In this episode of PodMD, Pain Medicine Physician and Interventional Pain Specialist Dr Akilan Velayudhan will be discussing the topic of dealing with complex pain patients on long-term opioid therapy.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Akilan Velayudhan, an Australian-trained Pain Medicine Physician and Interventional Pain Specialist with an interest in spinal, nerve, joints and extremities pain.
Dr Velayudhan has experience in practising as a Pain Specialist working in a multidisciplinary team for over 10 years in Australian, UK and Canada. He is currently providing care in Bundoora, Epping, Werribee and surrounding areas in Victoria.
Dr Velayudhan has Fellowships from Royal College of Australian and New Zealand College of Anaesthetists, Royal College of Anaesthetists from U.K and Ireland. He is also a Fellow of Interventional Pain Practice from World Institute of Pain and in addition has Pain Fellowship from Australian and New Zealand College of Anaesthetists.
He strongly believes in a holistic approach in chronic pain management and uses various pharmacological and non-pharmacological strategies such as interventional therapy, physical therapy and psychological approach in the overall management of chronic pain.
Today, we’ll be discussing the topic of dealing with complex pain patients on long-term opioid therapy.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Dr Akilan Velayudhan, thanks for talking with us on Pod MD today.
Akilan: Hello everyone. Thanks for having me.
Can you describe for our listeners who is a complex pain patient and when is someone like this on long-term opioid therapy?
Akilan: Complex pain is defined as a pain that is present for more than three months and is impacting on a person’s physical and/or psychological functioning. In addition to that, it is normally patients who have not responded to routine conservative management, and multiple investigations have ruled out serious pathology. So, in terms of long-term opioid therapy, this is someone who’s been on opioids for more than 90 days, but this threshold can range from a few months to a few years. Definitions also vary in terms of the frequency of use, whether it’s consistent daily dosing versus intermittent use, and if use is self-reported or based on dispensing records.
Question 1
How would a patient with chronic non-cancer pain on long-term opioid typically present?Akilan: It depends upon the age group of the patient. If you look into the POINT study, which is a pain and opioid in-treatment study that looked into a group of 1500 people who’ve been prescribed pharmaceutical opioids for chronic pain, a 2-year prospective cohort study. It investigated the participants who had been in pain for over 10 years and had been on prescription opioids for approximately 4 years. The study concluded that one in ten individuals was on a daily morphine equivalent and a daily dose of more than 200 milligrams. When they investigated the employment and income levels, they appeared to be of low socio-economic status, while the pain was having a significant impact on their employment status. When they screened into the mental health aspect, they found that 50% of these patients had moderate to severe depression and one in five had a lifetime suicidal attempt. In terms of the age-related difference, what the study had shown is that the younger groups experience higher levels of pain and pain interference, more mental health and substance use, and barriers to treatment compared to the older group. Overall, what the study found is that people who had been prescribed strong opioids for chronic pain had very complex demographics and clinical profiles. It also mentioned the major age-related differences in experiences of pain, coping, mental health, and substance use, suggesting the necessity of different approaches to treatments.
Question 2
What are the adverse effects of being on long-term opioid therapy?Akilan: In terms of the adverse effects from being on long-term opioid therapy, there’s mounting evidence to suggest that opioids are less effective for persistent pain than in acute pain. It has also shown that they help in reducing only 30% of pain in opioid-sensitive patients, and only very minimal help in neuropathic pain states. The most important thing is none of the studies reviewed so far with regard to opioid use ever lasted for more than 16 weeks. So, there is a big gap in terms of the long-term efficacy. There are also no randomised controlled trials on the long-term effectiveness of opioid use in chronic non-cancer pain. Another adverse effect is unexplained death. This is more so relating to the daily dose of opioids. What the studies have shown so far is that someone who has been on 100 milligrams of oral morphine per day is at twice the risk of death, and if there are more than 200 milligrams, the results indicated the risk of death increases threefold. The risk further increases when people use other sedative agents like benzodiazepines, alcohol, cannabis, and antihistamines. Besides this, there are other side effects including hypothalamic-pituitary axis suppression leading to reduced testosterone and aids. Other following effects include loss of libido, sexual dysfunction, infertility, muscle weakness, fluid retention, osteoporosis, and fractures. Other very important adverse side-effects in relation to opioids is opioid-induced ventilatory impairment. It is recommended that patients who require more than 50 milligrams of methadone or 150 milligrams of morphine equivalent per day should be referred for a formal sleep apnoea evaluation. It is also recommended to advise patients to decrease their daily opioid dose by at least 30% during an acute respiratory tract infection or asthmatic episode for safety reasons. The other side effects noted were opioid-induced hyperalgesia, where higher doses of opioids can make the pain experience more severe, and weaning opioids have shown to improve pain levels with fewer side effects. The important thing is, particularly in relation to the cognitive impairment, is it can affect the ability to drive. For example, the South Australian Drugs of Dependence Unit suggests a formal driving test is needed for drivers who need a daily dose of more than 200 milligrams of oral morphine equivalent. The other common side effects include constipation, which does not resolve over time, and there is an obvious increased risk of physical dependence and withdrawal reactions. Opioids do affect mood and levels of motivation, and this is quite evident from a lot of studies which have shown prescribing higher doses of opioids increases the risk of depression, bipolar, and anxiety disorders, particularly with its prolonged use.
Question 3
What are the treatment options?Akilan: The treatment options usually encompass a multidisciplinary approach, addressing comorbid mental health issues and teaching non-medication strategies for dealing with pain, with the principles mainly involved around pacing and this could include referral to the psychologist and physiotherapist. Another treatment option is identifying patients who are at risk of harm and strategies for minimising harm. Therefore, if the patient has persisting pain despite being on opioids, consider weaning opioids by a rate of 10% every one to two weeks to minimise side effects. The Faculty of Pain Medicine, in relation to opioids, mentions that the modified release of opioid products is indicated for the management of severe pain where one other treatment option has failed or is contraindicated, not tolerated, or otherwise inappropriate to produce sufficient management of time and number two, where the pain is opioid responsive and number three, where they need daily medications and the condition needs continuous and long-term treatment.
Question 4
How do you monitor patients on long-term opioid therapy for chronic non-cancer pain?Akilan: In terms of monitoring patients on long-term opioid therapy, it’s basically contingent upon firstly the demonstration of benefits such as increasing function as determined by an agreed activity or goal. Secondly, active surveillance of harms, and thirdly periodic attempts at dose minimisation. Another option is to investigate the five ways of opioid therapy, which looks into analgesia, activity, adverse effects, affect, and abhorrent behaviour.
Question 5
Are there any warning signs a GP should look out for?Akilan: In terms of the warning signs that a GP should look for, one is recognising patients who are presenting high signs of high-risk opioids and the second is recognising yellow flag signs. In trying to identify someone as being at high risk of opioids, you need to look into patients who have been prescribed other psychoactive medications, such as benzodiazepines, gabapentin, anticonvulsants, or antipsychotics, patients who have an active substance use disorder or younger people who have substance use issues and they are usually less than 35 years of age, and patients without a definitive pathology. Finally, patients with active psychiatric or mental health problems also fall in this category. In terms of recognising someone yellow flags, this is often used in chronic pain management and it refers to the psychosocial indicators that suggest an increased risk of progression to long-term distress and disability. They include attitudes or beliefs about pain, having unrealistic expectations about pain management, including access to opioid medications. It could also include depression, anxiety, and patients having a passive approach to rehabilitation activity and unsupportive families/social networks.
Question 6
How do you work with inherited or opioid legacy patients?Akilan: We tend to say inherited or legacy patients may present from other practices or prescribers requiring or requesting continuation of the long-term opioid prescriptions. In those patients, normally they are managed using a comprehensive clinical assessment which would include psychosocial assessment, confirmation of a pain diagnosis, establishing if the continued prescription is appropriate, using appropriate opioid responding tools, considering alternatives to opioid prescribing, visiting patients engagement with self-management strategies, verifying any concerns about misuse or opioid dependence with previous prescribers or pharmacies, or utilising the real-time prescription monitoring.
Question 7
What are GPs’ prescription obligations when it comes to these patients?Akilan: In terms of the GP’s accountability for prescribing opioids, I would say it’s firstly staying vigilant for any early signs of patients’ dose escalation and those requesting renewal for lost scripts. Secondly, looking for patients responding to yellow flags of high-risk use. Thirdly, having strategies in terms of providing a state supply of opioid prescriptions. Also included would be the obtaining of scripts from one doctor and one pharmacy and attending scheduled appointments. Perhaps this could be facilitated by using an opioid contract and continuing or coordinating care with officials who specialise in pain management under opioid use disorders.
Question 8
What role does the GP play in the treatment of the condition?Akilan: I would say a patient-centred pain management plan should specify realistic treatment goals under a time frame for reaching each goal and in the setting of containing opioid therapy. Monitoring opioid therapy with the five ways which was discussed earlier and staying vigilant for early signs of aberrant drug behaviour. As well as the use of take-home naloxone mixed with harm reduction strategies and patient-centred care.
Question 9
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast?Akilan: I would say the three take-home messages are number one, recognising patients who are at high risk of opioid use. Number two, prescription of opioids is contingent upon demonstration of benefits such as increasing functionality as determined by an agreed activity, goal or set of activities, and using five ways of opioid therapy. Number three, when the harm of taking an opioid prescription outweighs the perceived benefits, a comprehensive tapering plan agreed upon by patients and prescribers will be needed.
Thanks again for your time and the insights you’ve provided.
Akilan: Thank you.
