and enhance

quality of life as you treat your pain condition.

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Summary and Recommendations

• Patients are often scared and feel desperate

Desperate people say and do desperate things

• Provider’s approach is invaluable

• Expectations should be clear and reasonable and may need to be repeated or provided in written form

• The patient needs a plan or fear is increased, which escalates the problem

• An integrated approach with patient buy in and active participation can result in not only improved pain control, but enhanced quality of life for the patient

References

• Berna C et al. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc 2015;90:828-42.

• Berry ME et al. Non-pharmacological intervention for chronic pain in veterans: a pilot study of heart rate variability biofeedback. Glob Adv Health Med 2014;3:28-33.

• Bottemiller S. Opioid-induced hyperalgesia: an emerging treatment challenge. US Pharm 2012;37:HS-2-7.

• Cherkin DC et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA 2016;315:1240-9.

• Cunningham JL et al. Opioid tapering in fibromyalgia patients: experience from an interdisciplinary pain rehabilitation program. Pain Med 2016;17:1676-85.

• Doran NJ. Experiencing wellness within illness: exploring a mindfulness-based approach to chronic back pain. Qual Health Res 2014;24:749-60.

• Dowell D et al. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. MMWR Recomm Rep 2016;65:1-49.

• Ehde DM et al. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol 2014;69:153-66.

• Frank JW et al. Patients' perspectives on tapering of chronic opioid therapy: a qualitative study. Pain Med 2016;17:1838-47.

• Haas LJ et al. Management of the difficult patient. Am Fam Physician 2005;72:2063-8.

• Jensen MP, Turk DC. Contributions of psychology to the understanding and treatment of people with chronic pain: why it matters to ALL psychologists. Am Psychol 2014;69:105-18.

• Jensen MP, Patterson DR. Hypnotic approaches for chronic pain management: clinical implications of recent research findings. Am Psychol 2014;69:167-77.

• Linton SJ. Applying dialectical behavior therapy to chronic pain: a case study. Scand J Pain 2010;1:50-4.

References

• Lovejoy T et al. (453) Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. J Pain 2016;17:S87-8.

• Matthias MS et al. "I'm not gonna pull the rug out from under you": patient-provider communication about opioid tapering. J Pain 2017;doi:10.1016/j.jpain.2017.06.008.

• McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol 2014;69:178-87.

• Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. The Guilford Press, 2013.

• National Academies of Sciences, Engineering, and Medicine. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. 2017.

• Reims K et al. Brief Action Planning: A White Paper. 2013. Hope, BC, Centre for Comprehensive Motivational Interventions.

• Sielski R et al. Efficacy of biofeedback in chronic back pain: a meta-analysis. Int J Behav Med 2017;24:25-41.

• Thoma N et al. Contemporary cognitive behavior therapy: a review of theory, history, and evidence. Psychodyn Psychiatry 2015;43:423-61.

• VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. Version 3.0. 2017.

• Vong SK et al. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Phys Med Rehabil 2011;92:176-183.

• Yi P, Pryzbylkowski P. Opioid induced hyperalgesia. Pain Med 2015;16:S32-6.

• Zgierska AE et al. Mindfulness meditation and cognitive behavioral therapy intervention reduces pain severity and sensitivity in opioid-treated chronic low back pain: pilot findings from a randomized controlled trial. Pain Med 2016;17:1865-81.

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PCSS-O Colleague Support Program and Listserv

• PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications.

• PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management.

• Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties.

• The mentoring program is available at no cost to providers.

• Listserv: A resource that provides an “Expert of the Month” who will answer questions about educational content that has been presented through PCSS-O project. To join email: pcss-o@aaap.org.

For more information on requesting or becoming a mentor visit:

www.pcss-o.org/colleague-support

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PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in

partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology

(AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP),

American College of Physicians (ACP), American Dental Association (ADA), American Medical

Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American

Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN),

International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance

Abuse Training (SECSAT).

For more information visit: www.pcss-o.org

For questions email: pcss-o@aaap.org

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no.

5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and

moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade

names, commercial practices, or organizations imply endorsement by the U.S. Government.

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