San francisco safety net chronic pain management education day
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San Francisco Safety Net Chronic Pain Management Education Day. Finding Common Ground in the Gray Zone. Welcome!. Why are we here today?. Why are we here today?. Objectives. Identify and manage risk factors for opioid misuse Respond to patient behaviors that are concerning for opioid misuse

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San Francisco Safety Net Chronic Pain Management Education Day

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San francisco safety net chronic pain management education day

San Francisco Safety Net Chronic Pain Management Education Day

Finding Common Ground in the Gray Zone



Why are we here today

Why are we here today?

Why are we here today1

Why are we here today?



  • Identify and manage risk factors for opioid misuse

  • Respond to patient behaviors that are concerning for opioid misuse

  • Support patients in managing substance use disorders

  • Examine systems-level interventions that support safe pain management

  • Develop policies or procedures in your own clinic to improve pain management practices

Shape of the day

Shape of the Day

  • Keynote

  • Case-based panel

  • Break

  • Lecture

  • Lunch

    • Facilitator breakout

  • Small Groups

  • CURES Table



None of the speakers have financial disclosures to report

Managing the risks of opioid prescribing

Managing the Risks of Opioid Prescribing

Mr anderson

Mr. Anderson

  • 46 year old man discharged from LHH 8 days ago

  • Requesting refill of pain medications

  • Hospitalized 4 mo ago s/p MVA

    • Right femur fracture

    • Pelvic fracture

    • Multiple rib fractures

    • s/p surgical fixation of fractures

    • BZD, EtOH, opiates in blood and urine drug test

Mr anderson1

Mr. Anderson

  • Discharged to Laguna Honda

  • Discharged from rehab 8 days ago

  • Currently with pain in right leg, right chest

  • Leg pain constant ache, worst in cold

    • Able to walk 2 blocks

    • Increased irritability due to pain

    • Poor sleep

Mr anderson2

Mr. Anderson

  • Medications:

    • MS contin 100mg TID

    • Oxycodone 30mg q6 hrs PRN

  • No change in this regimen over 10 weeks at LHH

Mr anderson3

Mr. Anderson

  • Drank 2-4 beers daily before accident, none since

  • h/o heroin use, none for 3y before accident

  • Occasionally buys prescription opioids on the street, had taken Morphine the day before the accident

  • Occasional benzodiazepine use “when they’re around”

  • 1 ppd cigarettes

  • Unemployed, on GA, applying for disability

  • Mother with cocaine and EtOH dependence

Who is at high risk for harm from opioids

Who is at high risk for harm from opioids?

Characterizing risk of opioid misuse

Characterizing Risk of Opioid Misuse

What we don t want

What We Don’t Want

Opioid Use Disorder (abuse, dependency)

I prescribe opioids to my patient



How common is the bad stuff

How Common is the Bad Stuff

Fishbain et al. Pain Medicine; 9(4): 444-59. 2008

Risk assessment

Risk Assessment

  • Purpose of Risk Assessment

    • Prior to initiation of opioids

    • Ongoing monitoring

  • How to do it

    • Formal instruments

    • Clinical evaluation

  • Underlying principle: universal precautions

  • Guidelines (APS, AAPM), 2009

Chou et al. 2009. Journal of Pain. 10(2): 113-30.

Risk assessment instruments

Risk Assessment Instruments

  • Lots of them

    • Screener and Opioid Assessment for Patients with Pain (SOAPP) – 24 items

    • Pain Medication Questionnaire (PMQ) – 26 items

    • Prescription Drug Use Questionnaire –Patient Version (PDUQP) – 24 items

    • Opioid Risk Tool (ORT) – 5 items

    • Diagnosis, Intractability, Risk, Efficacy (DIRE) – 7 items

    • Alturi & Sudarshan – 6 items

Two options opioid risk tool ort

Two Options: Opioid Risk Tool (ORT)

  • Scoring patients:

  • low risk (0-3)

  • medium (4-7)

  • high (≥ 8)

  • High risk:

  • 91% sensitivity for ADRB

  • Positive LR 14

Webster LR, Webster RM. Pain Med. 2005;6(6):432-442

Second option

Second Option

Not willing to try non opioid modalities

Always asking about opioids (inc 1st visit)

Upset when denied opioids

Requesting particular med

  • Atluri Tool

    • 6 clinical criteria

      • Focus on opioids

      • Opioid overuse

      • Other substance use

      • Low functional status

      • Unclear etiology of pain

      • Exaggeration of pain

    • Score >3 OR of 16 for opioid misuse

ER visit for pain; Use up own supply too fast

History of drug/EtOH abuse

Currently using marijuana

Feels need for benzos

On disability or applying

Pain “everywhere”

Non-physiologic distribution

Atluri SL et al. Pain Physician 2004; 7:333-338.

Risk assessment tools

Risk Assessment Tools

  • Clinical Evaluation

    • Pain clinic study comparing: SOAPP-R, ORT, PMQ and a 45-min semi-structured interview with a psychologist

    • Psychologist’s evaluation of risk was the most sensitive predictor for later discharge from pain clinic

      • Note: psychologist had 27 years of clinical experience

        • 6 years in substance abuse

Jones et al. The Clinical Journal of Pain. 2012; 28(2): 93-100.

Substance use screening

Substance Use Screening

  • Single Item screeners

    • NIDA: “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”

    • NIAAA: “How many times in the past year have you had more than 4/3 drinks in a day?”

Substance use screening1

Substance Use Screening

Our patient

Our Patient

ORT score:


Second option1

Second Option

Not willing to try non opioid modalities

Always asking about opioids (inc 1st visit)

Upset when denied opioids

Requesting particular med

  • Atluri Tool

    • 6 clinical criteria

      • Focus on opioids

      • Opioid overuse

      • Other substance use

      • Low functional status

      • Unclear etiology of pain

      • Exaggeration of pain

    • Score >3 OR of 16 for opioid misuse

ER visit for pain; Uses up own supply too fast

History of drug/EtOH abuse

Currently using marijuana

Feels need for benzos

On disability or applying

Pain “everywhere”

Non-physiologic distribution

Atluri SL et al. Pain Physician 2004; 7:333-338.

What to do with the risk evaluation

What to do with the risk evaluation?

Atluri et al. Pain Physician; 2012; 15: ES177

Our patient1

Our Patient

  • High risk for “ADRBs”

    • Options

      • Taper off opioids

      • Continue opioids with close monitoring

        • Frequent Utox (q month)

        • Short refill interval (q 2 weeks)

        • Frequent CURES report (3-4 times per year)

        • Patient Agreement and Informed Consent with explanation of reasons for discontinuation (i.e. no show, refusal of alternative treatments, abnormal Utox results)

How do we assess and understand the impact of psychosocial issues on the pain experience

How do we assess and understand the impact of psychosocial issues on the pain experience?

Psychosocial assessment

Psychosocial Assessment

  • Brief Intervention vs.

    Detailed Psychosocial Assessment

  • Brief Intervention in Primary Care Behavioral Health

    • Review presenting problem/referral question

    • Assess/strengthen supports

    • Identify/build coping skills

Detailed psychosocial assessment may be gathered over time by various team members

Detailed Psychosocial Assessment(may be gathered over time by various team members)

  • Presenting problem/referral question

  • Culture/family history

  • Educational/work history

  • Relationship history/interpersonal issues

  • Trauma history

  • Substance use history

  • Psychiatric/medical history

  • Current:

    • Symptoms

    • Supports

    • Coping skills

Mr anderson s psychosocial assessment

Mr. Anderson’s Psychosocial Assessment

San francisco safety net chronic pain management education day

  • Culture/family history

    • Born in Ohio, family background Irish/German/Danish

    • No strong cultural/religious affiliations

    • Middle of 3 kids, father left when pt. was 7

    • Mother and siblings moved around

  • Educational/work history

    • Completed 10th grade, fair grades

    • Has worked odd jobs,

    • mostly house painting

    • Currently on GA, in SRO

San francisco safety net chronic pain management education day

  • Relationship history/interpersonal issues

    • Married twice, now lives with female partner

    • History of anger management problems including

    • IPV with partners

    • No longer speaks to siblings

    • Feels angry/disappointed with medical

    • system for not curing his pain

  • Trauma history

    • Vague memories of IPV between parents, mother verbally and physically abusive, sexual assault by an older man age 11

San francisco safety net chronic pain management education day

Substance use history

  • ”I’ve tried everything”

  • Drank 2-4 beers daily before accident, none since

  • •  H/O heroinuse, none for 3 years •Occasionally buys prescription

  • opioids on the street (Morphine) • Occasional benzodiazepine use  

  • 1 ppdcigarettes

San francisco safety net chronic pain management education day

  • Psychiatric history

    • Long history of depressive sx, “I’ve been depressed all my life”

    • No history of manic episodes, no psychiatric hospitalizations

    • On various antidepressants with little effect

    • Intermittent suicidal ideation, one non-lethal gesture as adolescent

Current symptoms

Current Symptoms

  • Depressed feelings, feeling “empty”, feeling like no one cares/no point in living, but no clear suicidal plan

  • Reports daily “mood swings”, but not mania

  • Feels that pain is intolerable, nothing helps

  • Angry that “system” is not helping him, feels abandoned by medical team for “withholding” medication

Psychosocial assessment strengths

Psychosocial Assessment: Strengths

  • Support

    • Has female partner of 3 years

    • Has one “buddy” he sees quite regularly

  • Coping skills

    • Intelligent, resourceful

    • Reasonably good eating/exercise habits

    • Has managed to reduce/abstain from substances since the accident

    • Can respond to encouragement, support

Psychosocial assessment findings

Psychosocial Assessment: Findings

  • Does NOT currently meet criteria for major depression, more likely dysthymia

  • Not acute PTSD (“complex PTSD”)

  • Borderline personality features

    • Mood instability

    • Interpersonal issues, extremes

    • Impulse control problems, suicidal thoughts/gestures

    • Chronic feelings of emptiness

    • Expectation/fear of abandonment

Patient s experience of pain

Patient’s Experience of Pain

  • May experience pain as unrelenting, not distinguishing between physical and emotional pain

  • Feels that no one/nothing can help

  • May test limits to see if can influence you

  • May see things in extremes, you are “a wonderful provider” when increasing meds, a “%#&^!?!” when setting limits

Discussing risk issues

Discussing Risk Issues

Use understanding of pt. when discussing limits and risk issues

  • Interpersonal

    • The relationship is paramount

    • Stress partnership, trust, working together, listen to pt’s concerns

    • Put in the context of caring for pt;

      communicate respect

Splitting thinking in extremes

Splitting, Thinking in Extremes

  • Recognize the patient’s “all-or-nothing” thinking;help to find middle ground

    “It’s not exactly black and white. Let’s weigh the risks and benefits of going up on your dose together. We have to find a way to find some balance between how it helps and what the downsides are.”

Testing will you abandon me

Testing (Will you abandon me?)

  • Clear limits, consequences, structure helpful

    “I want to be able to work with you to find our best options over time. The only way I can do that is if we have some agreement about how we’re going to do this.”

  • Consciously give patient choices when possible

    “Would you prefer to take your meds twice a day or three times a day?”



  • Understand your personal reactions

  • Don’t let yourself be provoked by testing

  • Don’t take patient’s anger at/rejection of you as a failure

How do we minimize the risks if we do prescribe

How do we minimize the risks if we do prescribe?

  • Clear patient-provider agreement

  • Frequent visits

  • Monitor function, not just pain score

  • Urine drug testing

  • CURES reports

  • Pill counts

How can we use naloxone to reduce the risk of death by overdose

How can we use Naloxone to reduce the risk of death by overdose?

Lay naloxone for overdose prevention

Lay Naloxone for Overdose Prevention

  • Readily reverses opioid overdoses

  • Patient & provider support

  • Training easy & effective

  • Frequent reversals reported

  • Community-level mortality reduced

Bazazi et al., J Health Care Poor Underserved 2010. Seal et al; Coffin et al., JUH 2003. Green et al., Addiction 2008. Enteen et al., JUH 2010. Walley et al., BMJ 2013; Albert et al., Pain Med 2011

Fatal opioid overdose rates by naloxone implementation

Fatal Opioid Overdose Rates by Naloxone Implementation

Walley et al. BMJ 2013; 346: f174.

Dope project dispensing 1993 2012

DOPE Project Dispensing 1993-2012

Heroin related deaths sf 1993 2010

Heroin Related Deaths: SF 1993-2010

Naloxone distribution begins

*Data compiled from San Francisco Medical Examiner’s Reports,**no data available for FY 2000-2001

Potential behavior changes

Potential Behavior Changes

  • Risk of non-fatal opioid overdose

    • U.S. Army Fort Bragg

    • EMS/ED visits in SF

    • Syringe sharing in Seattle

    • Model

  • Overdose may influence behavior

Why pain patients

Why pain patients?

  • Rx opioid deaths presaged an increase in heroin overdose and death (Unick et al., Plos One 2013)

  • Prescribed opioids associated with a transition to heroin (e.g. Young & Havens, Addiction 2012)

  • SF opioid analgesic overdose decedents engaged in primary care

    • 69% on chronic opioids

San francisco naloxone access

San Francisco Naloxone Access

Community-based dispensing

Drug Overdose Prevention and Education (DOPE)

Access for other populations

Primary care patients at selected sites and connected pharmacies

Mental health patients at CBHS clinics

Buprenorphine/methadone patients dosing at CBHS

Intranasal naloxone kit

Intranasal Naloxone Kit

  • Atomizer (2)

  • Brochure

  • Naloxone 2mg/2ml prefilled syringes (2)

Provider education

Provider Education

  • Training document on CBHS website

    • Naloxone Training for Providers

  • Key components

    • Causes

    • Recognition

    • Actions (call 911, rescue breathing, naloxone administration)

Primary care


Rx Opioid

Rx Naloxone





Dispense Opioid

Dispense Naloxone


Primary Care

Mental health


Opioid user

Rx Naloxone/disp Naloxone





Dispense Naloxone refill

Mental Health

Obot methadone buprenorphine


OBOT Methadone order


Rx buprenorphine

CBHS Pharmacy

Methadone or buprenorphine

Clinical Pharmacist Evaluation

Rx Naloxone/Disp Naloxone




OBOT Methadone/Buprenorphine

Sfdph naloxone distribution summary as of 4 11 2013

SFDPH Naloxone Distribution Summary as of 4/11/2013

Mr anderson part 2

Mr. Anderson part 2

  • You discussed your concerns about risk with the patient

  • You signed a patient provider agreement

    • May not use other controlled substances

    • May not give medications to others

    • Must take meds as prescribed

    • Must inform you if he receives prescriptions from other providers

    • Must follow up with diagnostic and treatment strategies

    • Will have regular urine drug tests

    • Will only receive refills in the context of scheduled appointments

    • Will not receive early refills

Mr anderson part 21

Mr. Anderson, part 2

  • Start gabapentin for neuropathic component of pain

  • Refer to behavioral health team for support with pain coping

    • Group or individual

Mr anderson part 22

Mr. Anderson, Part 2

  • Over the next few months:

    • Increase gabapentin dose, helping a little

    • Patient adheres to the patient-provider agreement

Mr anderson part 23

Mr. Anderson, Part 2

  • 4 months later

    • Drops in to clinic 1 week before appointment requesting early refill

    • Fell from a ladder, has been taking extra morphine and oxycodone for increased pain. Ran out early

    • Gets an early refill from urgent care provider

  • Misses his next appointment with you

Mr anderson part 24

Mr. Anderson, Part 2

  • Drops in one week later requesting morphine and oxycodone from urgent care provider

    • States that insurance would not cover the full monthly amount of his last rx, so he needs early refill

    • Provider requests urine drug test

    • Patient becomes angry and leaves without providing a urine sample

Mr anderson part 25

Mr. Anderson part 2

  • You schedule an appointment with the patient

    • Refill his medications

    • Order a urine drug test

  • Urine contains

    • Oxycodone

    • Morphine

    • Hydromorphone

    • Benzodiazepenes

What are your concerns at this point

What are your concerns at this point?

San francisco safety net chronic pain management education day

Given these concerns options include

Given these concerns, options include

  • Discontinue prescribing of all controlled substances

  • Require the patient to enter substance abuse treatment in order to continue prescribing

  • Increase visit frequency, urine drug test frequency, check CURES

  • Change to a medication that treats pain and substance abuse simultaneously

San francisco safety net chronic pain management education day

What is the role of buprenorphine/naloxone in the treatment of co-occurring pain and substance use disorder?

Scott Steiger, MD

Assistant Professor of Clinical Medicine

Division of General Internal Medicine

University of California – San Francisco

[email protected]



  • buprenorphine (bup) pharmacology

  • Buprenorphine/Naloxone (Bup/Nx) treats opioid dependence

  • Bup/Nx treats pain

  • Bup/Nx for this patient?

Buprenorphine is a partial agonist of the opioid receptor

Buprenorphine is a partial agonist of the µ-opioid receptor


Buprenorphine is a partial agonist of the opioid receptor1

Buprenorphine is a partial agonist of the µ-opioid receptor

RR <6


San francisco safety net chronic pain management education day

Perfect Fit - Maximum Opioid Effect

Empty Receptor

Euphoric Opioid Effect

No Withdrawal Pain



Empty Receptor

Receptor Sends Pain Signal to the Brain

Withdrawal Pain

Buprenorphine Still Blocks Opioids as It Dissipates

Imperfect Fit – Limited Euphoric Opioid Effect

Courtesy of NAABT, Inc. (

Buprenorphine formulations

Buprenorphine formulations

  • Temgesic (UK, sl)

  • Buprenex (IM)

  • Subutex and generic (sl)

  • Suboxone, Orexa, generics: coformulated with naloxone (sl)

  • Norspan and Butrans (td)

  • ?Nabuphine (subq implants)

Buprenorphine formulations1

Buprenorphine formulations

  • Temgesic (UK, sl)

  • Buprenex (IM)

  • Subutex(sl)

  • Suboxone, Orexa, generics: coformulated with naloxone (sl)

  • Norspan and Butrans (td)

  • ?Nabuphine(subq implants)

Bup nx comes in a couple of forms

Bup/Nx comes in a couple of forms

Bup nx is available for treatment of opioid dependence

Bup/Nx is available for treatment of opioid dependence

  • DATA 2000

    • Lower barrier to addiction tx

    • Requires extra training, DEA waiver

  • FDA approval in 2002

    • “Office based” opioid replacement

  • Medicaid covers in CA

Addiction or chronic pain

Addiction or chronic pain?

  • Tolerance?

  • Withdrawal?

  • Loss of control over use?

  • Use despite negative consequences?

Off label bup nx is effective for pain

Off label Bup/Nx is effective for pain

  • Acute pain in patients already on Bup/Nx

  • Chronic pain failing other opioids*

  • Chronic pain in “extremely high risk” patient?

*Malinoff et al Am J Ther 2005

Co occurring disorders clinic

Co-occurring disorders clinic

VA retrospective cohort of 1

  • Referrals from PCP, pain mgmt, hospital, substance abuse treatment

  • Screened, induced, then maintained

  • Bup/nx stopped if…

    • Uncontrolled pain on >28 mg bup/nx

    • Tox + 3+, miss 3+ visits, 3+ early refills

Pade et al. JSAT 2012

Change in pain scores and retention

Change in pain scores and retention

Pade et al. JSAT 2012

Bup nx maintenance better than taper for high risk patients

Bup/nx maintenance better than taper for high risk patients

“we found that it was quite difficult to wean opioids among those with chronic non-cancer pain and co- existent opioid addiction.”

Blondell et al J Addict Med 2010

Special considerations using bup nx for chronic pain

Special considerations using bup/nx for chronic pain

  • Induction

    • More “off time” required, esp with methadone

    • Low COWS?

      • ?safer just to taper

  • Dosing considerations

    • POTENT

    • Consider increased frequency for pain

  • Payor considerations

Initial dose must be appropriate

Initial dose must be appropriate

VA Co-occurring sorders clinic dropped everyone to MS 90 mg eq—and short-acting

Prospective cohort study NYC (n=12)

  • 3 highest doses (>300 MS eq) and 3 lowest doses (<20 MS eq) quit at induction

  • 4 who completed reported better pain control

Rosenblum J Opioid Manag 2012

46 yo m with high risk chronic pain

46 yo M with high risk chronic pain

Treat with bup/nx!!

Maybe we should hold off…

MAY meet criteria for SUD for benzos

Dose may be too high for easy transition

MAY have greater benefit from MMTP

  • Meets criteria for opioid use disorder

  • Risk < benefit of opiates

  • Poor candidate for abstinence only or naltrexone



  • Bup/nx’s pharmacology offers unique advantages compared to other opioids

  • Consider bup/nx in

    • Opioid dependence

    • High risk chronic pain

    • Pain refractory to other opioids

  • Bup/nx requires a DEA waiver to Rx

How do i get the waiver

How do I get the waiver?

May 15 Training

What else can we offer for pain

What else can we offer for pain?

Pain Treatment ≠ Opioids

How do opiates compare

How do opiates compare?

What about function?





How to think about concerning behaviors

How To Think About Concerning Behaviors

Concerning behaviors

Concerning Behaviors

  • Poor functionality

  • Requests for a specific medication

  • Tox (-) for drug prescribed

  • Tox (+) for other drugs

  • Early refill requests

  • Multiple prescribers

  • Hoarding

  • Lost or stolen medications

  • Comes for appointments only when opi needs refill

  • Neglects other aspects of care plan

  • Reports that pharmacy “shorted” the prescription

  • Alcohol/drug use

  • Forgery

  • over sedation (purposeful or not)

  • MVAs or other accidents

  • Self-initiated dose changes

  • Escalating/very high doses

  • Refusal to sign ROI

  • Drug cravings

  • Reports “allergies”

  • Refusal to take DOT

Prescribers dilemmas

Prescribers Dilemmas

  • Unproven standards

  • Stigma associated with treating patients

  • Conflicting guidelines and recommendations

  • Pressure to prescribe opiates and liberally treat pain

  • Wondering if pain is real

  • Epidemic of Rx overdoses and misuse

  • Addiction long associated with abstinence treatment models

  • Provider disciplinary action/malpractice

  • Mistrust of self/skills and patients

Goals in addressing concerning behaviors

Goals in addressing concerning behaviors

  • Improve pain and functioning

  • Reduce risks

  • Reduce suffering

  • Improve feeling of provider effectiveness

Framework how to structure thinking

Framework: How to structure thinking

Framework the nursing process

Framework:The Nursing Process

  • Assess

  • Diagnose

  • Outcome Identification

  • Plan

  • Implement and Evaluate

Research and risks

Research and Risks

  • Aberrant medication behavior rate: 5 % to 24% 1

  • For all patients on opioids for CNCP 2

    • Abuse/addiction rate = 3.27%

    • Aberrant behavior rate = 11.5%

  • For all patients excluding past or current SUD diagnosis: 2

    • Abuse/addiction rate = 0.19%

    • Aberrant behavior rate = 0.59%

1. Martel et al, 2007. 2. Fishbain et al, 2008.

Research and risks1

Research and Risks

  • Younger Age 1, 2, 3, 4, 5, 6

  • Male gender 2, 4

  • Caucasian/White 1

  • Mental Health Disorders 1, 3, 4, 5, 6, 7

  • Large dose or supply 3, 4, 8

  • Drug Cravings 7

  • relation to pain severity 2

1. Dowling et al, 2006. 2. Ives et al, 2006. 3. Edlund et al, 2010. 4. White et al, 2009. 5. Fleming et al, 2007. 6. Reid et al, 2002. 7. Wassan et al, 2007. 8. Dunn et al, 2010.

Research and risks2

Research and Risks


Personal Hx SUD 1, 2, 3

Specific Drugs

  • Cannabis 4, 5, 6

  • Cocaine 4, 6, 7, 8

  • Alcohol 8, 9

  • Heroin 4

1. Webster & Webster, 2005. 2. Edlund et al, 2010. 3. Turk et al, 2008. 4. Dowling et al, 2006.

5. Reisfield et al, 2009. 6. Fleming et al, 2007. 7. Meghani et al, 2009. 8. Ives et al, 2006. 9. Dunbar & Katz, 1996.

Research and risks3

Research and Risks

Pain, SUDs, and Functionality

  • SUD reported greater disability due to pain

  • Pts w/ SUD more likely to be prescribed an opioid analgesic

  • Pts w/ SUD less likely improvement in pain related function

Morasco et al, 2011.



  • H & P: SUD history, FHx, and psychosocial assessment.

  • Testing: UDT, other toxicology

  • Risk Assessment & stratification.

Differential diagnosis

Differential Diagnosis

  • Psychiatric disorders

  • Cognitive disorders

  • Diversion

  • Pseudo-addiction

  • Opioid tolerance

  • Allodynia or opioid-induced hyperalgesia

  • Addiction/abuse

Substance dependence

Substance Dependence

  • Tolerance

  • Withdrawal

  • Larger amounts or longer time than intended

  • Persistent desire or unsuccessful efforts to cut down

  • A lot of time spent to obtain or recover from use

  • Important activities given up

  • Substance use continues despite having a related persistent or recurrent health problem



  • Risks dictate structure

  • Structure helps

    • Reduce or resolve aberrant behaviors

    • Result in self-discharge

    • ID who needs higher level of care

Elements of structure

Elements of Structure

  • Visit Frequency

  • Refill frequency

  • Medication call backs

  • UDT

    • Presence/absence of rx’d drug

    • Presence/absence drugs of abuse

  • PDMP



When plan is insufficient to reduce risk: change it.

  • Explain why

  • Offer options

  • Refer: addiction care, ORT plus pain care, pain clinic

Opiate analgesics may not be appropriate if

Opiate analgesics may not be appropriate if…

  • Pain unimproved on upward titration

  • Unmanageable side effects

  • Recurrent non-adherence to treatment plan or agreement

  • Non-resolution of risky drug behaviors with tight controls

Assess the four a s

Assess the “Four A’s”

  • Analgesia

  • ADLs

  • Adverse events

  • Aberrant Behaviors





Passik & Weinreb, 2000.

Universal pain precautions

Universal Pain Precautions

  • Make diagnosis

  • Psychological Assessment

  • Informed consent

  • Treatment agreement

  • Pre-Intervention assessment of pain level and functioning

  • Pharmacotherapy trial

  • Post-intervention assessment of pain level and functioning

  • Assess the “Four A’s”

  • Review diagnosis and co-morbidities

  • Documentation

Gourlay, Heit & Almahrezi, 2005.

Opioid prescription management includes

Opioid prescription management includes

  • Both pharmacologic and psychosocial interventions

  • Regular monitoring

  • Routine evaluation of treatment goals

  • Patient education

  • Encourage patient to engage in the treatment process

  • Inclusion of other supports for overall health



  • Concerning behaviors: not always addiction

  • Assess and identify risks, balance with benefits

  • Formulate differential and diagnosis

  • Create plan including risk stratification

  • More risks indicate more elements of plan

  • Use a consistent, standardized approach to opioid prescribing with all patients, e.g. “universal precautions”

  • Join a team: multidimensional psychosocial, pharmacologic, non-pharmacologic, referrals and resources

  • Team decision making based on risks and successes

  • Apply essential elements of chronic disease management



  • Chou, R, Fanciullo, GJ, Fine, PG et al. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The journal of pain, 10(2), 113-130.

  • Dowling, K, Storr, C L, & Chilcoat, H D. (2006). Potential influences on initiation and persistence of extramedical prescription pain reliever use in the US population. The Clinical journal of pain, 22(9), 776-783.

  • Dunbar, S A, & Katz, N P. (1996). Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. Journal of pain and symptom management, 11(3), 163-171.

  • Edlund, M J, Martin, B C, Fan, M, et al. (2010). Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study. Drug and alcohol dependence, 112(1-2), 90-98.

  • Fishbain, D A, Cole, B, Lewis, J, et al. (2008). What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain medicine, 9(4), 444-459.

San francisco safety net chronic pain management education day

  • Fleming MF, Balousek, SL, Klessig, CL, et al. (2007). Substance use disorders in a primary care sample receiving daily opioid therapy. The journal of pain, 8(7), 573-582.

  • Gourlay, D L, Heit, H A, & Almahrezi, A. (2005). Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain medicine, 6(2), 107-112.

  • Ives, T J, Chelminski, P R, Hammett Stabler, C A, et al. (2006). Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC health services research, 6, 46-46.

  • Jamison, R N, Ross, E L, Michna, E, et al. (2010). Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain, 150(3), 390-400.

  • Martell, B A, O'Connor, P G, Kerns, R D, et al. (2007). Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146(2), 116-127.

  • Meghani, S H, Wiedemer, N L, Becker, W C, et al. (2009). Predictors of resolution of aberrant drug behavior in chronic pain patients treated in a structured opioid risk management program. Pain medicine, 10(5), 858-865.

  • Morasco, B J, Corson, K, Turk, D C, et al. (2011). Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain. The journal of pain, 12(3), 352-359.

  • Passik, S D. (2009). Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clinic proceedings, 84(7), 593-601.

  • Passik, S D, & Weinreb, H J. (2000). Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Advances in therapy, 17(2), 70-83.

  • Paulozzi, L J, Budnitz, D S, & Xi, Y. (2006). Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology and drug safety, 15(9), 618-627.

San francisco safety net chronic pain management education day

  • Reid, M C, Engles Horton, L, Weber, M B, et al. (2002). Use of opioid medications for chronic noncancer pain syndromes in primary care. Journal of general internal medicine, 17(3), 173-179.

  • Reisfield, G M, Wasan, A D, & Jamison, R N. (2009). The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: a review of the extant literature. Pain medicine, 10(8), 1434-1441.

  • Savage, S R. (2002). Assessment for addiction in pain-treatment settings. The Clinical journal of pain, 18(4 Suppl), S28-S38.

  • Savage, S R. (2009). Management of opioid medications in patients with chronic pain and risk of substance misuse. Current psychiatry reports, 11(5), 377-384.

  • Sehgal, N, Manchikanti, L, & Smith, H S. (2012). Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain physician, 15(3 Suppl), ES67-ES92.

  • Turk, D C, Swanson, K S, & Gatchel, R J. (2008). Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. The Clinical journal of pain, 24(6), 497-508.

  • Warner, M, Chen, L H, Makuc, D M, et al. (2011). Drug poisoning deaths in the United States, 1980-2008. NCHS data brief, (81), 1-8.

  • Wasan, A D, Ross, E L, Michna, E, et al. (2012). Craving of prescription opioids in patients with chronic pain: a longitudinal outcomes trial. The journal of pain, 13(2), 146-154.

  • Webster, L R, & Webster, R M. (2005). Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain medicine, 6(6), 432-442.

  • White, A G, Birnbaum, H G, Schiller, M, et al. (2009). Analytic models to identify patients at risk for prescription opioid abuse. The American journal of managed care, 15(12), 897-906

When and how to taper opioids

When and How to Taper Opioids

When to discontinue opioids

When to discontinue opioids

  • Treatment goals not met/opioid trial failed

    • Insufficient improvement of pain/function/quality of life

    • Significant non adherence to treatment plan

  • Risks/harms outweigh benefits

    • Intolerable/dangerous side effects

    • Concerning/dangerous behaviors suggesting:

      • Active substance abuse (opioid, other)

      • Diversion

      • Psychiatric instability

When where to taper opioids

When/Where to taper opioids

  • When

    • Patient taking medication

    • Physiologic dependence

    • Safe to do so

      • If clearly unsafe or illegal behaviors, stop and assess for withdrawal

  • Where

    • “Although there is insufficient evidence to guide specific recommendations on optimal strategies, a taper … can often be achieved in the outpatient setting in patients without severe medical or psychiatric comorbidities.”

Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009, 113-130.

Where how to taper opioids

Where/How to taper opioids

  • Assess patient’s opioid use, medical problems, and psychosocial issues

  • Involve other team members

  • Provide written instructions

Where how to taper opioids1

Where/How to taper opioids

  • Consider referral to methadone treatment program if opioid abuse

  • Consider referral to addiction medicine/ substance abuse or psychiatric treatment if (risk of) unsafe behaviors (e.g., suicidality, lack of impulse control)

How to taper opioids

How to taper opioids

  • “Evidence to guide specific recommendations on the rate of reductions is lacking, though a slower rate may help reduce the unpleasant symptoms of opioid withdrawal.”

  • Factors that may influence rate:

    • reason for discontinuing

    • medical/psychiatric comorbidities

    • withdrawal symptoms during process

Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009, 113-130.

How to taper opioids rules of thumb

How to taper opioids – rules of thumb

  • One taper regimen (Univ of Mich Health System):

    • Decrease 10% of original dose every week until 20% remains, then 5% of original dose until off

  • Other considerations:

    • Amount of opioid necessary to prevent withdrawal is 20% of previous day’s dose

    • Convert multiple medications to 1 medication, then taper

      • Reduce dose 20-50% because of incomplete cross tolerance

    • Taper faster at higher doses (>200mg morphine), slower when reach 60-80mg morphine/d

    • Some suggest the longer the treatment, the slower the taper

Opioid taper example

Opioid taper - example

  • MSSR 60mg 3x daily plus MSIR 30mg 1 q4hr (DNE 3/d)

  • Total daily dose: 60X3=180, 30X3=90→270mg

  • Initial taper

    • 100% to 20% initial dose → 270mg to 54mg

    • 10%/wk →27mg/wk (round to 30mg/wk)

  • Final taper

    • 5%/wk →14mg/wk (round to 15mg/wk)

  • MSSR pill strengths: 15, 30, 60, 100, 200mg

Opioid taper example1

Opioid taper - example

Managing withdrawal symptoms

Managing Withdrawal Symptoms

  • Rarely life threatening

  • May persist up to 6 mos

  • Treat symptomatically

    • Provide “kick pack” or have pt return if symptoms

  • Avoid opioids or benzodiazepines

Managing withdrawal symptoms1

Managing Withdrawal Symptoms

Other treatments support

Other treatments/support

  • Make efforts to preserve therapeutic relationship

    • Pt may not feel pain taken seriously

    • Pt’s clinical situation may deteriorate

    • Pt may feel poor quality of care and threaten action

Other treatments support1

Other treatments/support

  • Concerning behaviors may emerge during taper

    • May be mitigated by initial plan

    • Use clear, consistent message with focus on safety and harms/benefits

    • Offer counseling/support if significant behavioral issues

    • Make psychiatric, substance abuse referrals if indicated

Other treatments support2

Other treatments/support

  • Consider others’ support (team, provider, pharmacist)

  • If threats/intimidation occur, take appropriate steps, including preventive actions (other staff/ security present)



  • Agency Medical Directors Group. Interagency Guidelines on Opioid Dosing for Chronic Non-cancer Pain.

  • Chou et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 10(20), 2009, 113-130.

  • Group Health Cooperative. Chronic Opioid Therapy Safety Guideline For Patients With Chronic Non-Cancer Pain.

  • University of Michigan Health System. Managing Chronic Non-Terminal Pain in Adults.

  • VA/DoD. Clinical Practice Guidelines for Management of Opioid Therapy for Chronic Pain.

Treating substance use disorders

Treating Substance Use Disorders

Stimulants, Opioids, and Alcohol

Stimulant use cocaine and methamphetamine

Stimulant Use: cocaine and methamphetamine

Judith Martin, MD

Medical Director of Substance Abuse Services, SFDPH

Question for you

Question for you:

  • A patient who is on your clinic’s chronic pain registry tests positive for cocaine when she comes in for her opiate prescription. You ask her what she has noticed about effects of cocaine on her body. She says it makes her heart “jump” in her chest.

  • How would you explain this symptom, and how does your clinic protocol address a positive cocaine test?

Effects of stimulants short term

Effects of stimulants: short term

wakefulness, increased physical activity, decreased appetite, increased respiration, rapid heart rate, irregular heartbeat, increased blood pressure, and hyperthermia.

Effects of stimulants long term

Effects of stimulants, long term

  • Can be damaging to brain, emotions, and body.

  • Cardiovascular: high pulse, BP may lead to heart attack or stroke, leads to atherosclerosis, myopathy

  • Psychiatric: anxiety, paranoia, depression , egocentric delusions

  • Neurostimulation: formication, excoriations, seizures, tremor

Stimulant use treatment

Stimulant use, treatment

  • Many medications have been tried, none clearly useful.

  • CBT, incentives and MI have all been successful.

  • In the case of methamphetamine, brain recovery takes time.

Dats recover with abstinence

DATs Recover with Abstinence

Volkow et al., 2001

Summary stimulant use

Summary: stimulant use

  • Evaluate patient’s stage of change

  • Information about effects of drug

  • Information about types of treatment

  • Note: overlap with psychiatric and trauma histories, overlap with other risk behaviors, special urgency in cardiovascular disease.

Medically assisted treatment for opiate dependence

Medically Assisted treatment for Opiate dependence

Mat for opiate dependence

MAT for Opiate Dependence

  • Reduces overdose

  • Decrease illicit opiate use

  • Reduced HIV and HCV transmission

  • Reduces criminality

  • Improves medical, psychiatric, and social functioning

Nih consensus statement on opiate dependence 1997

NIH Consensus Statement on Opiate Dependence: 1997

  • Opioid addiction is a medical disorder that can be treated effectively

  • All should have access to opiate agonist treatment

  • Reduce unnecessary treatment regulations

  • Coverage should be a required benefit in public insurance programs

Approved medications

Approved Medications

  • Methadone

    • Full opiate agonist

    • Provided only at licensed specialized clinics

  • Buprenorphine

    • Partial opiate agonist

    • Office based settings

  • Naltrexone

    • Opiate antagonist

    • Office-based settings



  • Synthetic opioid

  • Full μ agonist

  • Repeated administration leads to physical dependence

  • Hepatic storage and subsequent slow release

  • Linear dose-response curve

  • Half life: 15 to 60 hours



  • Special Alert (2009): Recommendations for QTc interval screening before and during methadone treatment

  • CNS depression

  • Respiratory depression

  • Hypotension

  • Consider synergistic effects with sedative or alcohol abuse

CNS, central nervous system

Krantz MJ et al. Ann Intern Med. 2009;150:387-395.

Methadone prescribing

Methadone Prescribing

  • For pain with a DEA license

  • For opiate replacement

    • At licensed NTPs

    • Through OBOT methadone program: Tom Waddell and Potrero Hill Clinics only

  • Federal and State Regulations: Title 9 in California

    • Setting, dose limits, dosing frequency, drug testing, counseling (addiction)

    • Liquid formulation

Methadone and benzodiazepines

Methadone and Benzodiazepines

  • 51% to 70% of MMTP patients use benzodiazepines (similar to buprenorphine patients and heroin users not in treatment)1-3

  • 18% to 50% with problematic use1,3,4

  • In studies, benzodiazepine-related deaths for MMTP patients range from 10% to 80%5-8

1Gelkopf M et al. Drug Alcohol Depend. 1999;55:63-68; 2Stitzer ML et al. Drug Alcohol Depend. 1981;8:189–199; 3San L et al. Addiction. 1993;88:1341-1349; 4Ross J, Darke S. Addiction. 2000;95:1785-1793; 5Maxwell JC et al. Drug Alcohol Depend. 2005;78:73-81; 6Lintzeris N, Nielsen S. Am J Addictions. 2010;19:59-72; 7Williamson PA et al. Med J Australia. 1997;166:302-305; 8Zador D, Sunjic S. Addiction. 2000;95:77-84.

Methadone contraindications

Methadone: Contraindications

  • MAOIs: MTD within 14 days of MAOI increase the risk of serotonin syndrome1,2

  • Phenothiazines: additive effects include ileus, cardiac arrhythmias (QT prolongation), CNS depression, psychomotor impairment1,3

  • Venlafaxine: cardiac arrythmias (QT prolongation), serotonin syndrome, NMS4

  • Ziprasidone: additive effects5

1Roxane Laboratories, 2009; 2Gillman PK. Br J Anaesth. 2005;95:434-441; 3Baxter Healthcare Corporation. Phenergan (prescribing information. 2009; 4Wyeth Pharmaceuticals Inc. (venlafaxine) prescribing information. 2009; 5Pfizer Inc. (ziprasidone) prescribing information. 2009.

Methadone drug interactions

Methadone: Drug Interactions

  • CYP450 system: metabolized at 3A4, 2B6, 2C19, and (lesser) at 2C9, 2D61,2

1Roxane Laboratories. Methadone hydrochloride prescribing information. 2009; 2Mallinckrodt Inc. Methadose Oral Concentrate (methadone hydrochloride oral concentrate) prescribing information. 2009.

Methadone drug interactions1

Methadone: Drug Interactions

  • CYP inhibitors

    • Fluoxetine and norfluoxetine: CYP3A4, 2D6, 2C9. No clinically significant interaction in vivo1,2

    • Fluvoxamine: CYP3A4 and 2C9. Watch for methadone toxicity due to increase methadone levels. When stopping fluvoxamine watch for methadone withdrawal2,3

    • Quetiapine: increased methadone levels (CYP2D6)4

    • Grapefruit juice: moderate inhibitor at CYP3A42

  • 1Bertschy G et al. Ther Drug Monit. 1996;18:570-572; 2McCance-Katz EF et al. Am J Addict. 2009;19:4-16; 3Perucca E et al. Clin Pharmacokinet. 1994;27:175-190; 4Uehlinger C et al. J Clin Psychopharmacol. 2007;27:273-278.

Methadone drug interactions2

Methadone Drug Interactions

Methadone may inhibit metabolization at CYP2D6

  • Desipramine: levels may double or more1,2

  • Risperidone: 2D6 substrate, may have potential for adverse drug interaction, but no clinically significant reports of such and no human pharmacokinetic studies3

  • Phenothiazines: 2D6 substrate, consider potential for adverse drug interaction4

1Kosten et al. Am J Drug and Alcohol Abuse. 1990;16:329-336; 2Maany et al. Am J Psychiatry. 1989; 146:1611-1613; 3McCance-Katz et al Am J Addict. 2009;19:4-16; 4Ereshefsky et al. Clin. Pharmacokinet. 1995; 29(Suppl 1):10-18.

Methadone drug interactions3

Methadone Drug Interactions

CYP inducers

  • St. John’s Wort: CYP3A4 and 2C91-3

  • Carbamazepine, phenytoin, and barbiturates: CYP3A4. Lower methadone levels and lead to opiate withdrawal4,5

1Izzo AA. Int J Clin Pharmacol Ther. 2004;42:139-148; 2Puzantian T. Drug Interactions of Methadone and Psychiatric Medications; information brochure presented to staff and faculty of UCSF at San Francisco General Hospital. 1997; 3McCance-Katz EF et al. Am J Addictions. 2009;19:4-16; 4Bell J et al. Clin Pharmacol Ther. 1988;43:623-629; 5Perucca E. Br J Clin Pharmacol. 2006;61:246-255.

Reduced methadone levels

Reduced Methadone Levels


  • Risk for relapse to illicit opioids

  • Non-adherence to prescribed medications

  • McCance-Katz EF, Mandell TW. Am J Addict. 2010;19:2-3.

Sf methadone clinics

SF Methadone Clinics

  • Ward 93*

  • BAART Market Street*

  • BAART Turk Street*

  • Westside*

  • Bayview-Hunter’s Point*

  • Fort Help

  • VA Ft Miley

    *Referrals through COPE

San francisco safety net chronic pain management education day


  • Eligibility: Title 9, CHN, not Medi-Cal

  • Referral to COPE: phone 552-6242

  • COPE assessment: toxicology & pregnancy testing, counseling and medical visits per Title 9; DADP exception

  • Goal: methadone intake ASAP

  • Funding limits



  • Semi-synthetic derivative of thebaine (an opium alkaloid)

  • Partial μ agonist, antagonizes κ receptor

  • High binding affinity and slow dissociation for μ receptor

  • Sigmoidal dose-response curve: ceiling effect

  • Half life: 37 hours

  • Side effects: sedation, CNS depression, hypotension

Buprenorphine prescribing

Buprenorphine Prescribing

  • FDA approved in 2002 for opiate replacement, schedule III

    • Buprenex (FDA 1985), Suboxone*, Subutex

  • Requires 8 hours special training and DEA “waiver”

  • MDs mid-levels

  • Office-based setting

  • OBIC Clinic

Buprenorphine safety

Buprenorphine: Safety

  • Hepatic impairment1

  • Monitor CYP3A42

  • Monitor with other CNS depressants

    • BZD-BUP drug related deaths reported as high as 80%.

    • Deaths associated with IDU BUP and concomitant BZDs and neuroleptics3-5

  • Phenothiazines: enhance the hypotensive effect?6

  • Alcohol: enhanced CNS depression

1Zuin M et al. Dig Liver Dis. 2009;41:38-e10; 2Reckitt Benckiser Pharmaceuticals Inc. Suboxone prescribing information. 2010; 3Kintz P. Clin Biochem. 2002;35:513-516; 4Lintzeris N, Nielsen S. Am J Addict. 2010;19:59-72; 5Lai SH, Yao YJ, Lo DS. Forensic Sci Int. 2006;162(1-3):80-86; 6Thioridazine. Harrison’s Practice. *Reckitt Benckiser Pharmaceuticals Inc. Suboxone film prescribing information. 2010.

San francisco safety net chronic pain management education day


  • Referral to OBIC: phone 552-6242

  • Intake:

    • orientation appointment

    • Induction appointment

  • Stabilization. All OBIC notes in LCR.

  • Transfer back out to the community: integrated care

Obic services

OBIC Services

  • Induction and stabilization

  • Counseling and education: individual and group

  • Provider Education and Support

  • “Safety net” re-stabilization PRN

  • PRN health and mental health assessments and referrals.

  • Ancillary services PRN: pharmacy, UDT, counseling

Ibis integration flow any door the right door

IBIS: Integration Flow“any door the right door”



  • 1984: FDA approval for opiate dependence

  • Opiate antagonist

  • No significant drug interactions (opioids)

  • Black box warning: dose-related hepatocellular injury is possible: avoid in acute hepatitis or liver failure

  • Patients should be opioid-free for a minimum of 7 to 10 days



  • Most appropriate for those highly motivated and frequently monitored

  • Poorly accepted by patients

  • Long duration of action (24-72 hours) permitting less than daily dosing (TIW)

  • Oral form 50mg tablet (25mg on day 1)

  • I.M. 380mg Q 4 weeks

Fram et al J Sub Abuse Treatment 1989; 6:119-122.

Alcohol and opioids oh my

Alcohol and OpioidsOh My!

James J. Gasper, Pharm.D., BCPP

San Francisco Department of Public Health

Community Behavioral Health Services

Alcohol scope of the problem

Alcohol: Scope of the Problem

  • Alcohol abuse is common in chronic pain patients

    • About 40% (5 % current, 35 % past)

    • Preceded pain by average of 15 yrs

  • Alcohol use is dangerous in combination with opioids

    • Present in about 50% of heroin deaths and 30% of methadone deaths

    • Deaths occur at lower opioid and alcohol blood concentrations

Katon W, et al. Am J Psychiatry 1985;142:1156-1160. Hickman M, et al. Addiction 2008;103:1060-1062



Problematic Alcohol Use

Address Opioid

Address Alcohol

psychosocial interventions



Restrict supply

Refer to methadone maintenance




  • Medically assisted detoxification may be needed


  • Naltrexone contraindicated with concurrent opioids

  • Available options: disulfiram, acamprosate, topiramate



  • A few small studies of disulfiram use in methadone maintenance

  • “Reinforced Disulfiram”

    • Methadone dose contingent on taking disulfiram

    • (N=25) 2% of days spent drinking vs. 21%

Liebson IA, et al. An Int Med 1978;89:342-344

Alcohol treatment opioid dependence pathway

Alcohol Treatment:Opioid Dependence Pathway




Disulfiram + Acamprosate


CBHS Alcohol Dependence Guidelines 8/6/2009

Principles of motivational interviewing

Principles of Motivational Interviewing

Matt Tierney, NP

Motivational interviewing is

Motivational Interviewing is:

  • A collaborative and goal-oriented style of communication with particular attention to the language of change

Rollnick S & Miller WR (2013). Motivational interviewing: helping people change. (3nd Ed.) Guilford Press: New York

Spirit of mi

Spirit of MI

  • Partnership

  • Acceptance

    • Absolute worth

    • Accurate empathy

    • Autonomy support

    • Affirmation

  • Compassion

  • Evocation

Mi four key processes

MI: Four key processes

Develop commitment to change AND formulate a concrete plan of action

Mi is not

MI is Not

  • Based on the Transtheoretical Model of change

  • A way of tricking people into doing what you want them to do

  • A solution for all clinical dilemmas

  • Decisional balance, equally exploring pros and cons of change

  • A form of CBT

  • Easy to learnMiller & Rollnick, 2008 & 2013

Mi is about exploring

MI is about Exploring

… the discrepancy between current behavior and a core value. A powerful motivator for change when explored in a safe and supportive atmosphere.

Common mi traps

Common MI Traps

  • “Expert” trap

  • “Question-answer” trap

  • “I rectify gaps in knowledge.”

  • “Fear is a motivator” trap.

  • “I just need to tell them clearly what to do.”

Ethics and mi

Ethics and MI

Three conditions that present ethical complexities in MI:

  • When client’s aspirations are dissonant with the interviewer’s or institution’s goals of what is in the client’s best interest

  • When the interviewer has an increasing personal investment in the direction the person takes

  • When the nature of the relationship includes coercive power of the interviewer to influence the direction the client takes

Miller & Rollnick, 2008 & 2013

The case

The Case

  • 51 yo woman here to renew opioid prescription

  • Pain began 3 years ago after a car accident

  • 7/10, constant aching in the low back. No red flags.

  • PMH: COPD, Depression

  • SH: lives alone, on disability, smokes tobacco, recently cut down to 1/2ppd

  • No h/o illicit drug use

The case1

The Case

  • FH: Father died of cirrhosis, h/o breast cancer on mother’s side

  • Meds:

    • morphine SR 30 mg TID

    • oxycodone IR 15 mg q6 PRN BTP

    • bupropion 300 mg daily

    • inhalers for COPD

The case2

The Case

  • After attending a conference on pain management, you realize that you have not asked about alcohol use.

  • 4 or more drinks in a day in last year? No.

  • Drinks 1 beer a night, 7 days/week.

  • Drinking not more than intended; no risk of bodily harm.

Motivational interviewing skills

Motivational Interviewing Skills

How do you increase motivation

How do you increase motivation?

Sharing information without generating resistance

Sharing information without generating resistance


  • Open ended question, listen to patient

  • Respond with additional advice or information

  • Ask how that advice or information lands for the patient







Change talk

Change talk

Any speech in favor of changing a target behavior.

The more a patient engages in change talk, the more likely he or she is to change.

Change talk1

Change Talk

Desire: I want to…

Ability: I can…

Reasons: I should change because…

Need: I really need to… I have to

Commitment Talk: I’m going to… I intend to… I will… I plan to…

Taking Steps: I started…

Find the change talk

Find the change talk

I want to stay clean and sober. But I can’t get a job because of this court thing, and so I have to live with my brother who drinks all the time.

Find the change talk1

Find the change talk

I want to stay clean and sober. But I can’t get a job because of this court thing, and so I have to live with my brother who drinks all the time.”

Find the change talk2

Find the change talk

I don’t want to die of lung cancer, but everyone has to die sometime.

Find the change talk3

Find the change talk

I don’t want to die of lung cancer, but everyone has to die sometime.



Listen for the meaning in what someone is saying and repeat it back to them

Types of reflection

Types of reflection

  • Repeating

  • Paraphrasing

  • Reflect feeling

  • Reflect values

  • Double sided

  • Amplified

San francisco safety net chronic pain management education day


Part 1 continued

Two major predictors of a patient s likelihood to change are

Two major predictors of a patient’s likelihood to change are

  • The amount of change talk that occurs in the visit

  • The patient’s sense of self-efficacy



Reflective listening exercise

Reflective Listening Exercise

  • Repeating

  • Paraphrasing

  • Reflect feeling

  • Reflect values

  • Double sided

  • Amplified

    One thing I like about myself is…

Small group practice motivational interviewing

Small Group Practice: Motivational Interviewing

San francisco safety net chronic pain management education day


Part II

Your tasks

Your Tasks

  • Affirm patient’s decision to engage in more intensive monitoring

  • Share your concerns about the potential harms of mixing alcohol and opioid analgesics in the setting of COPD

  • Learn the patient’s perspective

  • Provide information on reducing alcohol through self-management strategies

Your tools

Your Tools

  • Use reflective listening to find out what the patient thinks about her drinking

  • Use Ask-Tell-Ask to give information on

    • her risk of opioid analgesic overdose in the setting of alcohol and COPD

    • strategies to reduce her alcohol consumption.

  • When you find something to affirm in the patient’s behavior, express your affirmation of the patient’s strengths and ability to care for herself.

Small group practice difficult conversations

Small Group Practice: Difficult Conversations

Case part 3 difficult conversations

Case Part 3Difficult Conversations

At this point, the case will become more complicated and the provider decides to discontinue opioids.

Your tasks1

Your Tasks

  • Explain why observed behavior raises your concern for alcohol use disorder

  • Inform the patient that you cannot safely prescribe opioid analgesics; benefits no longer outweigh risks

  • Develop an opioid analgesic taper plan

  • Listen for signs that patient wants to change her behavior

  • Offer information and referral for alcohol treatment and/or depressed mood

  • Maintain your primary care relationship

Your tools1

Your Tools

  • Maintain a non-confrontational stance: avoid arguments; resist the righting reflex

  • Stay 100% in “Benefit/Risk” mindset

  • Share decision making: include patient in treatment planning

  • Respect her autonomy

  • Use reflections and affirmations to reinforce patient’s strengths and any change talk

  • Use Ask-tell-ask to provide information about alcohol treatment

San francisco safety net chronic pain management education day

Navigating the intersection between pain and addiction:

SFHP’s role in supporting a system of safe, effective, patient-centered pain management

Kelly Pfeifer, MD

Chief Medical Officer

[email protected]

Beth s story

Beth’s story

  • 38 years old, erratically employed

  • Anxious and depressed – “counseling doesn’t help”

  • Chronic LBP s/p MVA

  • 8 Vicodin/day --> 180 mg daily of Morphine over 5 years

  • Ativan for anxiety

  • Some concerning behaviors:

    • 1 urine positive for cocaine

    • 1 drug test refused

    • Didn’t follow through with

      PT or behavioral referral



Found dead of accidental overdose:

  • Methadone

  • Ativan

  • Morphine

  • Cocaine

What did the pcp do wrong

What did the PCP do wrong?

  • According to Chou and Portland clinics:

    • Combined benzos and opiates

    • Continued opiates after positive cocaine UDS

    • Untreated depression and anxiety

    • Methadone clinic client (not known)

    • Poor indication (opiates not effective in chronic LBP)

    • Over 120 mg a day

San francisco safety net chronic pain management education day

“We are not accountable for everything that leads up to drug deaths – poverty, addiction, childhood trauma, despair.

But we are responsible. With our pens, we are writing the drugs into the hands of 8th graders”

Amit Shah, previous Medical Director, Multnomah County Public Health Clinics

Based on mmwr 1 9 35 161 461

Based on MMWR: 1:9:35:161:461

Myth 1

Myth # 1

  • More opiates means better pain relief

No change in pain score with large opiate increases

No change in pain score with large opiate increases

 J. Pain 2013. Vol 14 (4): 384

Myth 2

Myth # 2

  • We know when our patients are misusing meds

Pcps can t accurately assess misuse

PCPs can’t accurately assess misuse

  • 72% misuse in SFGH chronic pain cohort

  • No concordance between PCPs’ opinions and participants’ self-reports of past-year misuse:

    • Missed 38% of those who WERE misusing

    • Misjudged 46% of those who WEREN’T misusing (often based on race)

Vijayaraghavan M, Penko J, Guzman D, Miaskowski C, Kushel MB. Primary Care Providers' Judgments of Opioid Analgesic Misuse in a Community-Based Cohort of HIV-Infected Indigent Adults. J Gen Intern Med. 2011;26(4):412–8.

Myth 3

Myth # 3

  • We know when our patients are diverting meds

The incentive to divert is overwhelming

The incentive to divert is overwhelming

  • Typical yearly income for patient on SSI: $13,000

  • Typical street value:

    • $1 per mg

    • $370 mg a day or $135,000 per year

    • Selling 10% of meds doubles income

This is the Oxy corner. Vicodin is next block.

Can I get some Vicodin?

Partnership health plan

Partnership Health Plan

  • Formulary implemented in Marin in 2009

  • Local cop:

    “Within months the level of Oxycontin on the street had dropped dramatically”

Mike s story

Mike’s story

  • Occasional marijuana use as a junior, heavy use as a senior

  • Tried Vicodin at State College… liked it

    • 2nd most common drug of abuse for 8th graders

  • Got too expensive; switched to heroin

  • Now homeless

There is a lot of drug on the streets

There is a lot of drug on the streets

  • 585 mg of morphine equivalents prescribed per SF resident in 2010

  • Enough opiates for each San Franciscan to take the equivalent of 1 Vicodin every 6 hours for a month

    CURES data, courtesy of James Gaspar

Should we consider a dose ceiling in san francisco

Should we consider a dose ceiling in San Francisco?

  • There is evidence that high doses of opiates:

    • Do not improve pain; may make it worse J Pain, 2011. Vol 12(2): 288.   

    • Increase death rates (JAMA 2011:30(13): 1315-1321; Annals of Internal Medicine, 2010:152: 85-92; Arch Intern Med. 2011:171(7): 686-691)

    • Increase depression, and increase pain perception (hyperalgesia) (General Hospital Psychiatry 34 2012, 581-587)

San francisco safety net chronic pain management education day

  • There is evidence that lowering doses reduces mortality and pain scores

    Am J Ind Med. 2012 Apr;55(4):325-31.

    J Opioid Manag 2:277-282, 2006

We are not at fault but we are responsible

“We are not at fault…. But we are responsible”

Medicaid patients have six times the death rate of the general population when given opiates

Current approach

Current approach

  • Practice Improvement Program measure

    • For 2013: applies to only 6 clinics with 30 or more high-dose patients

    • Requires all providers to agree to consistent best practices

    • Requires population management:

      • Updated pain management agreement in last 12 months

      • Urine Drug Screen in last 12 months

Potential steps for sfhp

Potential steps for SFHP

  • 2014: expand Practice Improvement Program measure

    • All clinics

    • Providers agree to consistent protocols

    • Panel management of pain patients

    • Opiate Oversight Committees

  • Spread opportunity for technical assistance for clinics

    • Registries

    • Opiate Oversight Committees

Possible future directions for sfhp

Possible future directions for SFHP

  • Should we implement lock-in programs?

    • One pharmacy

    • One prescriber

  • Should we implement dose limits?

  • PA requirements for high-dose patients?

  • Waive PAs for clinics with good pain management infrastructure?

Are dose limits manageable

Are dose limits manageable?

  • 487 SFHP members in DPH or SFCCC clinics on >120 mg morphine equivalents daily

    • Only 6 clinics with over 30 on the list

  • 21 prescribers have >6 patients on the list

    • For these 21 prescribers:

      • range 7 – 26 patients

      • average 13 patients

Why would providers ask sfhp to take this role

Why would providers ask SFHP to take this role?

  • SFHP could provide structure to liberate providers from policing and judging role

“Budget cuts – I’m good cop and bad cop.”

Mission of sf safety net pain management workgroup

Mission of SF Safety Net Pain Management Workgroup:

We aim to create a consistent system of patient-centered, effective and safe pain management across the safety net.

I welcome your feedback.

Thank you!

[email protected]

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