Introduction to Pain/Opioid Management Patricia Pade, MD Pete Smith, MD.

Introduction to Pain/Opioid Management

Patricia Pade, MDPete Smith, MD

Prevalence of the Problem

- 116 million people in the US suffer with pain – which is more than diabetes, cancer and heart disease combined

- Annual health care costs – expenses, lost wages, productivity loss estimated to be $600 billion

1. National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain. http://www.cdc.gov/nchs/data/hus/hus06.pdf. 2. National Centers of Health, NIH guide: new directions in pain research: 1. Bethesda, MD: National Institutes of Health. 1998 Sept 4. http://grants.nih.gov/grants/guide/pa-files/PA-98-102.html.

Opioids - Use of opioids has increased substantially over the past 20 years despite limited evidence for efficacy in chronic noncancer pain.

- Rise in opioids utilization corresponds to rise in opioid abuse and dependence – rates of opioid misuse (includes abuse and dependence as well as recreational use) estimated between 18 to 41% and aberrant medication behavior as high as 50%

3. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10:113-30. 4. Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain 2004;109:514-9.5. Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of

opioids. Pain Physician 2008;11:S63-88. 6. 6. Hojsted J, Sjogren P. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain 2007;11:490-518.

Problem: expectations

Problem: misconceptions

Opioids = Pain Relief

therefore:

More Pain Relief = More Opioids

6

Steady Increases in Opioid and Stimulant Prescriptions Dispensed by U.S. Retail Pharmacies,

1991-2011

0

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

75,500,98277,560,27380,359,94486,225,85390,783,07395,609,108100,013,912

108,512,184119,817,010

130,598,364138,991,972144,302,410

150,984,759158,300,965

168,866,683179,870,752

192,377,001201,008,960201,727,195

209,557,752219,233,516

Opioids Hydrocodone Oxycodone

IMS’s Source Prescription Audit (SPA) & Vector One®: National (VONA)

Pres

crip

tions

(mill

ions

)

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

3,990,8185,078,9256,701,313

9,158,90712,030,671

13,804,56915,040,81216,382,63618,018,984

19,407,90121,065,820

23,773,02024,047,14026,393,378

29,093,50430,045,64632,775,001

36,307,86239,109,988

44,661,632

51,410,700

Stimulants Methylphenidate Amphetamine

IMS’s Source Prescription Audit (SPA) & Vector One®: Na-tional (VONA)

Pres

crip

tions

(mill

ions

)

Now with increased attention to Prescription Opioids – Heroin use is rising

Unintentional Overdose Deaths have quadrupled since 1998

Consequences of Rx Drug Abuse are Increasing

15--24 25--34 35--44 45--54 55--64 ≥650

2

4

6

8

10

12

3.7

7.18.3

10.4

5

12.2

4.45.3

6

2.5

0.3

Deaths from Opioid Pain Relievers Ex-ceed Those from Illegal Drugs in all Age

GroupsOpioid pain relievers Illegal drugs

Age Group

Death

s per

100,0

00 p

opula

tion

More Drug Overdose Deaths are Associated with Opioid Pain Relievers than with Illegal Drugs. Data are for 2008. Illegal drug deaths include deaths from overdose of heroin, cocaine, hallucinogens, or stimulants. Source: CDC, Morbidity and Mortality Weekly Report, 60(43): 1489, 2011.

The Problem

• Providers:Addiction providers

uncomfortable treating pain

Pain Management providers uncomfortable treating addiction

PCPs uncomfortable treating both and PCPs prescribe the opioids

• PatientsStigmatization to addictionBelieve pain is primary

problem not addictionFear their pain will not be

addressedMany will agree to

treatment in Primary Care but are reluctant to go to SUD treatment

Ambitious Agenda• Session 1: Overview: Scope of problem- Dr.Pade/Pete List of topics Presenting a case/with essentials Confidentiality • Session 2: Chronic pain: definition, Pathophysiology - Dr. Rzasa lynn• Session 3: Particular types of chronic pain: nocioceptive, neuropathic, central, mixed - Dr. Rzasa lynn• Session 4: Pre visit data collection - Pete/Elizabeth• Session 5: Pharmacology opioids, part 1 focus of short acting – Joe Saseen• Session 6: Pharmacology opioids part 2 focus on long acting – Joe Saseen• Session 7: Aberrant behavior: Pade• Session 8: Addiction: Martin/Pade• Session 9: Narcan: Pade• Session 10: Epic tips: Amber• Session 11: Urine toxicology screening: Lam• Session 12: Weaning and tapering off opioids/rotations: Saseen/Pade• Session 13: Buprenorphine for pain/opioid dependence: Pade• Session 14: Adjunctive pharmacological measures to treating pain: Dr. Rzasa Lynn• Session 15: Adjunctive measures Coping strategies, pain psychology: Brown levey• Session 16: Critical conversations: Pade• Session 17: Psychiatric considerations: Martin

• Any other topics???

Case Presentation• History of Pain: Location, duration, onset, radiations, aggravating factors,

relieving factors.• Prior interventions and therapies• Medications current and past• Aberrant behavior Hx• PMH/Psychiatric Hx• Substance use history: alcohol, opioids, illicit substances, smoking

tobacco (and other substances) and prior treatment(s)• Family Hx including psychiatric and SUD• Social Hx: work, family, support or lack thereof• Pertinent physical findings• PMP, lab data, urine screens• Screening instruments such as SOAPP, DIRE if available.

Confidentiality

• HIPAA and CFR 42 Part 2 confidentiality apply.• If consent, then patient identifiers can be

used.• If no consent obtained, please do not use

patient identifiers.• All parties participating need to hold

information in the usual HIPAA compliant and CFR 42 Part 2 compliant standards.