10/12/2012 1 JEREMY A. ADLER, MS, PA-C PACIFIC PAIN MEDICINE CONSULTANTS UPDATE: CHRONIC PAIN Consultant • Depomed • Endo Pharmaceuticals • Pfizer • Janssen Pharmaceuticals • Jazz Pharma • St. Jude Neuromodulation As part of this presentation, off-label uses of pharmaceuticals and devices may be discussed. Products mentioned do not include full prescribing information, please refer to FDA approved information DISCLOSURES National Institutes of Health Funding 2010 http://report.nih.gov/categorical_spending.aspx
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J E R E M Y A . A D L E R , M S , P A - CP A C I F I C P A I N M E D I C I N E C O N S U L T A N T S
UPDATE: CHRONIC PAIN
Consultant• Depomed• Endo Pharmaceuticals• Pfizer• Janssen Pharmaceuticals• Jazz Pharma• St. Jude Neuromodulation
As part of this presentation, off-label uses of pharmaceuticals and devices may be discussed.
Products mentioned do not include full prescribing information, please refer to FDA approved information
DISCLOSURES
National Institutes of Health
Funding 2010
http://report.nih.gov/categorical_spending.aspx
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AGENDA
• Burden of Chronic Pain • Pathophysiology - Disease Model• Pain Assessment• Multi-disciplinary Approach• Updates in Management
• “the relief of suffering, it would appear, is considered one of the primary ends of medicine by patients and lay persons, but not by the medical profession.”
Cassel E. The nature of suffering and the goals of medicine N Eng J Med. 1982; 306: 639-645.
BURDEN OF CHRONIC PAIN
• Institutes of Medicine 2011• “Pain as a Public Health Problem”• Prevalence: ~100 Million Americans• “Given the burden of pain in human lives, dollars, and social
consequences, relieving pain should be a national priority”• Leading Cause of Disability• Primary reason patients seek healthcare
• 80% of visits have pain complaint• Tremendous Costs
• Total U.S. Expenditures: $560 - $630 Billion• Lost Productivity
• Chronic Pain• Vital Signs Stable• Possibly No Pain Behaviors
• Verbal Analog Scale (0-10 with 10/10 worse)• Visual Analog Scale (100mm None to Severe Pain)• Wong-Baker Faces• Multidimensional Scales (McGill, SF-36, etc.)
• Indicated for Post-herpetic Neuralgia• Binds Peripheral Vanilloid Receptor
• Stimulated by heat, abrasion• Ongoing receptor binding results in Sp Depletion• Sp results in C-fiber Functionality = Pain• Neurodegeneration with high potency
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• Blocks binding of Acetylcholine containing vesicle and subsequent release
• New Indication for Botox:• Migraine Headache
• Prevent headache in adults with 15 or more days of headache and lasting more than 4 hours
BOTULINUM TOXIN TRIPTANS
• Needleless SC Sumatriptan (Sumavel Dosepro)• Tmax = 12 minutes (Oral sumatriptan Tmax = 2.5 hrs)• Can be used 1 hr after oral sumatriptan if relief not
obtained• No sharps
CANNABINOIDS
• Sativex• Delta-9-THC and Cannabidiol Mouth Spray• Available in many countries• Pending FDA approval• Use includes management of muscle spasms in multiple
sclerosis• Seeking approval for cancer pain OPIOID UPDATE
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• Presynaptic Binding • Ca2+ channel
inhibition• G-protein linked
• Postsynaptic Binding • Membrane Hyper-
polarization by opening K+ channels
• Suppress Peripheral Inflammatory Cells
• Central Actions
OPIOID PHARMACOLOGY UPDATE
• Expanded Indication• Tapentadol ER (Nucynta ER)
• Opioid Agonist / NE Reuptake Inhibitor• Neuropathic Pain Associated with Diabetic Peripheral Neuropathy
• Transdermal• Buprenorphine (Butrans)• Only Schedule III sustained-release opioid for around the clock pain• Partial μ & δ agonist, κ antagonist
• Tablet Technology• Oxycodone CR (OxyContin)• Oxymorphone ER (Opana ER)• Hydromorphone ER (Exalgo)• Tapentadol ER (Nucynta ER)• Morphine ER (Embeda) – Approved, but voluntary recall
TABLET TECHNOLOGY
• Drug Delivery• Oros – Hydromorphone ER (Exalgo)
• Uses osmotic pressure through laser drilled hole• Pelleted Capsule – Morphine ER (Kadian/Embeda)
• Rate limiting membrane over morphine with core• SODAS – Morphine ER (Avinza)
• Polymer coated morphine• Contin – Morphine ER (MSContin), Oxycodone ER
• Extended-Release and Long-Acting Opioids• Mandatory elements for manufactures, voluntary for
prescribers• Provider Education – Voluntary• Expect education programs by March 1, 2013
• Anticipate Industry grants to CE programs• AAPM – Safe Opioid Prescribing Course
• Patient Education via REMS approved Patient Counseling Document is recommended in interim
• All Brand and Generic Medications• Immediate-release medications not effected
MONITORING UPDATES
URINE DRUG TESTING
• Supported by multiple Clinical Practice Guidelines• Need working relationship with lab/toxicologist• Cut-offs (Negative = below cut off)• Metabolism / Contaminants• Parent/Child Drugs• Immunoassay
• Qualitative• Many false positive / false negative
• Confirmatory (GC/LC/MS)• Quantitative
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PRESCRIPTION DRUG DATABASE MONITORING (CURES)
• California has oldest PDMP in country• Threatened to be dissolved (budget)• Indexes Millions of Controlled Substance Rx• Online Access• Recommended as part of Comprehensive
Approach to Prescription Drug Abuse/Diversion:• Published Guidelines for Opioid Management• Centers for Disease Control• White House
REGISTER FOR CURES
• Sign up in Cyber Café• Need:
• Government Issued ID (Drivers License)• DEA Certificate• PA Medical License