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

Steady Increases in Opioid and Stimulant Prescriptions Dispensed by U Steady Increases in Opioid and Stimulant Prescriptions Dispensed by U.S. Retail Pharmacies, 1991-2011

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

Consequences of Rx Drug Abuse are Increasing Unintentional Overdose Deaths have quadrupled since 1998

The Problem Providers: Patients Addiction providers uncomfortable treating pain Pain Management providers uncomfortable treating addiction PCPs uncomfortable treating both and PCPs prescribe the opioids Patients Stigmatization to addiction Believe pain is primary problem not addiction Fear their pain will not be addressed Many 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.