Principles for managing OUD related to chronic pain in the Nordic countries based on a structured assessment of current practice

Principles for managing OUD related to chronic pain in the Nordic countries based on a structured... Background: Long-term use of opioid analgesics (OA) for chronic pain may result in opioid use disorder (OUD). This is associated with adverse outcomes for individuals, families and society. Treatment needs of people with OUD related to chronic pain are different compared to dependence related to use, and also injection, of illicit opioids. In Nordic countries, day-to-day practical advice to assist clinical decision-making is insufficient. Aim: To develop principles based on expert clinical insights for treatment of OUD related to the long-term use of OA in the context of chronic pain. Methods: Current status including an assessment of barriers to effective treatment in Finland, Denmark, Iceland, Norway, Sweden was defined using a patient pathway model. Evidence to describe best practice was identified from published literature, clinical guidelines and expert recommendations from practice experience. Results: Availability of national treatment guidelines for OUD related to chronic pain is limited across the Nordics. Important barriers to effective care identified: patients unlikely to present for help, healthcare system set up limits success, diagnosis tools not used, referral pathways unclear and treatment choices not elucidated. Principles include the development of a specific treatment pathway, awareness/ education programs for teams in primary care, guidance on use of diagnostic tools and a flexible treatment plan to encourage best practice in referral, treatment assessment, choice and ongoing management via an integrated care pathway. Healthcare systems and registries in Nordic countries offer an opportunity to further research and identify population risks and solutions. Conclusions: There is an opportunity to improve outcomes for patients with OUD related to chronic pain by developing and introducing care pathways tailored to specific needs of the population. Keywords: Opioid use disorder, Chronic pain, Nordics countries Background heterogeneous population [3]. For the patient, each dose The long-term use of opioid analgesics (OA) in the con- will provide some immediate relief, but repeated use of text of chronic pain syndromes may result in opioid use opioids can worsen pain, and associated psychological disorder (OUD) [1]. This is associated with harm to indi- symptoms. Dependence, when established, interacts with viduals, their families and also to society [2]. OUD in pain and associated symptoms such as sleep-disturbance, this population ranges from mild disease with few psychological distress, tiredness and cognitive symptoms. criteria of OUD fulfilled to severe and represents a This may result in a perceived need for opioids or other medication for control of such symptoms [4]. Chronic * Correspondence: johan.kakko@vll.se pain may alone interfere severely with the ability to par- Department of Clinical Sciences, Psychiatry, Umeå University, Psykiatriska ticipate in work and social life; the impact of long-term Kliniken Umeå, Norrlands Universitetssjukhus, SE-901 85 Umeå, Sweden opioid therapy at the individual level is unclear. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 2 of 9 Long-term opioid therapy, often considered in excess of defined based on a patient journey model describing 3months [5, 6], has a dose-dependent relation to the care in a series of steps from patient initial engagement, development of OUD and consistent use of high doses through diagnosis to treatment. The patient journey may indicate risk of the problem [7]. model was defined by the authors based on their experi- Without intervention, OUD commonly results in ser- ence and with reference to other similar examples [24]. ious psychosocial issues, medical problems and a signifi- Sources describing clinical practice, such as national cant risk from overdose [8]. Pharmacological choices OUD and pain management guidelines, were identified indicated for the treatment of OUD in this population in- by experts in relevant fields and collected. Data from clude tapering of OA or maintenance therapy with opioid sources were extracted and assessed by two reviewers agonist therapy (OAT) such as buprenorphine/ naloxone familiar with analysis and the therapy area. Based on the or buprenorphine [9, 10] and methadone [11, 12]. results, a consensus on principles for clinical care to Prescription of OAT for OUD must be considered as improve outcomes and future research were developed. distinct from use of opioids for pain, even though prod- ucts may have use in both situations. Results It is recognised that the characteristics [13], behav- Care was assessed in Denmark, Finland, Iceland, Norway iours [14] and needs [15] of patients with OUD related and Sweden. National treatment guidelines for the use to chronic pain are often different when compared to of OA (e.g. in patients with chronic non-cancer pain or patients with dependence related to use and also injec- acute post-surgery treatment) were identified from pro- tion of illicit opioids [12]. OUD may often be in the con- fessional societies or bodies responsible at national level text of the use of many sources and types of opioid for care, in Norway [25], Finland [26], Denmark [27], especially when severe, however when related to chronic and Sweden [28]. National or similar guidelines for the pain distinct features are present. Problems such as management of OUD care in general were identified in social disadvantage, contact with the criminal justice Denmark [29], Finland [30], Norway [31], Sweden [32] system, and co-existent health problems may be less and Iceland [33]. Specific guidance on the treatment of common in those with OUD related to chronic pain and OUD related to chronic pain was identified in Sweden prescribed OA [12], especially during early phases of the [32]. Limits to effective care were identified and are de- problem. Illicit heroin is now not the only source of scribed according to the patient journey model (Fig. 1). opioid and in some countries, is not the major problem: Structured assessment of the limits to successful care: OA may make up a large proportion of the opioid prob- lem whether prescribed, illicit or obtained from family (1) Engagement or other contacts [16]. These differences point to the Patients or users of OA often do not engage with potential for early intervention and the need for a healthcare services to seek help for OUD related to specific treatment approach tailored to the requirements chronic pain. This is due to a lack of awareness of of this population [12]. the potential problems of long-term opioid therapy Countries have published guidelines for the use of OA aiming to reduce symptoms associated with chronic in relation to chronic pain (e.g. USA [17], UK [18], pain from both patients and prescribing doctors, Australia [19]) and for the management of OUD in gen- limited knowledge on the benefits of treatment, and eral [20]. Specific guidance for OUD related to chronic limited engagement with the addiction services, pain is only available in a limited number of countries (e.g. which provide care mainly for patients with UK [21], Spain [22], Australia [23]) and does not aid the problems related to injection of illicit opioids and/ set-up of care services or support practical, day-to-day or psychoactive drugs, due to fear or stigma. decisions in management: the problem has not been ad- Advocacy from healthcare professionals (HCP) in dressed optimally in any country so far. In the Nordics primary care (PC) and other settings may be common approaches to the management of OUD and insufficient in many cases, reducing the chance of access to healthcare is an opportunity to assess clinical patients agreeing to further steps towards diagnosis, practice. This work aims to assess current approaches, referral and treatment. This lack of advocacy is limits and successes for care of patients with OUD related often related to a low level of knowledge in PC of to chronic pain and, based on this analysis, outline princi- OUD in general and options for care specifically ples for policy and practice development in the Nordic related to OUD and chronic pain. countries to improve outcomes for patients [12]. (2) Diagnosis in PC and addiction specialist settings is not optimal. Method Physicians, nurses and other HCP often have little A structured approach to collect evidence and assess training in the recognition and treatment of OUD. clinical practice in OUD related to chronic pain was A lack of familiarity with appropriate diagnostic Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 3 of 9 Fig. 1 Current status of treatment, policy & practice. Treatment of OUD related to long-term opioid analgesic use and chronic pain tools limits ability to effectively define patient (4) Treatment assessment must be based on a full problems and progress to appropriate care. clinical picture and understanding of the needs of Diagnosis may be difficult; for some patients it may the patient. be a challenge to accept that OUD is present, The goal of early intervention is important to especially because the source of the dependence – prevent the gradual worsening of OUD and OA pain medication – was prescribed and provided associated comorbidities over time. The difficulty in from within the medical system and is taken to establishing a detailed clinical picture for each reduce symptoms. Some pain relief is recognised individual patient, including OUD, pain, psychiatric upon taking the medication by the patient but less comorbidity (anxiety disorders and depression), and is recognised of side-effects such as the risk in escal- also in building relationships with patients due to ating doses, developing dependence, cognitive limited engagement and inappropriate treatment impairment, gastrointestinal symptoms or other service set-up often complicate adequate assess- symptoms caused by opioids. Patients may avoid ment. Success in treatment is limited due to lack of diagnosis despite evident problems due to a fear of an integrated and holistic approach to care. Across attracting stigma when entering the conventional the range of stakeholders who provide the necessary OUD treatment pathway. parts of care, a lack or insufficient awareness of the (3) Referral pathways are poorly defined or are specific and different nature of treatment for OUD inadequate. related to chronic pain make it hard to deliver an This limits the potential for progress with effective integrated program required for success. management. Care services developed for the (5) Treatment success is limited if the approach is not management of addiction, related commonly to specific to the needs of patients with OUD related illicit opioid or drug use, often do not meet the to chronic pain. needs of this specific population. The stigma Treatment must be based on a holistic approach associated with using existing, conventional and individual needs. The chronic pain patients seek treatment services limits participation of many relief from is difficult to treat in terms of reduced patients after referral. HCP may be unaware of the pain independent of given treatment. When risk of progression from OA use related to chronic tapering of opioids HCP should consider the pain to other forms of opioids and the risk of harm potential of opioids to induce hyperalgesia and the associated – limiting the urgency of referral. possible outcome of, in a part of the population, Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 4 of 9 worsening pain and function in daily life. Many care may not be sufficiently useful beyond providing stakeholders are required for effective care and general information; it is recommended that such policy outcomes are not optimal if clinical services are not and guidance is developed further to meet the needs of integrated and aligned. Inappropriate treatment the patients considering the comorbidity and challenges choices regarding medication, duration and therapy of treatment of this group. In relation to this, principles may result from inexperience or uninformed for best practice care of people with OUD related to decisions. Guidelines do not provide information to chronic pain are described according to a patient jour- assist clinicians in the practicalities of building and ney model (Fig. 2). delivering a treatment plan by means of an integrated team specialized in this particular setting. Increase engagement Functions including medical treatment, Presentation and engagement with care – the starting psychological and social therapy must be aligned for point for treatment – can be made easier and more success – a lack of awareness and experience in accessible. Awareness, advocacy and risk-based reviews treating patients in this population makes this more of treatment are needed in services that are perceived as difficult to achieve. Disjointed management across attractive, relevant and are specifically designed for the different healthcare functions may lead to patient population [34]. inadequate service delivery and poor outcomes. 1. In PC and with specialists in addiction medicine, Overall the lack of understanding of the size and na- provide educational programs aimed at increasing ture of the epidemiology of OUD related to chronic pain advocacy by building awareness of the problem, limits the development and provision of care services. In knowledge of referral pathways and successful policy, at national and regional level, there is often a lack interventions [35, 36]. of clarity on the commitment to provide appropriate 2. Consider prescription data reviews to identify resources to ensure the identification and treatment of patients at risk, with a potential need for help, as in OUD related to chronic pain. other locations including: Europe [37], UK [12], Denmark [38], US [36], Australia [23, 39]. Discussion 3. Develop simple decision-support tools to help pre- There is potential to improve the approach for the man- scribers of OA, pharmacists and others to target, agement of OUD related to chronic pain. Current policy plan and hold discussions with patients about de- and practice does not reflect the specific needs of pa- pendence problems, referral and treatment options tients and available guidance does not provide sufficient [36, 39]. direction on the practicalities of care overall. Guidance 4. Set up and support the use of digital and other for clinical practice in pain management and/or OUD easy-to-access, publicly available tools (digital Fig. 2 Suggested treatment approach, OUD related to chronic pain Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 5 of 9 applications to self-assess, telephone and web help- 3. Provide tools to assist HCP in working with line/ chat websites) to provide support and trusted patients to agree a “contract” defining goals of resources for patients, carers, and family members treatment and prescription renewal. If this contract [36, 40]. cannot be maintained, this may be a point of acceptance of the need for help. Experience with a trial of tapering of prescribed opioids, performed in Improve diagnosis cooperation with the patient, is an important step The gap in diagnosis and referral limits uptake of suc- in diagnosis; a lack of progress in dose tapering may cessful interventions and is based on limited awareness indicate OUD. of proven tools and successful pathways to treatment. Increase the chance of successful referral to specialist 1. Provide specific training for HCP in PC to improve care skills and knowledge of diagnosis and referral Referrals to specialist care are limited because of unclear pathways. Addiction and pain management or inappropriate pathways. specialists and national authorities should collaborate in providing educational pathways for 1. Ensure at policy and clinical practice level that HCP and psychiatrists. This includes drug screening there is a referral pathway appropriate to the needs and detection of relevant behavioural changes such of patients with an option, when practical, to offer as using opioids for reasons other than pain, to “get initial specialist consultation in PC to reduce stigma high” or “manage stress” [41], rapidly escalating [40]. Patient with OUD related to chronic pain are demands for dose increases, unusual increase in more likely to engage, and be retained, in treatment doses, observed or reported intoxication or if care pathways are provided that are distinct to unexplained withdrawal symptoms, repeatedly the services offered to persons with OUD related to reporting that opioid medication was lost, stolen, or use and injection of illicit opioids [12, 51]. destroyed; injection of opioids; threatening or harassing staff; repeatedly seeking prescriptions Improve treatment assessment and choices from other providers or emergency rooms; Non-optimal treatment assessment and choices of treat- alteration, borrowing, stealing or selling ment may result from inexperience of HCP. prescriptions [42]; poor attendance at treatment review; appearing sedated at times; resisting drug 1. A specific clinical assessment is recommended for screening; and deteriorating social function [21]. patients with OUD related to chronic pain [21, 46, Education on modern diagnostic tools [36, 43, 44], 52]. A detailed profile or treatment inventory is access to training resources [45], practical required with status (e.g. pain, mental health status, guidelines for diagnosis [46] is recommended. anxiety, depression, other psychiatric disorders), Diagnostic and screening tools include those severity of dependence and identification of other specific to OA or chronic pain (Current Opioid substances in use (non-opioid medications with Misuse Measure [47], Prescription Opioid Misuse addictive potential such as benzodiazepines, Index [44]). General tools may also be useful, stimulants, alcohol/ nicotine and other substances). including Leeds Dependence Questionnaire (LDQ) A pain assessment is required; if pain is a dominant [48], Diagnostic and Statistical Manual of Mental feature, management led by pain specialists may be Disorders, (DSM-5) [49], and International recommended. A biopsychosocial approach is useful Statistical Classification of Diseases and Related in pain investigation to understand how pain Health Problems 10th Revision (ICD-10) [50]. interferes with life and to understand how long- 2. Provide resources to set up and encourage the term opioid use may contribute to suffering at indi- development of clinical practice aiming to achieve vidual level. Many tools to assess pain may be used: diagnosis in a joint effort between pain The Brief Pain Inventory (BPI) [53], The Client management specialists, addiction specialists and Health Questionnaire (PHQ-9) [54], EQ-5D-5 L PC [46]. The model of care may be different in each [55] or a composition of tools as in Swedish Quality location but the aim is co-operation with joint Registry for Pain Rehabilitation [56]. For patients goals, plans and coordinated delivery of care with with co-existing mental health problems, plans measurement of outcomes supported by patient should be made to manage these issues. Severity of registries. The ideal model of care presents a dedi- dependence guides decision-making and is the key cated service for patients based on organisation of for treatment assessment. Patients with severe prob- resources from PC, pain and addiction services. lems may require higher doses of medication or Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 6 of 9 need longer to achieve recovery. This may be assessed treatment programs [52] and strategies to respond with tools such as DSM-5 [49]or ICD-10 [50]. in the event of relapse should be in place. 2. A joint individualised [52, 57] treatment plan 8. Adjustments of dose and choice of programs for integrated across addiction services, pain clinics, psychosocial support may be necessary; decisions psychiatry and PC services with a long-term view are guided by clinical progress including factors on care is required [46]. such as use of other opioids or addictive substances, 3. Management of existing OA medications for craving and potentially other psychiatric symptoms chronic pain and planning to reduce or taper such as anxiety or depression. medications over time in agreement with the 9. Cessation of OAT is guided by clinical response; patient [46]. Tapering can be performed with the many patients are expected to complete therapy prescribed drug or a switch to buprenorphine/ and cease using any opioids. Duration of therapy naloxone [58]. It may be possible to stop opioid may extend beyond 1 year [21]. Therapy should not medications and use adjunctive medication to be stopped prematurely and against the patient's support those agreeing to this plan, and not will; therapy discontinuation should be carefully displaying signs of psychological dependence. planned in discussion with patients and HCP 4. Treatment choices start with a managed reduction/ jointly. tapering of current OA, which can be tried either as 10. Access to appropriate specialist support groups a slow tapering in an outpatient setting, or faster in specific to OUD and chronic pain problems for an inpatient setting. If these options are not patients and their families should be available and successful, treatment with opioid agonist therapy actively referred to, for example behavioural therapy (OAT) as part of an integrated psychosocial care [12]. Therapy focused on acceptance of the problem program may be required [39, 46, 52]. Treatment is also recommended; this may include mindfulness should be planned on the basis of a detailed patient coaching. Special education about the nature of assessment or “inventory” [46, 52]. chronic pain and support for patients is important; 5. Treatment with OAT may be recommended if dose catastrophizing thoughts about the severity of pain reduction/ tapering does not lead to improvement and problems in relation to changing analgesic and OUD is considered to be moderate to severe. mediations are common in many patients. It is Based on the patient inventory including full listing important to address this issue as it may be of prescription and other drugs in use by the possible, at least in some part, to address it with patient, a single dose of one opioid agonist can be education and development of coping strategies. prescribed. Commonly prescribed options include buprenorphine/ naloxone (as recommended in This analysis focuses on the steps of care specific to specific, existing national guidelines in Sweden), OUD related to chronic pain; it is important to also act methadone or buprenorphine [52]. The decision to to prevent problems emerging. It is important that all use OAT, and the exact treatment plan including patients with chronic pain receive appropriate care. choice of medication, is based on clinical scenario, Where treatment with OA is considered, screening for risk profile, social & family situation, patient risk of substance use disorder (SUD) in general is preference and assessment of safety and risk factors important in the evaluation of medication treatment of such as misuse, diversion, risk at home, concurrent pain. Prescribing OA needs special attention for people addictive behaviour to other substances (e.g. alcohol at risk for SUD and special precautions are needed if or benzodiazepines), previous overdoses, psychiatric OA are necessary. OA prescription practice should be comorbidity [46]. well-founded to ensure appropriate pain care is provided 6. Buprenorphine/ naloxone is a common initial for chronic pain patients – this in turn will limit initi- recommendation if OAT medication is considered, ation of large scale harmful opioid use. Early interven- in alignment with guidance [32]. Buprenorphine, tion is needed to avoid treatment with OA for pain because of potential for diversion, and methadone, developing into chronic OUD. An integrated and multi- due its profile with side effects including sedation disciplinary service should be provided for all patients and risk of overdose [45], may commonly be less who develop OUD in relation to chronic pain. It is attractive starting choices. No one choice of important to set up an environment in which there is an medical therapy is suitable for all patients; it is ongoing recognition of the specific needs of populations important to tailor therapy based on the needs of with OUD related to chronic pain, to design care ser- the individuals [52]. vices to meet the needs of these groups and to support 7. Intensive treatment monitoring is needed as HCP and other services in providing integrated and indi- standard [21], especially at the beginning of vidualised care. It is important to define the ideal care Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 7 of 9 set up at community and specialist levels, with goals of Authors’ contributions All authors made substantial contributions to conception and design the initial, short and longer-term treatment. In the manuscript, acquisition of national data, drafting, review and final approval longer-term perspective education to reduce the impact of the manuscript. of stigma and related barriers to treatment may be valu- Ethics approval and consent to participate able: starting with practical treatment steps can also be a Not applicable. part of changing this. This work is based on an assessment of current Competing interests The authors declare that they have no competing interests. approaches to OUD care in chronic pain setting with in- sights from specialists each with at least 10 years’ experi- Publisher’sNote ence in OUD (10) and pain management (1); there can Springer Nature remains neutral with regard to jurisdictional claims in be benefit in including other pain specialists and organi- published maps and institutional affiliations. sations. This work is based on review of evidence from Author details Nordic countries; this may limit wider applicability but Department of Clinical Sciences, Psychiatry, Umeå University, Psykiatriska the challenges and principles for managing OUD related Kliniken Umeå, Norrlands Universitetssjukhus, SE-901 85 Umeå, Sweden. 2 3 to chronic pain identified here likely do however apply Solstenen i Skane, Addiction Centre, Lund, Sweden. Capio Maria, Stockholm and Skåne, Sweden. Department of Clinical Sciences Lund University, more widely. The existence of health registries and the Malmö, Sweden. Pain Rehabilitation Department, Skåne University Hospital, similar approaches to OUD management and healthcare 6 Skåne, Sweden. Overlæge, Odense Kommune, Misbrugsbehandling, Odense, in general in Nordic countries present an opportunity to Denmark. Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway. SAA – National Center of Addiction Medicine, Vogur Hospital, collect evidence to define the magnitude of the problem Reykjavik, Iceland. A-Clinic Foundation/ A-clinic oy, University of Helsinki and in greater detail, for example by assessing OA prescrip- 10 Helsinki University Hospital, Helsinki, Finland. Applied strategic, London, UK. tion data, and to develop further evidence-based Abdominal Center, University Hospital and University of Helsinki, Helsinki, Finland. Department of Pharmaceutical Biosciences, Uppsala University, approaches to clinical practice. Uppsala, Sweden. Received: 8 March 2018 Accepted: 17 May 2018 Conclusion The population with OUD related to chronic pain may References be underserved for healthcare and find it hard to access 1. 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J Opioid Manag. 2006;2:277–82. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Substance Abuse Treatment, Prevention, and Policy Springer Journals

Principles for managing OUD related to chronic pain in the Nordic countries based on a structured assessment of current practice

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Medicine & Public Health; Public Health; Social Policy; Social Work; Pharmacology/Toxicology; Health Psychology
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Abstract

Background: Long-term use of opioid analgesics (OA) for chronic pain may result in opioid use disorder (OUD). This is associated with adverse outcomes for individuals, families and society. Treatment needs of people with OUD related to chronic pain are different compared to dependence related to use, and also injection, of illicit opioids. In Nordic countries, day-to-day practical advice to assist clinical decision-making is insufficient. Aim: To develop principles based on expert clinical insights for treatment of OUD related to the long-term use of OA in the context of chronic pain. Methods: Current status including an assessment of barriers to effective treatment in Finland, Denmark, Iceland, Norway, Sweden was defined using a patient pathway model. Evidence to describe best practice was identified from published literature, clinical guidelines and expert recommendations from practice experience. Results: Availability of national treatment guidelines for OUD related to chronic pain is limited across the Nordics. Important barriers to effective care identified: patients unlikely to present for help, healthcare system set up limits success, diagnosis tools not used, referral pathways unclear and treatment choices not elucidated. Principles include the development of a specific treatment pathway, awareness/ education programs for teams in primary care, guidance on use of diagnostic tools and a flexible treatment plan to encourage best practice in referral, treatment assessment, choice and ongoing management via an integrated care pathway. Healthcare systems and registries in Nordic countries offer an opportunity to further research and identify population risks and solutions. Conclusions: There is an opportunity to improve outcomes for patients with OUD related to chronic pain by developing and introducing care pathways tailored to specific needs of the population. Keywords: Opioid use disorder, Chronic pain, Nordics countries Background heterogeneous population [3]. For the patient, each dose The long-term use of opioid analgesics (OA) in the con- will provide some immediate relief, but repeated use of text of chronic pain syndromes may result in opioid use opioids can worsen pain, and associated psychological disorder (OUD) [1]. This is associated with harm to indi- symptoms. Dependence, when established, interacts with viduals, their families and also to society [2]. OUD in pain and associated symptoms such as sleep-disturbance, this population ranges from mild disease with few psychological distress, tiredness and cognitive symptoms. criteria of OUD fulfilled to severe and represents a This may result in a perceived need for opioids or other medication for control of such symptoms [4]. Chronic * Correspondence: johan.kakko@vll.se pain may alone interfere severely with the ability to par- Department of Clinical Sciences, Psychiatry, Umeå University, Psykiatriska ticipate in work and social life; the impact of long-term Kliniken Umeå, Norrlands Universitetssjukhus, SE-901 85 Umeå, Sweden opioid therapy at the individual level is unclear. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 2 of 9 Long-term opioid therapy, often considered in excess of defined based on a patient journey model describing 3months [5, 6], has a dose-dependent relation to the care in a series of steps from patient initial engagement, development of OUD and consistent use of high doses through diagnosis to treatment. The patient journey may indicate risk of the problem [7]. model was defined by the authors based on their experi- Without intervention, OUD commonly results in ser- ence and with reference to other similar examples [24]. ious psychosocial issues, medical problems and a signifi- Sources describing clinical practice, such as national cant risk from overdose [8]. Pharmacological choices OUD and pain management guidelines, were identified indicated for the treatment of OUD in this population in- by experts in relevant fields and collected. Data from clude tapering of OA or maintenance therapy with opioid sources were extracted and assessed by two reviewers agonist therapy (OAT) such as buprenorphine/ naloxone familiar with analysis and the therapy area. Based on the or buprenorphine [9, 10] and methadone [11, 12]. results, a consensus on principles for clinical care to Prescription of OAT for OUD must be considered as improve outcomes and future research were developed. distinct from use of opioids for pain, even though prod- ucts may have use in both situations. Results It is recognised that the characteristics [13], behav- Care was assessed in Denmark, Finland, Iceland, Norway iours [14] and needs [15] of patients with OUD related and Sweden. National treatment guidelines for the use to chronic pain are often different when compared to of OA (e.g. in patients with chronic non-cancer pain or patients with dependence related to use and also injec- acute post-surgery treatment) were identified from pro- tion of illicit opioids [12]. OUD may often be in the con- fessional societies or bodies responsible at national level text of the use of many sources and types of opioid for care, in Norway [25], Finland [26], Denmark [27], especially when severe, however when related to chronic and Sweden [28]. National or similar guidelines for the pain distinct features are present. Problems such as management of OUD care in general were identified in social disadvantage, contact with the criminal justice Denmark [29], Finland [30], Norway [31], Sweden [32] system, and co-existent health problems may be less and Iceland [33]. Specific guidance on the treatment of common in those with OUD related to chronic pain and OUD related to chronic pain was identified in Sweden prescribed OA [12], especially during early phases of the [32]. Limits to effective care were identified and are de- problem. Illicit heroin is now not the only source of scribed according to the patient journey model (Fig. 1). opioid and in some countries, is not the major problem: Structured assessment of the limits to successful care: OA may make up a large proportion of the opioid prob- lem whether prescribed, illicit or obtained from family (1) Engagement or other contacts [16]. These differences point to the Patients or users of OA often do not engage with potential for early intervention and the need for a healthcare services to seek help for OUD related to specific treatment approach tailored to the requirements chronic pain. This is due to a lack of awareness of of this population [12]. the potential problems of long-term opioid therapy Countries have published guidelines for the use of OA aiming to reduce symptoms associated with chronic in relation to chronic pain (e.g. USA [17], UK [18], pain from both patients and prescribing doctors, Australia [19]) and for the management of OUD in gen- limited knowledge on the benefits of treatment, and eral [20]. Specific guidance for OUD related to chronic limited engagement with the addiction services, pain is only available in a limited number of countries (e.g. which provide care mainly for patients with UK [21], Spain [22], Australia [23]) and does not aid the problems related to injection of illicit opioids and/ set-up of care services or support practical, day-to-day or psychoactive drugs, due to fear or stigma. decisions in management: the problem has not been ad- Advocacy from healthcare professionals (HCP) in dressed optimally in any country so far. In the Nordics primary care (PC) and other settings may be common approaches to the management of OUD and insufficient in many cases, reducing the chance of access to healthcare is an opportunity to assess clinical patients agreeing to further steps towards diagnosis, practice. This work aims to assess current approaches, referral and treatment. This lack of advocacy is limits and successes for care of patients with OUD related often related to a low level of knowledge in PC of to chronic pain and, based on this analysis, outline princi- OUD in general and options for care specifically ples for policy and practice development in the Nordic related to OUD and chronic pain. countries to improve outcomes for patients [12]. (2) Diagnosis in PC and addiction specialist settings is not optimal. Method Physicians, nurses and other HCP often have little A structured approach to collect evidence and assess training in the recognition and treatment of OUD. clinical practice in OUD related to chronic pain was A lack of familiarity with appropriate diagnostic Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 3 of 9 Fig. 1 Current status of treatment, policy & practice. Treatment of OUD related to long-term opioid analgesic use and chronic pain tools limits ability to effectively define patient (4) Treatment assessment must be based on a full problems and progress to appropriate care. clinical picture and understanding of the needs of Diagnosis may be difficult; for some patients it may the patient. be a challenge to accept that OUD is present, The goal of early intervention is important to especially because the source of the dependence – prevent the gradual worsening of OUD and OA pain medication – was prescribed and provided associated comorbidities over time. The difficulty in from within the medical system and is taken to establishing a detailed clinical picture for each reduce symptoms. Some pain relief is recognised individual patient, including OUD, pain, psychiatric upon taking the medication by the patient but less comorbidity (anxiety disorders and depression), and is recognised of side-effects such as the risk in escal- also in building relationships with patients due to ating doses, developing dependence, cognitive limited engagement and inappropriate treatment impairment, gastrointestinal symptoms or other service set-up often complicate adequate assess- symptoms caused by opioids. Patients may avoid ment. Success in treatment is limited due to lack of diagnosis despite evident problems due to a fear of an integrated and holistic approach to care. Across attracting stigma when entering the conventional the range of stakeholders who provide the necessary OUD treatment pathway. parts of care, a lack or insufficient awareness of the (3) Referral pathways are poorly defined or are specific and different nature of treatment for OUD inadequate. related to chronic pain make it hard to deliver an This limits the potential for progress with effective integrated program required for success. management. Care services developed for the (5) Treatment success is limited if the approach is not management of addiction, related commonly to specific to the needs of patients with OUD related illicit opioid or drug use, often do not meet the to chronic pain. needs of this specific population. The stigma Treatment must be based on a holistic approach associated with using existing, conventional and individual needs. The chronic pain patients seek treatment services limits participation of many relief from is difficult to treat in terms of reduced patients after referral. HCP may be unaware of the pain independent of given treatment. When risk of progression from OA use related to chronic tapering of opioids HCP should consider the pain to other forms of opioids and the risk of harm potential of opioids to induce hyperalgesia and the associated – limiting the urgency of referral. possible outcome of, in a part of the population, Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 4 of 9 worsening pain and function in daily life. Many care may not be sufficiently useful beyond providing stakeholders are required for effective care and general information; it is recommended that such policy outcomes are not optimal if clinical services are not and guidance is developed further to meet the needs of integrated and aligned. Inappropriate treatment the patients considering the comorbidity and challenges choices regarding medication, duration and therapy of treatment of this group. In relation to this, principles may result from inexperience or uninformed for best practice care of people with OUD related to decisions. Guidelines do not provide information to chronic pain are described according to a patient jour- assist clinicians in the practicalities of building and ney model (Fig. 2). delivering a treatment plan by means of an integrated team specialized in this particular setting. Increase engagement Functions including medical treatment, Presentation and engagement with care – the starting psychological and social therapy must be aligned for point for treatment – can be made easier and more success – a lack of awareness and experience in accessible. Awareness, advocacy and risk-based reviews treating patients in this population makes this more of treatment are needed in services that are perceived as difficult to achieve. Disjointed management across attractive, relevant and are specifically designed for the different healthcare functions may lead to patient population [34]. inadequate service delivery and poor outcomes. 1. In PC and with specialists in addiction medicine, Overall the lack of understanding of the size and na- provide educational programs aimed at increasing ture of the epidemiology of OUD related to chronic pain advocacy by building awareness of the problem, limits the development and provision of care services. In knowledge of referral pathways and successful policy, at national and regional level, there is often a lack interventions [35, 36]. of clarity on the commitment to provide appropriate 2. Consider prescription data reviews to identify resources to ensure the identification and treatment of patients at risk, with a potential need for help, as in OUD related to chronic pain. other locations including: Europe [37], UK [12], Denmark [38], US [36], Australia [23, 39]. Discussion 3. Develop simple decision-support tools to help pre- There is potential to improve the approach for the man- scribers of OA, pharmacists and others to target, agement of OUD related to chronic pain. Current policy plan and hold discussions with patients about de- and practice does not reflect the specific needs of pa- pendence problems, referral and treatment options tients and available guidance does not provide sufficient [36, 39]. direction on the practicalities of care overall. Guidance 4. Set up and support the use of digital and other for clinical practice in pain management and/or OUD easy-to-access, publicly available tools (digital Fig. 2 Suggested treatment approach, OUD related to chronic pain Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 5 of 9 applications to self-assess, telephone and web help- 3. Provide tools to assist HCP in working with line/ chat websites) to provide support and trusted patients to agree a “contract” defining goals of resources for patients, carers, and family members treatment and prescription renewal. If this contract [36, 40]. cannot be maintained, this may be a point of acceptance of the need for help. Experience with a trial of tapering of prescribed opioids, performed in Improve diagnosis cooperation with the patient, is an important step The gap in diagnosis and referral limits uptake of suc- in diagnosis; a lack of progress in dose tapering may cessful interventions and is based on limited awareness indicate OUD. of proven tools and successful pathways to treatment. Increase the chance of successful referral to specialist 1. Provide specific training for HCP in PC to improve care skills and knowledge of diagnosis and referral Referrals to specialist care are limited because of unclear pathways. Addiction and pain management or inappropriate pathways. specialists and national authorities should collaborate in providing educational pathways for 1. Ensure at policy and clinical practice level that HCP and psychiatrists. This includes drug screening there is a referral pathway appropriate to the needs and detection of relevant behavioural changes such of patients with an option, when practical, to offer as using opioids for reasons other than pain, to “get initial specialist consultation in PC to reduce stigma high” or “manage stress” [41], rapidly escalating [40]. Patient with OUD related to chronic pain are demands for dose increases, unusual increase in more likely to engage, and be retained, in treatment doses, observed or reported intoxication or if care pathways are provided that are distinct to unexplained withdrawal symptoms, repeatedly the services offered to persons with OUD related to reporting that opioid medication was lost, stolen, or use and injection of illicit opioids [12, 51]. destroyed; injection of opioids; threatening or harassing staff; repeatedly seeking prescriptions Improve treatment assessment and choices from other providers or emergency rooms; Non-optimal treatment assessment and choices of treat- alteration, borrowing, stealing or selling ment may result from inexperience of HCP. prescriptions [42]; poor attendance at treatment review; appearing sedated at times; resisting drug 1. A specific clinical assessment is recommended for screening; and deteriorating social function [21]. patients with OUD related to chronic pain [21, 46, Education on modern diagnostic tools [36, 43, 44], 52]. A detailed profile or treatment inventory is access to training resources [45], practical required with status (e.g. pain, mental health status, guidelines for diagnosis [46] is recommended. anxiety, depression, other psychiatric disorders), Diagnostic and screening tools include those severity of dependence and identification of other specific to OA or chronic pain (Current Opioid substances in use (non-opioid medications with Misuse Measure [47], Prescription Opioid Misuse addictive potential such as benzodiazepines, Index [44]). General tools may also be useful, stimulants, alcohol/ nicotine and other substances). including Leeds Dependence Questionnaire (LDQ) A pain assessment is required; if pain is a dominant [48], Diagnostic and Statistical Manual of Mental feature, management led by pain specialists may be Disorders, (DSM-5) [49], and International recommended. A biopsychosocial approach is useful Statistical Classification of Diseases and Related in pain investigation to understand how pain Health Problems 10th Revision (ICD-10) [50]. interferes with life and to understand how long- 2. Provide resources to set up and encourage the term opioid use may contribute to suffering at indi- development of clinical practice aiming to achieve vidual level. Many tools to assess pain may be used: diagnosis in a joint effort between pain The Brief Pain Inventory (BPI) [53], The Client management specialists, addiction specialists and Health Questionnaire (PHQ-9) [54], EQ-5D-5 L PC [46]. The model of care may be different in each [55] or a composition of tools as in Swedish Quality location but the aim is co-operation with joint Registry for Pain Rehabilitation [56]. For patients goals, plans and coordinated delivery of care with with co-existing mental health problems, plans measurement of outcomes supported by patient should be made to manage these issues. Severity of registries. The ideal model of care presents a dedi- dependence guides decision-making and is the key cated service for patients based on organisation of for treatment assessment. Patients with severe prob- resources from PC, pain and addiction services. lems may require higher doses of medication or Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 6 of 9 need longer to achieve recovery. This may be assessed treatment programs [52] and strategies to respond with tools such as DSM-5 [49]or ICD-10 [50]. in the event of relapse should be in place. 2. A joint individualised [52, 57] treatment plan 8. Adjustments of dose and choice of programs for integrated across addiction services, pain clinics, psychosocial support may be necessary; decisions psychiatry and PC services with a long-term view are guided by clinical progress including factors on care is required [46]. such as use of other opioids or addictive substances, 3. Management of existing OA medications for craving and potentially other psychiatric symptoms chronic pain and planning to reduce or taper such as anxiety or depression. medications over time in agreement with the 9. Cessation of OAT is guided by clinical response; patient [46]. Tapering can be performed with the many patients are expected to complete therapy prescribed drug or a switch to buprenorphine/ and cease using any opioids. Duration of therapy naloxone [58]. It may be possible to stop opioid may extend beyond 1 year [21]. Therapy should not medications and use adjunctive medication to be stopped prematurely and against the patient's support those agreeing to this plan, and not will; therapy discontinuation should be carefully displaying signs of psychological dependence. planned in discussion with patients and HCP 4. Treatment choices start with a managed reduction/ jointly. tapering of current OA, which can be tried either as 10. Access to appropriate specialist support groups a slow tapering in an outpatient setting, or faster in specific to OUD and chronic pain problems for an inpatient setting. If these options are not patients and their families should be available and successful, treatment with opioid agonist therapy actively referred to, for example behavioural therapy (OAT) as part of an integrated psychosocial care [12]. Therapy focused on acceptance of the problem program may be required [39, 46, 52]. Treatment is also recommended; this may include mindfulness should be planned on the basis of a detailed patient coaching. Special education about the nature of assessment or “inventory” [46, 52]. chronic pain and support for patients is important; 5. Treatment with OAT may be recommended if dose catastrophizing thoughts about the severity of pain reduction/ tapering does not lead to improvement and problems in relation to changing analgesic and OUD is considered to be moderate to severe. mediations are common in many patients. It is Based on the patient inventory including full listing important to address this issue as it may be of prescription and other drugs in use by the possible, at least in some part, to address it with patient, a single dose of one opioid agonist can be education and development of coping strategies. prescribed. Commonly prescribed options include buprenorphine/ naloxone (as recommended in This analysis focuses on the steps of care specific to specific, existing national guidelines in Sweden), OUD related to chronic pain; it is important to also act methadone or buprenorphine [52]. The decision to to prevent problems emerging. It is important that all use OAT, and the exact treatment plan including patients with chronic pain receive appropriate care. choice of medication, is based on clinical scenario, Where treatment with OA is considered, screening for risk profile, social & family situation, patient risk of substance use disorder (SUD) in general is preference and assessment of safety and risk factors important in the evaluation of medication treatment of such as misuse, diversion, risk at home, concurrent pain. Prescribing OA needs special attention for people addictive behaviour to other substances (e.g. alcohol at risk for SUD and special precautions are needed if or benzodiazepines), previous overdoses, psychiatric OA are necessary. OA prescription practice should be comorbidity [46]. well-founded to ensure appropriate pain care is provided 6. Buprenorphine/ naloxone is a common initial for chronic pain patients – this in turn will limit initi- recommendation if OAT medication is considered, ation of large scale harmful opioid use. Early interven- in alignment with guidance [32]. Buprenorphine, tion is needed to avoid treatment with OA for pain because of potential for diversion, and methadone, developing into chronic OUD. An integrated and multi- due its profile with side effects including sedation disciplinary service should be provided for all patients and risk of overdose [45], may commonly be less who develop OUD in relation to chronic pain. It is attractive starting choices. No one choice of important to set up an environment in which there is an medical therapy is suitable for all patients; it is ongoing recognition of the specific needs of populations important to tailor therapy based on the needs of with OUD related to chronic pain, to design care ser- the individuals [52]. vices to meet the needs of these groups and to support 7. Intensive treatment monitoring is needed as HCP and other services in providing integrated and indi- standard [21], especially at the beginning of vidualised care. It is important to define the ideal care Kakko et al. Substance Abuse Treatment, Prevention, and Policy (2018) 13:22 Page 7 of 9 set up at community and specialist levels, with goals of Authors’ contributions All authors made substantial contributions to conception and design the initial, short and longer-term treatment. In the manuscript, acquisition of national data, drafting, review and final approval longer-term perspective education to reduce the impact of the manuscript. of stigma and related barriers to treatment may be valu- Ethics approval and consent to participate able: starting with practical treatment steps can also be a Not applicable. part of changing this. This work is based on an assessment of current Competing interests The authors declare that they have no competing interests. approaches to OUD care in chronic pain setting with in- sights from specialists each with at least 10 years’ experi- Publisher’sNote ence in OUD (10) and pain management (1); there can Springer Nature remains neutral with regard to jurisdictional claims in be benefit in including other pain specialists and organi- published maps and institutional affiliations. sations. This work is based on review of evidence from Author details Nordic countries; this may limit wider applicability but Department of Clinical Sciences, Psychiatry, Umeå University, Psykiatriska the challenges and principles for managing OUD related Kliniken Umeå, Norrlands Universitetssjukhus, SE-901 85 Umeå, Sweden. 2 3 to chronic pain identified here likely do however apply Solstenen i Skane, Addiction Centre, Lund, Sweden. Capio Maria, Stockholm and Skåne, Sweden. Department of Clinical Sciences Lund University, more widely. The existence of health registries and the Malmö, Sweden. Pain Rehabilitation Department, Skåne University Hospital, similar approaches to OUD management and healthcare 6 Skåne, Sweden. Overlæge, Odense Kommune, Misbrugsbehandling, Odense, in general in Nordic countries present an opportunity to Denmark. Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway. SAA – National Center of Addiction Medicine, Vogur Hospital, collect evidence to define the magnitude of the problem Reykjavik, Iceland. A-Clinic Foundation/ A-clinic oy, University of Helsinki and in greater detail, for example by assessing OA prescrip- 10 Helsinki University Hospital, Helsinki, Finland. Applied strategic, London, UK. tion data, and to develop further evidence-based Abdominal Center, University Hospital and University of Helsinki, Helsinki, Finland. Department of Pharmaceutical Biosciences, Uppsala University, approaches to clinical practice. Uppsala, Sweden. Received: 8 March 2018 Accepted: 17 May 2018 Conclusion The population with OUD related to chronic pain may References be underserved for healthcare and find it hard to access 1. 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