De-Stressing Pain Management

DO.fm Clinical Podcast

This month we welcome Robert Agnello, DO, FACOFP to the Clinical Podcast to talk about pain management and opioid use disorder. We cover integrating opioid analgesics into treatment plans along with patient education, handling patient opioid use outside of prescribed use and how to talk to patients about incorporating OMT into their treatment plan.

Transcript

This transcript was created with the aid of automatic speech recognition technology.

Steve Legault: Welcome to the ACOFP DO.FM Clinical Podcast, I'm your host, Stephen Legault, the Director of Knowledge, Learning and Assessment at ACOFP.

Steve Legault: On today's episode. We're going to be talking about pain management with a specific focus on opioids. Opioid use disorder affects about 2.1 million people in the United States.

Steve Legault: We're glad to be joined for this episode by Robert Agnello, DO, FACOFP.

Steve Legault: He's an Assistant Professor of Family Medicine and Pain Medicine at Campbell University.

Steve Legault: He also serves as the Faculty Senate chair at QSOM for the University and is the NBOME Clinical Family Chair.

Steve Legault: Dr. Agnello serves on the Board of the American Academy of Osteopathy, and on a number of education focused committees here at ACOFP, including the Substance Use Disorder Task Force.

Steve Legault: welcome the Podcast Dr. Nolan. Anything I missed in your background that'd be helpful.

Robert Agnello: Oh, that sounds great, Steve, I think you covered it completely.

Steve Legault: Excellent. Well, thank you. And again, glad to have you here.

Steve Legault: you know you were one of the subject matter experts who created our de-stress pain management, rethinking opioid non opioid therapy, and we cover a lot in that course, and I encourage anyone listening to go and take a look at it and complete it. It will satisfy your DEA requirements, and it's also just a great in-depth resource for anyone looking to learn more about pain management.

Steve Legault: And it's also free. So any anybody who is in healthcare is welcome to do that regardless of ACOFP membership. So we encourage everyone to participate. But I wanted to ask your thoughts on a few specific aspects we cover in the course.

Steve Legault: When looking to safely integrate opioid analgesics into treatment plans, what considerations need to be made around patient education?

Robert Agnello: Oh, thank you so much, Steve, for that question. I think it's very important that all clinicians, physicians all provider types that are involved in chronic pain management. Consider the opportunities for opioid medications, you know, regarding analgesic management.

Robert Agnello: They are an option, you know. We are recovering from some very significant limiting recommendations that were out in the round 2016, and finally was recognized and loosened up upon in 2022 by the CDC.

Robert Agnello: There are patients that benefit from analgesic medications, including opioids. And there are tools that we have to help us select. You know the correct patients that could do well on opioid medications. First, we always want to make sure we have a wonderful history physical exam, and then come up with a complete his treatment plan.

Robert Agnello: And in that treatment plan we should be very integrative about our approach, very osteopathic about our approach, considering optimizing non-pharmacologic strategies, interventional procedures, and different adjunctive pain medications. There's a whole host to choose from.

Robert Agnello: But every now and then I like to give this example. You're going to get that patient. I won't say any specific age, but they have very extensive degenerative change, maybe in their spine, their hips, their knees, their quality of life is impacted, their functional status impacted and their pain levels are high and maybe they have a little bit of renal insufficiency.

Robert Agnello: Maybe they've had a bleed, a Gi. Bleed in the past. Maybe they aren't the ideal patient for typical types of medications like non-steroidal anti inflammatories that we use with patients. It. Perhaps they've already maxed out the amount of acetaminophen that they use per day.

Robert Agnello: It's possible that they're not great candidates for some of those adjunct adjunctive medications like duloxetine or amitriptyline or maybe a nerve stabilizing medication like a Gabapentin.

Robert Agnello: So where are you? What do you have to offer that patient?

Robert Agnello: Probably an Opioid, and I would suggest, you know, that you consider adding to your toolkit a medication like buprenorphine. And you're going to hear more about that.

Robert Agnello: Maybe you already heard about it. In our course that we we've helped to provide. But buprenorphine is a wonderful medication that has both some opioid agonist activity on the opioid mu receptor, just like the common opioids we're used to. But in addition, it has an impact on a receptor called opioid Kappa receptor. And what's great about that is it helps to keep things awake right? So you don't get the respiratory, depressing effects that you get from medications like oxycodone, hydromorphone, oxycontin, etc. So I think that there is a great place for utilizing these medications. Now, education is key and we typically recommend thinking about an opioid consent. Form not not the medication agreement, but this is how you can keep things safe. You use an opioid consent form just like you would for a procedure.

Robert Agnello: And you go over all of the possible positive and negative outcomes that this met type of medication may cause or contribute to so that's how we go ahead. We also want to screen patients typically before we start them on an opioid for depression, anxiety, and for risk of developing a problem with an opioid and there's a wonderful tool for that called the opioid risk tool that you can utilize to help determine if there's like no risk mild, moderate, or severe risk for your patient utilizing that medication in developing, and an addiction or an opioid use disorder.

Steve Legault: Excellent. Thank you. And kind of keeping in line with that, another thing covered in the course is the tapering of opioids in line with evidence-based practices. So do you have any pearls in this area you'd like to share with our listeners.

Robert Agnello: Oh, Steve, this is a tough one, you know. There are a lot of wonderful guides and tools out there. First of all, when it comes to tapering, there could be a variety of reasons. Number one, maybe your patients just ready.

Robert Agnello: Guess what it is possible that your patient could just be ready and they want to try to be off of opioids.

Robert Agnello: And that could be because you provided other complementary integrative strategies that have been successful. And they've seen the light.

Robert Agnello: Perhaps you are running into a problem with the way they're using opioids.

Robert Agnello: And there is an opioid use disorder, or they're not really getting the benefits anticipated for the opioid. They're not improving in their function or their quality of life.

Robert Agnello: So tapering is interesting. There are a lot of guides.

Robert Agnello: There's plenty of great recommendations out there. My biggest pearl. What I've really learned over the course of time is to go slow.

Robert Agnello: and and you may see recommendations out there that recommend or say, you can reduce by 10 or 15 or 20 per month for people that have been on their opioid for 10 to 15 years that might not work, and it might really scare them. So I've learned that reducing by maybe 2 and a half percent or 5% of their morphine equivalents daily okay, or their morphine milli equivalents used in a daily basis. There's a lot of different ways that that's being looked at now, but knowing what that number is, will help you to slowly titrate that medication down over the course of time. Yes, some people can do it quicker. Some people are slower, some people you might get down to just that very last little nighttime dose right? And they can't. They just can't. They can't. It helps them sleep, maybe find out the reason why. Ask them the questions. But you might have reduced them 50, 75, even 90% on their total Opioid milli equivalents daily. That's fantastic.

Robert Agnello: Be happy, you know. Maybe you stop until they're like coming back to you and saying I did it all on my own and that's some of the tips. I think that work best for me in regard to tapering, which may lead into thinking about buprenorphine as well so some people maybe they convert at least to a safer opioid. You've got them down solo now, maybe below. What if you look in most of your guides if you look in Buprenorphine's information, getting them below 30 morphine milli equivalents of whatever opioid they're taking, could open up the doorway to do that pretty safely without inducing any kind of withdrawal symptoms. And so that could be at least an alternate safer opportunity.

Steve Legault: Excellent. Thank you for that. Something we get in follow up questions when we have courses on pain management around clinical presentations of patients at risk for opioid use disorder, or who may be inappropriately, inappropriately using opioids. So what advice do you have for it for physicians that suspect a patient of theirs might be using opioids outside of their prescribed use.

Robert Agnello: Yeah, in regard to this, you know, I think, that it's very important that you have tools to help identify this. You know, we already spoke about a tool to identify starting a patient on an opioid. There are tools that we should at least probably do once a year on continuing opioids. There is a tool called the continuing opioids misuse measurement scale, otherwise known as the COM. There's another tool known as Dyer, and there's several other tools as well. And and those might indicate to you, okay, we need to have a new conversation or an updated conversation about the safety with you and the opioid medication.

Robert Agnello: I I think that if you do suspect a problem, let's say the dates are coming sooner and sooner. When your patients, requesting a refill or you go into the registry. The State registry, which is almost like a national registry now, but the registry, and there seems to be medications filled from other providers. You do a urine test and there's another substance that you don't expect. Right. What do you do you? You talk to the patient? Did you expect that that was going to be there and find out? Why? Why is Tetrahydro cannabinoid there? Why is cocaine there? And you have a conversation, and maybe you identify that they don't just have an opioid use disorder, but maybe they have another substance use and that is not grounds any more for discharging a patient from your practice. That's what I just wanted you to walk out with tonight. Don't discharge those patients. Don't send them to another place. Don't pass the buck, as I like to say these people need your help and in these circumstances conversations can go far. Regaining trust can go far I use a lot of different strategies. We might only refill the medications one week at a time instead of 30, 28, or 30 days we might recheck those urines more frequently and if they ever get to a point where I continue to not be able to trust them, then we're going to work on titrating the medication down, and I will take care of them in every other way possible and we will. We'll work out a plan. And so that's kind of the advice that I would pro, you know, provide regarding, you know, if you think a patient is using opioids outside of their prescribed use. One other one, you know it's so interesting, Steve. You should prescribe your opioid very specifically but so on your directions. It should be oxycodone 5 milligrams every 6 h for pain level, greater than 7 over 10 for low back pain. If a patient decides to take that for their elbow, they are inappropriately using the medication. And so again, that would be another thing that would prompt conversation. To make sure that patient uses the Opioid correctly in the future.

Steve Legault: Excellent. Thank you. You know, having conversations like this kind of reminds me of the live case forms that we have that are part of this program. You know, where healthcare providers are coming, and they're bringing their cases to their peers. And then together, they're kind of devising solutions or getting ideas on treatment. Sowith that in mind, what's your favorite aspect of that portion of that program that with that live learning.

Robert Agnello: I think, Steve, that this has been so well received. The idea that we came up with as an organization working with ACOI and formulating a course where 6 h are asynchronous 6 and a half. Whatever we've kind of decided is and and the materials for that are very interactive. By the way, I just want to let you know those of you that haven't taken it, this is interactive material. There are some videos. There's some dragging columns. There's multiple choice. There are timelines. There's a lot of great, interesting, interactive stuff. I even learned stuff from our course from my colleagues. This is something always to learn about pain management. I always say it's the most fun field in medicine, you know, is pain management. So I try to get people as excited as I am about it. But I think the live format and the conversations that come from that live format are really invaluable and you know, I can tell you, I can share that Dr. Farrell and I, when we presented this information in New Orleans at our National ACOFP Conference that we were nervous, that nobody was going to talk, so we even prepared like 20 backup slides and we presented a couple of slides, and then offered it up and said, We want to hear about your patients. How can we help you? Or how can your colleagues that are out there sitting with you, help your patients. And well, once one person got going we heard from many more people. We spoke and went on for that full hour and a half allotted time, and probably could have filled up another hour or 2 based on the conversations we were having. And what does that also lead to. It leads to those sideline conversations after the live talk is over, that you're just not going to get in a virtual environment right? Somebody's pulls their colleague from the residency program. Wow, how did you guys implement opioid management in a family medicine residency buprenorphine opioid use disorder. That's what happened, and we're looking forward, Steve, to do that again this year at OMED, in San Antonio in September.

Steve Legault: Exactly. It's going to be a good time. I encourage anybody who hasn't registered yet. Registration just opened in June, so please do register. ACOI is having their live case form at their conference as well. It's going to be in October. So we're looking forward to that.

Steve Legault: For the final area. I wanted to touch on with pain management around OMT, it's a unique to Osteopathic physicians. So when a patient is, you know, looking for pain, relief, how do you bring up the idea of trying OMT? If they've never done it before.

Robert Agnello: Wow, that's a wonderful question. I offer up basically a menu of integrative opportunities for patients. A lot of the times. A good way, Steve, to get going with this is to have a screening tool to find out where a patient's interests lie. I have a tool that I utilize. That's comes from the integrative medicine and functional medicine world. That is a 14 page intake paperwork. That helps to really identify and figure out what the roots of this might be. How we can really optimize self-care, self-treatment, strategies which are probably the most studied and most important to fortify those routes I always like to mention. You know that if we could get people to eat well, sleep well, stress well, move well and get along with others. Well, the 5 roots alright! Guess what? Regardless of what's going up there in the branches and the leaves, patients are going to start to feel better.

Robert Agnello: So that's where we start. And I make sure that they're interested. So on my screening tool from ill, say, from one to 5, are you interested in changing your food, lifestyle? Are you interested in talking about herbs or supplements for your pain? Are you into and so on? Are you interested in manipulation acupuncture. If I have a patient that's marks that opportunity office 5 out of 5 or 4 out of 5, we're going to go for it now. Many of these patients have tried lots of things. You know, and so sometimes you got to get them a little glimmer of hope somewhere else along the path of where you're when you're treating them, and then they come back, and they might be like, now I would like to try osteopathic manipulation.

Robert Agnello: But you don't want to come in that door on that first visit and be like. I think OMT is going to be the answer, and they've marked one out of 5, their interest in manipulation. You're going to chase them right out the door. They're not going to trust you. You need to meet people where they are. And I talked them all about how osteopathic manipulation can help, just like we would with any other patient. How it impacts their autonomic nervous system, right? So their sympathetics and their parasympathetics, how it affects their biomechanics, and how it affects their circulation, and if we could get things just moving better and less congested that might give them moments where they are like. Wow! I didn't take my oxycodone for 4 extra hours, or I didn't take it for a couple of days and now they might be willing to work on discontinuing opioid medications. So I offer it. And all my patients really pretty much want it. Sometimes it's practicality. It's access it's insurance. So there could be a lot of reasons that could get in the way from certain complementary care strategies that we offer so we do have to meet patients and have to accept their means where they are. Really kind of identifying some of those things makes a big difference. And then, having conversations, you know there are. I've had patients, Steve, that in a million years I would never think they've wanted would want to try acupuncture. And so maybe they just built up trust. Wow! He didn't take my oxy cod on away. I'm still on my 40 morphine equivalents daily and 3 months in. They're like, you know what? I remember you mentioned something. I see this sign about acupuncture. What do you recommend? And we might do a little ear acupuncture needles that they go home with for 5 days, and they come out the next time they come back. And like, Wow! I I didn't need to use my opioids while those were in you know. As soon as they fell out I restarted them, or at least maybe as needed, and so providing opportunities. That's what I think we need to build up our tool kits. So we can really, you know, give our patients the chance to move forward.

Steve Legault: Excellent. Well, thank you so much for coming on the podcast and having this conversation on opioid use, disorder and approaches to pain management. It was a real pleasure getting to talk to you.

Robert Agnello: Steve is a pleasure speaking with you as well. Thank you so much.

Steve Legault: Excellent, and thank you for listening to the ACOFP DO.fm Clinical Podcast, a production of the American College of osteopathic, family physicians.

Mentioned in this episode:

De-stress Pain Management