Learning Objectives After attending this presentation learners will be able to Discuss the difference between acute and chronic pain Describe the opiate epidemic Discuss the appropriate management of pain ID: 930706
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Slide1
Where are we with opiates in 2020
Slide2Learning Objectives
After attending this presentation, learners will be able to:
Discuss
the difference between acute and chronic
painDescribe the opiate epidemicDiscuss the appropriate management of pain
Slide3Slide4The biggest problem we face in treatment of pain
Opiate pain medicines relieve acute pain
Opiate pain medicines cause tolerance (loss of effectiveness over time) so the dose must be continually increased to maintain the effect
Opiate pain medications are not very effective for chronic pain
Chronic opiates can increase pain (opiate mediated hyperalgesia)
Slide5The Newest Opiate Epidemic
From 2000 to 2014 nearly half a million people died from drug overdoses.
78
Americans die every day from an opioid overdose.
Overdoses from prescription opioid pain relievers are a driving factor in the 15-year increase in opioid overdose deaths. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupledDeaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have also quadrupled since 1999
Slide6In 2010 the US consumed
99%
of the world’s
hydrocodone
80 percent of the world’s oxycodone65 percent of the world’s hydromorphone
Slide7Slide8Opiate epidemic Timeline 1
Acetaminophen and hydrocodone approved 1978
Morphine approved 1987
Slide9Slide10Cited 693 times Google
Slide11Design:
Case series of 38 patients at a single center, no standard opioid treatment used. Different diagnoses. Measured personality tests. Median follow up of greater than 4 years.
Rationale:
Chronic opioids are used for cancer pain without too much abuse or long term problems. There is no evidence for chronic use in non cancer patients
Results: 4 patients had formal psych dx. 1 patient increased doses on their own, another diverted drugs. Of the 38 11 rated their relief as adequate 13 partially adequate Conclusion: “We conclude that opioid maintenance therapy can be a safe, salutary, and more human alternative to the options of surgery or no treatment in those patients with intractable nonmalignant pain and no history of drug abuse” Cited 491 timesGoogle Scholar
Slide12The Tragedy of Needless Pain
SCIENTIFIC AMERICAN
February 1990 Volume 262 Number 2
Contrary
to popular belief, the author says, morphine taken solely to control pain is not addictive. Yet patients worldwide continue to be undertreated and to suffer unnecessary agonyby Ronald Melzack
Slide13Opiate epidemic Timeline 2
Oxycodone approved 1996
oxycodone 2002
oxycodone coupons
Slide14Slide15Dollar Spent Marketing
Branded
Oxycodone-ER
(1996-2001)
Slide16Total Sales & Prescriptions
for
Oxycodone-ER
(1996-2002)
Oxycodone
Slide17Federation of State Medical Boards (gets on board)
In 1998, the Federation of State Medical Boards released a recommended policy reassuring doctors that they wouldn't face regulatory action for prescribing even large amounts of narcotics, as long as it was in the course of medical treatment.
In 2004 the group
(The American Pain Society) called
on state medical boards to make undertreatment of pain punishable for the first time.
Slide18Slide19Slide202009
Slide21Who did it? The main suspects:
American Pain Society
The VA
JCAHO (now just “The Joint Commission”)
Purdue (and other pharma)The insurance industryThe doctors
Slide22The
Joint Commission seeks to clarify 'misperceptions' of its pain
standards Apr
27, 2016The
Joint Commission’s pain standards are unfairly blamed for the current prescription opioid epidemic because of “misperceptions” of what it requires hospitals and other accredited institutions to do, says David Baker, M.D., The Joint Commission’s executive vice president for health care quality evaluation.The Joint Commission says “we didn’t do it”
Slide23Misconception #1:
The Joint Commission endorses pain as a vital
sign
Misconception #2: The Joint Commission requires pain assessment for all patients
.Misconception #3: The Joint Commission requires that pain be treated until the pain score reaches zero.Misconception #4: The Joint Commission standards push doctors to prescribe opioidsMisconception #5: The Joint Commission pain standards caused a sharp rise in opioid prescriptions.The Joint Commission didn’t do it
Slide24"
Pain control has become a problem because of confusion as to who is responsible [for it], a general lack of knowledge about pain, and misconceptions about drug tolerance and addiction
,”
"The pain management paradigm is about to shift,"
(Dr. Dennis O'Leary-JCAHO)Pain Management will beA patient rights issueAn education and training issueA measurement issue (placing it on a 10-point scale)A safe management issueAll this adds up to a heightened awareness of pain as the "fifth vital sign" a shift from traditional pain control practices (from) physician decision making …to a more systematic approach.D.M Philips JCAHO pain management standards are unveiled JAMA, 284 (4) (2000), pp. 428–429JCAHO Pain management standards unveiled 2000
Slide25The Joint Commission didn’t do it
The Joint Commission published a guide sponsored by Purdue
Pharma
. "Some clinicians
have inaccurate and exaggerated concerns" about addiction, tolerance and risk of death, the guide said. "This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control.”The Joint Commission said its standards didn't encourage physicians and hospitals to increase prescriptions. "I think that's a very distorted and not helpful explanation of what's going on," said Ana McKee, the Joint Commission's chief medical officer.
Slide26Slide 38 of 70
Slide27The Joint Commission didn’t do it
Slide28Doctors were Pressured to Prescribe
71%
to
avoid administrative and regulatory criticism
57% to avoid negative impact on Joint Commission surveys46% to avoid decreased patient satisfaction scores and decreased reimbursement40 % either they or one of their colleagues have been formally disciplined for failure to acquiesce to a patient's request for an opioid prescriptionKelly S, Johnson GT, Harbison RD. "Pressured to prescribe" The impact of economic and regulatory factors on South-Eastern ED physicians when managing the drug seeking patient. J Emerg Trauma Shock. 2016 Apr-Jun;9(2):58-63
Slide29Increased patient satisfaction correlates with increased mortality
The cost of
satisfaction
: a national study of
patient satisfaction, health care utilization, expenditures, and mortality. Fenton JJ,
Jerant
AF,
Bertakis
KD, Franks P.
Arch
Intern Med. 2012 Mar 12;172(5):405-11.
CMS says more than 3,000 hospitals will be affected. Under the proposal, patient scores would determine 30 percent of the bonuses, while clinical measures for basic quality care would set the rest. Hospitals argue the scores should have less weight, but nevertheless are trying to figure out how to improve their rankings
Medicare To Begin Basing Hospital Payments On Patient-Satisfaction
Scores
2012
Slide30Slide31Portenoy says he did it
“ ‘I gave innumerable lectures in the late 1980s and ‘90s about addiction that weren’t true’ ”
He argued that opioids are a ‘gift from nature’ that were being forsaken because of ‘
opiophobia
’"It had all the makings of a religious movement at the time.”Dr. Portenoy disclosed relationships with Endo, Abbott, Cephalon, Purdue, Johnson and Johnson
Slide32The courts say Purdue did it
Slide33The insurance companies say: Who, me?
Slide34The CDC: Just say NO but
…
CDC Guidelines
1) when to initiate or continue opioids for chronic pain;
2) opioid selection, dosage, duration, follow-up, and discontinuation;3) assessing risk and addressing harms of opioid use.
Slide35Cutting back on opiate prescriptions CDC website
2014-15
Florida 22.7 % increase
(CDC)
2014-15 New York 20.4 % increase(CDC)2014-15 Tennessee 13.8 % increase(CDC)2014-2015 Death increases https://www.cdc.gov/drugoverdose/policy/successes.htmlhttps://www.cdc.gov/drugoverdose/data/statedeaths.html
Slide36Slide37opioids
Slide38Florida 22.7 % increase 2014-15
Slide39US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / June 9, 2017 / Vol. 66 / No. 22
Slide40Slide41Slide42National Overdose Deaths
Number of Deaths from Heroin
Slide43Pain
Pain is made up of 2 parts:
A sensory experience associated with
particular types of stimulation
An emotional response of distress and anxiety related to the sensory information
Slide44Pain can be chronic or acute
Acute pain is the resu
lt of stimulation of sensory receptors for injury or trauma
Can include chronic conditions such as burns, cancer
, infection, auto-immune tissue damageChronic pain which is the result of an adaptation of the nervous system Pain which continues when the original injury that provoked the initial pain has resolved.
Slide45Acute pain
Tissue damage
Burns
Cancer
TraumaVisceral stretchIschemiaInflammationNerve activationToxinsTraumaIschemia
Slide46Treatment of acute pain
Blocks
Anti-inflammatories
Steroids
Non-steroidal anti-inflammatoriesImmunomodulatorsOpiate analgesicsDissociative anestheticsNon-opiate analgesics
Slide47Categorization of Chronic pain
Peripheral nerve dysfunction
peripheral sensitization
deafferentation
Sympathetic dysregulation-sympathetically maintained painCentral sensitizationsympathetic activationcortical painThalamic painConditioned painSomatization
Slide48PNS
TCAs
Anticonvulsants
Local anesthetics
Opioids
Spinal
cord
Brain
Descending Modulation
Central
α-agonists
TCAs
SNRIs
Opioids/
Tramadol
Central Sensitization
Peripheral Sensitization
Terminal
NSAIDs
Vanilloids
Opioids/tramadol
Central
α-agonists
NMDA antagonists
Anticonvulsants
Chronic pain mechanisms
CNS
Ectopic Activity
Na
+
channel blockers
Ca
+2
channel modulators
GABAergic
enhancement
Glutaminergic
inhibition
Woolf C, Max M Anesthesiology 2001
Slide49Chronic
P
ain Mechanisms
Loss of large diameter myelinated sensory afferent inhibition of nociceptive
transmissionNeuropathic “noise” from damaged peripheral neuronsDeafferentation hyperactivity in dorsal horn cellsCentral sensitization (increased gain)Ectopic impulse generationsites of injury, demyelination, and regenerationSMP sensitivity of primary afferent nociceptorsAntidromic release of sensitizing neuromediators
Slide50Pain amplification
Blockade of pain
sensation (opiates)
Increased sympathetic
activity Immune activationInterference with pain “gating mechanisms”Conditioning-learned painMajor depression
Slide51Non-pharmacologic treatment of chronic pain
Hypnosis
Acupuncture
Meditation and mindfulness
Information givingRelaxationGuided imageryBreathing trainingCognitive reframingDistraction (visual and auditory)Massage
Slide52Approach to patients with chronic pain on opiates
Type of pain including postulated mechanism
Co-morbidities that exacerbate pain
Careful evaluation of the factors that contribute to morbidity
Provide patients with a diagnostically based treatment planDiscussion of the goals of treatment and your roleIdeally taper all addictive symptomatic medications Gradual engagement EXPECT RESISTANCE
Slide53Taper opiates
Opiate mediated hyperalgesia plays a role in pain
Patients with dependence may be reluctant to stop opiates
Patients with true addiction may need chronic opiate maintenance which can still produce opiate mediated hyperalgesia
Each case requires individual evaluation and a treatment tailored to the patient
Slide54Chronic pain pharmacology
Most chronic
pain cases
respond to neuromodulators
Chronic opiates make this pain worse and prevent the response to neuromodulators
Slide55Target behaviors for pain treatment
Time-contingent medications (and taper)
Graded activation (exercise)
Social reinforcement (
spouse and social supports)Self control skillsSelf monitoringSelf reinforcementRelaxation training
Slide56Mastery of exercise-acquired skills
Relaxation
Imagery
Self hypnotic analgesia
Distraction techniquesGraded physical recovery exercisesAssertiveness trainingMindfulness
Slide57Treat psychiatric co-morbidity
Depression
Personality vulnerabilities
Life experiences
Slide58Issues that complicate pain treatment
Combined acute and chronic pain
Fatigue with pain management methods
Immune activation and pain amplification
Psychiatric comorbiditiesDepression DemoralizationTemperament and personalityBehavioral conditioningPoor coping skills
Slide59Slide60References
Portenoy
RK,
Foley
KM. Pain. 1986;25(2):171-186 Porter J, Jick H. N Engl J Med. 1980;302(2):123 Peters PJ et al. N Engl J Med 2016;375:229-239CDC MMWR / June 9, 2017 / Vol. 66 / No. 22 cdc.gov/drugoverdose/policy/successes.htmlcdc.gov/drugoverdose/data/statedeaths.htmlKelly S et al. J Emerg Trauma Shock. 2016 Apr-Jun;9(2):58-63Fenton JJ et al. Arch Intern Med. 2012 Mar 12;172(5):405-11.Weissman DE et al. Pain. 1989;36(3):363–6Greene MS et al. Curr Addict Rep. 2015;2(4):310-317Melzach R. Sci Am. 1990;262:27-33
Slide61Number of Adults Filling a Benzodiazepine Prescription, Quantity Filled, and Overdose Deaths Involving Benzodiazepines: United States, 1996–2013