Opioids and Cannabinoids in Neurology Practice With Dr. Friedhelm Sandbrink

Opioids may be considered for temporary use in patients with severe pain related to selected neuropathic pain conditions and only as part of a multimodal treatment regimen. Close follow-up when initiating or adjusting opioid therapy and frequent reevaluation during long-term opioid therapy is required. In this episode, Allison Weathers, MD, FAAN speaks with Friedhelm Sandbrink, MD, FAAN, an author of the article “Opioids and Cannabinoids in Neurology Practice,” in the Continuum® October 2024 Pain Management in Neurology issue. Dr. Weathers is a Continuum Audio interviewer and the associate chief medical information officer at the Cleveland Clinic in Cleveland, Ohio. Dr. Sandbrink is the national program director of Pain Management, Opioid Safety and Prescription Drug Monitoring Programs at the Veterans Health Administration, Uniformed Services University in Bethesda, Maryland. Additional Resources Read the article: Opioids and Cannabinoids in Neurology Practice Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media @ContinuumAAN facebook.com/continuumcme Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum Journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal and how to get CME. Dr Weathers: I'm Dr Allison Weathers. Today I'm interviewing Dr Friedhelm Sandbrink, who is one of the authors of the article Opioids and Cannabinoids for the Practicing Neurologist from the October 2024 Continuum issue on pain management Neurology. Welcome to the podcast and please introduce yourself to our audience.  Dr Sandbrink: Yeah, hi. So, I'm Friedhelm Sandbrink. I'm a neurologist and pain physician. I work at the Washington DC VA Medical Center, where I lead our intercessory pain management team, and I have a role also in the VA central office for pain management. I'm also associate professor, clinical associate professor at George Washington University and at the Uniformed Services University in Bethesda.  Dr Weathers: A lot of expertise, which you obviously brought to this article. And I do want to emphasize before we get started, although the article discusses both opioids and cannabinoids, as I said in the introduction, you worked in specifically on opioids. And so that's the part of the article where we'll focus our conversation today. Of course, I think all of our Continuum Audio topics are really fascinating. I know that some may not resonate as much, especially with our non-neurology listeners as others. Clearly not the case with your articles. I was reading it and preparing for a conversation today. I was really struck by how broadly applicable this topic is, not only to all neurologists but, really, all physicians, and even it should be to all of our listeners. Especially with what happened been going on over the last several years, what's been in the news about the opioid epidemic. And while usually like to start with this question, it feels even more pertinent in your case, what is the most important clinical message of your article? Dr Sandbrink: So, the role of the opioid, the role of opioid therapy, really, for pain care has changed dramatically over the last many years right? I mean, it's we, we still consider opioids like the most potent analgesic medication for treatment of acute pain. The benefit for chronic pain really has changed right I mean, you know, we- the understanding in that regard and they're controversial. So, they're generally not recommended for chronic treatment for neuropathic pain conditions or for headache, but there are probably situations when opioids are still indicated and may be considered especially for temporary use. So, one example is probably the patient who has severe acute post hepatic neuralgia and we know that we use other medications for that, you know, the gabapentinoids and duloxetine and but they may take several days or weeks to work, right? And we have to titrate them up. And when more acute pain relief is needed, the opioid medication may be may be an option for temporary use. But I think what we need to keep in mind is that when we use it, we need to be informed about how to mitigate the risks, right? What, what are our best ways to reduce harms? And we need to also know the regulatory, you know, situation right I mean, what is that that we have to do nowadays to stay within the frameworks, right? And so, one of the main emphasis on this article is really go through what the clinical that the CDC has now established as the standards for opiate therapy when we use opioids I think we all need to know the rules right I mean, we know what to do to mitigate risks. What is expected from us in regard to use it as safely as possible, right? And that's important for the patient. That's also important for us in our practice.  Dr Weathers: I think very important advice. And this seems so obvious, but at the same time, I think it's worth very clearly stating why is it so important for neurology clinicians and again, really all clinicians, to read this article? Dr Sandbrink: Yeah. We need to know the words regarding opiate prescribing right in the clinic. You know, the CDC has now issued their opiate practice guide, the Opiate Therapy Guideline. Really, it's a guideline for pain care in 2022. It's an update from 2016 that made some major changes in that regard. And I think we need to know really where we are nowadays in regard to expectations. I think we need to place the opiate therapy appropriately in our armamentarium regarding the many options that we have for pain care. But then when we use them, we need to know what we need to do to make it safe. Right? So, I'm thinking about the prescription drug monitoring programs and the patient education that's expected. We use in our practice an informed consent process even for patients on chronic pain, When and how to interpret urine drug screens, right? And how to issue, and maybe when to issue a naloxone comedication in order to have a rescue medication in case the patient is in a terrible situation. So, these are just things that have become nowadays standards of care and part of our practice. And we need to be familiar with it and use them as we take care of the patients. And for instance, in regard to opiate medication, we need to know about the specific rules regarding telehealth, prescribing of controlled substances, controlled Substances Act and the Ryan Hate Act that mandates in person evaluations for patients when we prescribe controlled substances. That obviously has been somewhat amended or changed or temporarily put on hold during the COVID crisis. And many states now have started developing their own guidance in regard to what's available and what's possible during telehealth. And we need to be familiar about that also.  Dr Weathers: I think those are such important and thoughtful points. I, I've mentioned it several times on this podcast before. I am a clinical informaticist and this is a topic that really lends itself to the EHR being able to help support. So, a lot of the things that you just mentioned, the consents for patients, the prescribing of naloxone, some of the support, clinical decision support can really be done in the electronic health record to help support providers. However, it's also one of those things where if people don't understand what's behind it, it can become a little bit of a crutch. And so, as I was reading the article, I was really struck by how helpful it is to really have that background. I think people can become very dependent and it becomes almost just doing it all for them and, and they lose the- then you can make this argument about probably a lot of the other clinical decision supports in there, but really understanding the why behind a lot of the support that's there around all of the, the tools that are in there to, to support safe opioid prescribing. I think it's so important for that people have that background that the article provides.  Dr Sandbrink: I think often it feels like you're going through a checklist of things to do right and, and, and you do right. But at the same time, as you said, you need to know why you're doing it right And, and I think it's very important for us to know what the rules are and the expectations in regard to standards of care. So, we also know what is the framework that we have to follow, but where can we make modifications? Where can we individualize based on the patient's need? What is really that that is still within our ability to do and how to modify that? Because in the very end, it really is about good care of the patient. We need to know what we are allowed to do, but we also need to know where the limits are right And I hope that that article provides really some information about that, especially as it outlines what the CDC expects. But then also, I think it gives - hopefully, and this is a message that the CDC also has – it really emphasizes that it's about good communication with the patient, truly informing them and about what are the range of options and the limits that we have, but also at the same time never to abandon the patient. You know, I think this is something that we need to understand. It's not really about us. The rules are there to make the care of the patients safer. The rules are not the primary goal itself. It is still patient care. So, in that regard, we need to make sure to never abandon the patient, even if the patient for instance, may come to us and maybe they took more opiates and prescribed or you know, and they ran out early and figure out what exactly was that drove the patient for that, right? I mean, you know, so that we know maybe it is actually worse than pain. Maybe there was something that happened that caused the patient to have a significant increase of it. You know, I think one of the biggest misconceptions is really also that patients who make sure some misuse of medication, that everybody has opioid abuse disorder, addiction. Common, far too common, right? And I think we've learned over the years how common it is. Clearly pain itself, intractable pain is a very strong driver of behavior. If you're in pain, if a patient is in pain, they are desperate often to seek some kind of relief. And taking extra medication in itself, while it's not at all something that we can endorse and tolerate, obviously in many ways, right, we have to still take it as a possible sign of pain control rather than opiate use disorder in itself. So, we need to be very careful of how to assess such a patient and that we guide them into the right direction in regard to the next.  Dr Weathers: That, again, is very important advice, and thinking about how chronic pain on a very different level than acute pain, right? Understanding how these patients are processing pain in a very different way than patients with acute pain. And again, also, I think a very important point that the pendulum has swung kind of back and forth over the years. You know, that they were in pain was another vital sign and it was make sure you're asking your patient about pain. And then all of a sudden it was, oh, we have to be really careful and people should not, nobody should be on these medications, which you- to your point, led to sudden abandonment. And that's not the point. That's not what we should be doing as providers. I know, though, there's very sensitive and challenging situations when you find out a patient though, perhaps taking more than expected because of chronic pain, but perhaps diversion. How have you handled those challenging cases? Dr Sandbrink: I think diversion needs to be taken obviously very, very seriously. And you know, if a patient is truly diverting medication and there are obviously multiple variations of that, right? I mean, it's like giving it to a family member, for instance. That's one thing. It's on the other hand actually selling it. I think a patient who diverts is such a situation where opioid prescribing has to stop immediately, right? I mean, this is not a patient that we would take off at this point. I mean, so I think it's one of the very, very few occasions where you'd say that you have to just stop it immediately. I think there are other situations really in general, I think the patients who have been on opioids long term, especially in higher doses, I mean the majority of patients are not different. We have to be aware of it. We have to always look out for it. That's part of our risk mitigation. But we also have to make sure that patients on long term opioid therapy, right, that we guide them appropriately. I think the guidance probably in many ways is that we want to make sure whether opioids, the opioid medications still have helps them to achieve their functional goal. Are they truly helpful for the patients in achieving what they aspire to do in regard to their work life, in regard to the family situation. I think a lot of times for patients who have been on opioids long term, it's probably not that it really helps them that much for pain anymore, but they've often made that experience and they try to stop it. Pain gets worse, which is the effect obviously, that that happens with opiates right I mean, the moment you stop them, the opposite of the effect happens right I mean, they become irritable, right? The sleep gets worse, the pain gets worse, right? And it's a temporary phenomenon. And so, when we try to talk to a patient about possibly reducing the medication, I think this is one of the most challenging aspects that we have, that we really look at the patient and try to motivate them to be part of that plan. It's not something that we want to impose on the patient, but rather that we motivate the patient to look towards in the long term, probably more efficient pain care, which is really much more comprehensive pain care using all modalities. And I think one of the things that we learned over the last years is that when we make opiate medication reductions, we have to go very slowly. I think in the past we've talked about a matter of weeks and now the guidance including from the CDC guideline is probably more- closer to 10% per month to reducing it. So, you make reductions that may take many months to a year even, right. And the patient is allowed to help us, guide us how fast we can go. And you're allowed to make pauses if needed for the patient to adjust physiologically to reduction. And we want to go slowly enough that we don't run into an acute withdrawal situation right If you do it very gradually, it's much more manageable for the patient to do that. Then they'll be much more motivated to work with you. But still, it's a challenge right I think that we do. And I think at the very end, it's really providing good patient care that allows us to build that rapport with the patient that they trust us and that they say, Hey, you know, yes, I'm, I'm willing to work with you, doc, to maybe reduce my reliance on the medication, right? So that that I don't end up on this. You know, one of the things that I sometimes do is asking patients when they come to us this first time and there are a lot of opiate medication maybe is like, what's your goal in this regard? Where do you see yourself in, in five or ten years? Are you thinking you will still be on this medication or would you want to come off? And how can we help you then if that's your goal? So, I think this is all part of our important conversation that we have to have in order to motivate the patient.  Dr Weathers: What I heard you say repeatedly through that. And what I really want to emphasize for our listeners is that the therapeutic relationship with that patient that no matter what that scenario, really keeping them and their goals at the focus and really making it a partnership, not a paternalistic relationship, not dictating to them what the plan will be, but really emphasizing shared decision-making. And I think again, that's such a key take home point for our listeners. And also, even going back to my original question about diversion, what really struck me in your response is even though you said yes, then that was one of the few cases or perhaps even the only case where you said, all right, this is where we have to cut it off immediately. It still wasn't abandoning them as a patient, although you said we have to stop the medication. It wasn't about ending that relationship with that patient necessarily, but ending that therapy option. So really critical in how we think about opioids therapy and our relationship overall with patients.  Dr Sandbrink: So, Allison, maybe I can add on, you know, I think the patient with diversion is the one aspect where we have to look at the population as a whole and the opioid that makes it to somebody else, potentially a vulnerable child, right, even you know, who could die from it, right? Another aspect of probably the patients we mentioned them earlier who have opioid use disorder, who maybe take more than prescribed and where we as a neurologist feel often quite uncomfortable dealing with that. And I think that's so important that at that point we don't abandoned the patient, right. I mean, you know, maybe we want to continue, we don't want to continue the opiate medication for the treatment of the pain. But as we diagnose and initially suspect opiate use disorder and have a conversation about it with a patient, we need to guide them to therapy. It's a treatable condition, right? It's an untreated, it's, it's actually rather lethal in many situations, right? So, we have to make sure that we provide an integrated access to the treatment or we have a warm hand off to somebody who will continue that and not abandon the patient in regard to that pain care, as we said earlier also, right? I mean, because that second condition really doesn't obviously I mean in any way that the pain is any better. No, I mean it's a common concurrent situation and we need to make sure that they still have the better pain care possible. Dr Weathers: Again, it's a really key point for our listeners as and as I emphasized at the beginning, regardless of their subspecialty or specialty or even if they're physicians, I hope for everybody listening they can take away something from this. How did you become interested in pain management? I know that this was something that that you became interested in even when still in training. What struck you about this? Dr Sandbrink: So, yeah, so my initial fellowship actually after residence was clinical neurophysiology. So, you know, a lot of the spine and different nerve conditions really was, was, but then when I began practice, clearly longitudinal care, chronic disease management, I think many of us in neurology do that right That, that became an emphasis. And I think building that accord with the patients right and, and, and that having that ability to provide pain care is something that really worked out very well. I think I love teamwork and part of teamwork pain care in in our setting is a collaborative approach right You have other disciplines, physical therapist, psychologist, right? You know, you have intervention and nonintervention provider. I think nowadays we even have integrative modalities available to us. So, I'm working together on a team, trying to optimize it here with many team members that we have with everybody bringing that personal expertise is something that I really cherish. Dr Weathers: I feel like that's such a great example and I feel like a lot of people don't necessarily think about this specialty as one that is, that is collaborative in that way. And it really is. So, I, I think that's a wonderful way to highlight it. I always like to end on a hopeful note. And I know that there hasn't been necessarily a lot of hope or positive news in regards to, to opioid use, opioid therapy in the last several years. But are there developments that give you hope that you're excited about?  Dr Sandbrink: So, you know, I think there are probably two things I would mention. On one hand, I think patients are so much more aware now about the risk of opioids. So that is actually much easier to look and get them motivated about comprehensive pain care. There's much more interest in integrative modalities. Patients nowadays would be much more willing to maybe try acupuncture or mindfulness or yoga or Tai chi. So, I think that's actually a really nice development in that regard. But if I think about opioids specifically, I think the availability of buprenorphine as a medication, it's certainly something we should mention in this interview here, right? I mean, buprenorphine is now increasingly used for pain as well, not just in the higher dosage for opiate use disorder. It really is a good choice for patients who have. pain conditions, chronic pain conditions, severe pain and to require a daily opioid, especially in regard to safety aspect when the patient has medical conditions or mental health conditions that may put them at higher risk and they have to be on an opiate anyway. This is really something that I think has changed our practice. As you know, we don't have to rely on the X waiver anymore. Anybody with a DA license can prescribe buprenorphine. Even for opiate disuse disorder, it really has become something that I think many of us integrate much more into our practice and I want to encourage the listener to really look into that direction.  Dr Weathers: Excellent advice and I'll actually refer our listeners who are subscribers of Continuum to reference, specifically, Table 4 where you dive into the buprenorphine. It's just a fantastic table, as are all the tables. It really goes into detail of the commonly prescribed opioids for pain with the special characteristics and the conversion of morphine equivalent, but especially for this one about how to prescribe the details of us. Again, when I was preparing for this, I said wow. Like for me as a neurohospitalist and thinking about when I'm on service, how to use it, when to use it, I thought it was incredibly useful for that management of patients, especially as a powerful point of care tool. Well, thank you so much for being here with me today for this great conversation.  Dr Sandbrink: Yeah, thank you. That was my pleasure. Dr Weathers: Again, today I've been interviewing Dr Friedhelm Sandbrink, whose article on opioids and cannabinoids for the practicing neurologist, written with Dr Nathaniel Schuster, appears in the most recent issue of Continuum on Pain Management and Neurology. To learn more about the topics of opioids and cannabinoids, be sure to read the full article. And don't forget to listen to Continuum audio episodes from this and other issues. Thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/AudioCME. Thank you for listening to Continuum Audio.