1. Challenges and Controversies
Pain and Addiction
Challenges and Controversies
Mel Pohl, MD, FASAM
Medical Director
Las Vegas Recovery Center 1 1

2. 5 Key Facts: All pain is real.
Emotions drive the experience of chronic pain.
Opioids often make pain worse.
Treat to improve function.
Expectations influence outcomes. 2

3. Pain Definition “An unpleasant sensory and emotional experience
associated with actual or potential tissue damage ….”
The International Association for the Study of Pain
(Mesky,1979) 3

4. 4 4

5. Structural Remodeling
How does acute pain become chronic pain?
CNS
Neuroplasticity
Hyperactivity
Structural Remodeling
Sustained
Activation
Peripheral
Nociceptive
Fibers
Sensitization
Surgery or injury causes inflammation
Peripheral
Nociceptive
Fibers
Transient Activation
Sustained
currents
CHRONIC
PAIN
ACUTE
PAIN
Woolf CJ, et al. Ann Intern Med. 2004;140: ; Petersen-Felix S, et al. Swiss Med Weekly. 2002;132: ; Woolf CJ. Nature.1983;306: ; Woolf CJ, et al. Nature. 1992;355:75-78. 5 5 5
Petersen-Felix S, Curatolo M. Neuroplasticity--an important factor in acute and chronic pain. Swiss Med Wkly. 2002;132(21-22):
Woolf CJ. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med. 2004;140(6):

6. Pain is influenced by: Culture Context
Anticipation and previous experience
Emotional and cognitive factors 6

7. Pain Switchboard – Lower Threshold
GENETICS
TRAUMA N O C I E P T P A I N
COMT
Pain is what the patient says it is. Nociception does not necessarily translate directly into pain. There are a number of “switchboards” in the pain pathways from peripheral nociceptors to the brain, which can influence how much pain gets through to higher brain centres as well as the response to pain in the brain. For example the enzyme catechol-O- methyl transferase (COMT)… SEE APPENDIX # 16 IN HANDOUT FOR AN EXPLANATION. There are at least 20 splice variants of the Mu opioid receptor (MOR) which respond differently to the various opioids. The melanocortin-1 receptor (MC1R) has been recently discovered to predict responsiveness to Kappa opioids – as well as coding for red hair and freckled skin. One of the “hottest” areas in pain research today is the pharmacogenetics of pain. The response to many pain medications, such as gabapentin and pregabalin, is increasingly being found to be under genetic influence.
Suffering, the net result of pain on the patient’s quality of life, is further influenced by psychosocial factors such as cognition (the meaning of the pain), emotions (most often depression) and the patient’s environment (family, work, etc). As clinicians, we are really in the business of treating suffering rather than just pain. 7 7 7

8. NORMAL PAIN RESPONSE 8 8

9. CENTRAL SENSITIZATION9 9

10. So he feels two pains, physical and mental.
“…When touched with a feeling of pain, the ordinary uninstructed person sorrows, grieves, and laments, beats his breast, becomes distraught.
So he feels two pains, physical and mental.
Just as if they were to shoot a man with an arrow and, right afterward, were to shoot him with another one, so that he would feel the pains of two arrows…”
The Buddha 10 10

11. Chronic Pain Syndrome Pain > 6 months
Depression, anxiety, anger, fear
Restriction in daily activities
Excessive use of medications and medical services
Multiple, non-productive tests, treatment, surgeries
No clear relationship to organic disorder 11

12. unless proven otherwise”
Pain Assessment Scale: Clinical definition of pain: “Whatever the patient says it is...
unless proven otherwise” 12 12

13. Reasonable Goals of Pain Management: Enhance Quality of Life!!
Maintain function
Improve function
Reduce discomfort by 50% 13

14. Pharmacologic Non-Opioid
NSAID’S, COX 2S
Tricyclics, SNRI’S
Anticonvulsants
Muscle Relaxants— (AVOID SOMA/carisoprodol)
Topicals 14

15. Promoting More Conservative Prescribing
Think beyond drugs
Practice more strategic prescribing
Heightened vigilance regarding adverse effects
Caution and skepticism regarding new drugs
Shared agenda with patients
Weigh longer-term broader effects
Schiff GD, Galanter WL. JAMA. 2009;301(8): 15

16. Barriers to Conservative Prescribing
Time pressure.
Income bonuses linked to patient satisfaction.
Industry-funded research promotes bias towards prescribing.
Ethical qualms about withholding adequate pain treatment.
Schiff GD, Galanter WL. JAMA. 2009;301(8,): 16

17. Treating Chronic Pain with Opioids
Clinical Trial
Ongoing Assessment
Need exit strategy 17

18. Entry Strategy: Screening Before Prescribing
SOAPP – Screener and Opioid Assessment for Patients in Pain (5, 14, and 24 items – 5 point scale)
CAGE-AID Questionnaire (4 items)
ORT – Opioid Risk Tool (5 items – weighted)
Psychological/psychiatric screening
Awareness of chemical coping styles
Family history of addiction/mental illness
Passik SD, Squire P. Pain Med. 2009;10 Suppl 2:S
Butler SF, et al. J Pain. 2008;9:

19. Ongoing Assessment 5 A’s PDMP’s Patient agreements Urine toxicology
Affect
Analgesia
Aberrant behaviors
Adverse effects
Addiction
PDMP’s
Patient agreements
Urine toxicology

20. EXIT STRATEGY
Discuss options - continuation of conversation from entry
Be consistent, supportive, informative, nonjudgmental and firm
DO NOT BE PUNITIVE
Gather resources for support
Discuss detoxification options

21. Problems with Opioids Side Effects Tolerance and physical dependence
Loss of function
Perceive emotional pain as physical pain (chemical copers)
Hyperalgesia 21

22. NEJM, Ballantyne & Mao Nov 200322

23. Pendulum Swings 23

24. 80 mg pills of oxycodone (OxyContin) are being abused by increasing numbers of users. Users crush the time-release tablets to get the drug full force. The sensation is described as similar to a heroin rush. Diversion of the drug is fairly common. This drug originally came in 160 mg tablets, but the amount of abuse and number of overdoses caused by the 160 mg tablets caused the manufacturer pull them from the market. Image courtesy of the Drug Enforcement Administration
OxyContin 80mg 24 24

25. So, by 2012: New Oxycontin® Formulation to Mitigate Abuse April 2010
1. Freeze Oxy or
2. Opana®
New formulation added clumping substance making harder to liquefy for injection abuse or crush to circumvent the time release coating and snort to abuse. Reports of increasing number of Oxy addicts now turning to heroin addicts.
Oxycodone
Oxymorphone 25 25

26. Emergence of an Epidemic

27. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over) 27

28. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over) 28

29. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over) 29

30. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over) 30

31. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over) 31

32. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over) 32

33. U.S. Rates of Death from Unintentional Drug Overdoses
Okie S. N Engl J Med 2010;363:
U.S. Rates of Death from Unintentional Drug Overdoses and Numbers of Deaths, According to Major Type of Drug. Shown are nationwide rates of death from unintentional drug overdoses from 1970 through 2007 (Panel A) and the numbers of such deaths from opioid analgesics, cocaine, and heroin from 1999 through 2007 (Panel B). Data are from the National Vital Statistics System, Centers for Disease Control and Prevention. 33 33

34. U.S. Numbers of Deaths, According to Major Type of Drug.
U.S. Rates of Death from Unintentional Drug Overdoses and Numbers of Deaths, According to Major Type of Drug. Shown are nationwide rates of death from unintentional drug overdoses from 1970 through 2007 (Panel A) and the numbers of such deaths from opioid analgesics, cocaine, and heroin from 1999 through 2007 (Panel B). Data are from the National Vital Statistics System, Centers for Disease Control and Prevention.
U.S. Numbers of Deaths, According to Major Type of Drug.
Okie S. N Engl J Med 2010;363: 34 34

35. 35 35

36. Hazard Ratio of Serious Overdose
Dunn, et al. 2010
9940 patients;
Results:
Morphine Dose
Hazard Ratio of Serious Overdose
None
0.19
1 - <20 mg /day
1.00
20 - <50 mg/day
1.19
50 - <100 mg/day
3.11
100 + mg/day
11.18 36

37. High Opioid Dose and Overdose Risk
11.18
3.11
1.19
1.00
This slide from Group Health shows the distribution opioid usage in a population being prescribed opioids with diagnoses of chronic pain. It therefore represents a population obtaining opioids by prescription for a legitimate reason.
It shows that risk of overdose increased steadily with increasing dosage to nearly a nine-fold increase at dosages of 100+ mg/day.
This suggests that a high-risk strategy concentrating on people getting higher dosages might be most cost-efficient for patients using opioids under medical supervision.
People with dosages of 20+ mg/day represented only 21.7% of patients but accounted for almost half of the overdoses.
* Overdose defined as death, hospitalization, unconsciousness, or respiratory failure.
Dunn et al. Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92. 37

38. Rates of prescription painkiller sales, deaths and substance abuse treatment admissions (1999-2010)
SOURCES: National Vital Statistics System, ; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), ; Treatment Episode Data Set, 38

39. Industry-influenced “Education” on Opioids for Chronic Non-Cancer Pain Emphasizes:
Physicians are needlessly allowing patients to suffer because of “opiophobia.”
Opioids are safe and effective for chronic pain.
Opioid therapy can be easily discontinued.
Opioid addiction is rare in pain patients. 39

40. “Only four cases of addiction among 11,882 patients treated with opioids.”
Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med Jan 10;302(2):123
Cited 693 times (Google Scholar) 40

41. N Engl J Med Jan 10;302(2):123. 41

42. Total Sales & Prescriptions for OxyContin (1996-2002)
Source: United States General Accounting Office: Dec. 2003, “OxyContin Abuse and Diversion and Efforts to Address the Problem.”
2013 – US sales of Rx painkillers = $12 Billion (IMS Health) 42 42 42 42

43. 43

44. FDA used to permit drug manufacturers to advertise opioids as safe and effective for chronic pain.44

45. Photo taken at the7th International Conference on Pain and Chemical Dependency, June 200745

46. Methadone (Dolophine, Methadose) Leading Cause of Rx OD Deaths 2010-2011

47. Heroin: making a big comeback since 2010!
Texas “Cheese Heroin”:
Black Tar Mixed with Tylenol PM
Black Tar heroin

49. Medication Assisted Treatment
Methadone
Buprenorphine
Naltrexone
Naloxone 49

50. Suboxone tablets (RB)

51. Naloxone
Handheld Device That Delivers Opioid Overdose Treatment Approved by FDA

52. ASAM Short Definition of Addiction
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.
Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.
This is reflected in an individual
pathologically pursuing reward and/or relief by substance use and other behaviors... 52

53. This is a false dichotomy
Aberrant drug use behaviors are common in pain patients
63% admitted to using opioids for purposes other than pain1
Pain Patients
“Drug Abusers”
35% met DSM V criteria for addiction2
92% of opioid OD decedents were prescribed opioids for chronic pain.
1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy. J Pain 2007;8:
2. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:
3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of Decedents by Next of Kin or Best Contact, Utah, J Gen Intern Med Oct 16.

54. Emotional Intensifiers
Guilt
Anger – Resentments
Loneliness
Helplessness
Fear 54

55. Cycle of Uncontrolled Pain and Fear
Avoidance
Behaviors
FEAR
FEAR
Decreased
Mobility
Pain
FEAR
FEAR
Social
Limitations
Altered
Functional
Status
Diminished
Self-
Efficacy
FEAR
FEAR 55 55 55 55

56. Ways to reduce pain intensity
Cognitive/Behavioral Therapy (CBT)
DBT/ACT
Attention/Distraction
Control/Placebo effect
Fear reduction 56

57. Reversal of Cycle of Fear and Pain
Exercise
Increased
Mobility
Pain
Less
Pain
Improved
Function
Enhanced
Self-
Efficacy 57 57 57 57

58. Pain Pearls Conditioning Increases Pain. Pain Patients Are A Pain.
Secondary Gain Prevents Getting Well. 58

59. Pain Recovery – Develop Balance
Mental
Emotional
Physical
Spiritual
RESULTING CHANGES
Relationships
Positive actions and behaviors 59

60. Non-Medication Treatments at LVRC
Exercise – Physical Therapy
Chiropractic Treatments
Therapeutic Massage
Reiki
Acupuncture
Nutrition
Individual + group therapy
Mindfulness-Based Stress Reduction (Kabat-Zinn)
Yoga - Chi Gong 60

61. 5 Key Facts: All pain is real.
Emotions drive the experience of chronic pain.
Opioids often make pain worse.
Treat to improve function.
Expectations influence outcomes. 61

62. THANK YOU Mel Pohl, MD, FASAM 702-515-1373 mpohl@centralrecovery.com
adaywithoutpain.com 62