Chronic Pain and Concurrent Opioid Use Disorder

Key points for treatment of Opioid use disorder

• Stabilize with opioid agonist therapy (suboxone, methadone, sublacade, etc.)

• Limit carries (limit how much opioid is given at a time - 1 week dosages for ex.)

• Frequent urine drug testing

If patient has concurrent chronic pain and opioid use disorder, which do you treat first?

Treat OUD first, then chronic pain

Results of treating opioid use disorder

• Reduce opioid hyperalgesia

• Reduce tolerance

• Reduce withdrawal hyperalgesia

Key treatment points of chronic pain disease

• Non-pharmacological treatment (exercise, physiotherapy, psychology)

• Non-opioid therapy (Gabapentin, NSAIDs)

• Carries: enough until they see the doc next

• Less frequent urine drug testing

Chronic pain in canada

1/5 canadians live with chronic pain, with 1/3 of Canadians over the age of 65 living with chronic pain

31-55% of people with substance abuse disorder report chronic pain

Impact of chronic pain in Albert

Est. 940 000 people have chronic pain in AB, costing the AB healthcare system 1.2-1.7 billion (6-8% of provincial health expenditure)

Loss of alberta productivity due to chronic pain

3.4 to 4.7 billion dollars a year

How many people use opioids in alberta, and how many are considered problematic users

596 000 people use opioids as pain relievers, and 58 000 of them are considered problematic users

Chronic Pain WHO identification

Chronic pain is identified as its own disease, with a primary and secondary subset

What is primary chronic pain

Pain persists after the body has completely healed or no identifiable causes

Examples of primary chronic pain

Fibromyalgia, pelvic pain, musculoskeletal pain, lower back pain

What is secondary chronic pain

Pain occurring with an underlying disease or issue

Examples of chronic secondary pain

Cancer pain, post-surgical pain, rheumatoid arthritis

Course of back pain

Majority of people with backpain will have resolved pain in 2 weeks

• 90% of back pains will resolve in 6 months

• But 20-40% of people will have a flareup within the year

Use of using a baseline urine drug screen for chronic pain

Can display if patient has:

1. Substance use disorder

2. Chronic pain issue

3. Somewhere in between

Measures risk, monitors compliance

Use of monitoring patients on opioids with urine drug screens

Helps prevent the use of illicit opioids, and establishes a good patient doctor relationship

Benefit of using buprenorphine in elderly patients with chronic pain

Drug does not go through the kidneys (important in people with reduced kidney function)

If UDS baseline shows substance in it, what could this mean

Patient may be receiving opioids from illicit sources - could be opioid overuse disorder

If UDS monitoring shows no substance (even if given opioids) what could this mean

Patient is either not asking medication, or is using too much

Use of opioid risk tool

Administered to patients prior to beginning opioid therapy for pain management. Indicates risk of future opioid abuse

Why is cancer pain becoming more prevalent in medicine

Growing number of patients are surviving a cancer diagnosis with improved surgery, chemo, radiation

Why is morphine doses usually given at 90 mg or less for chronic pain

As opioid dose increases >100 mg, hyperalgesia worsens

Is hyperalgesia in opioid use related more to dose or propensity for OUD

Propensity for oud.

Patients with chronic pain who are at risk for OUD more likely to report increased pain sensitivity regardless of whether they were on no, low, or high doses

What is the main goal of chronic paon treatment

Goal is to improve function! NOT decrease pain.

Steps of chronic pain treatment:

1. Physical therapy

2. Psychological therapy

3. Safe drug prescriptions: NSAIDs, Steroids, SNRIs

Treatment of Fibromyalgia

Exercise, antidepressants, gabapentinoids

Use of opioids and cannabinoids in Fibromyalgia treatment

No convincing evidence of benefit, and should be avoided due to potential harms