1. Chronic Pain Treatments:
How We Missed the Boat
Mel Pohl, MD, DFASAM
Chief Medical Officer
Las Vegas Recovery Center

3. 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.

4. 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)

6. 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.

7. Chronic pain is associated With decreased prefrontal
And thalamic gray matter
density.
Apkarian AV, 2004, 2009, 2011, 2015

8. Pain Switchboard – Lower Threshold
GENETICS
TRAUMA N O C I E P T P A I N
COMT

9. NORMAL PAIN RESPONSE

10. CENTRAL SENSITIZATION

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.

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

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

14. Pharmacologic Non-Opioid
NSAIDs.
Tricyclics and SNRIs.
Anti-convulsants.
Muscle Relaxants— (AVOID SOMA/carisoprodol).
Topicals.

15. Simple Approach to Treating Non-Malignant Pain
If it hurts…..
If it hurts a lot…
If it REALLY hurts…
If it still REALLY hurts…
If it REALLY hurts for a long time….
If it’s getting worse no matter what I prescribe…
Give ibuprofen
Give hydrocodone
Give something stronger
Give more
Keep giving more
Discharge patient
“ Hmmm. Something
is just not right.”

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

17. Appropriate Opioid Prescribing – Utilizing CDC Guidelines
Never vs. Always vs. It depends?
Should be part of a larger, comprehensive management program based on assessment, trust, relationship, and verification.
Conscientious, judicious use.
Balance risks and benefits.
Informed consent and agreement.
Communicate and connect.
Assess and Document 5 A’s -- Analgesia, ADL’s, Adverse Side Effects, Aberrancy, Addiction.

18. CDC: #5 Use lowest effective dosage
When opioids are started, clinicians should prescribe
the lowest effective dosage.
Clinicians should use caution when prescribing opioids at any dosage,
should carefully reassess evidence of individual benefits and risks when considering increasing dosage
to ≥50 morphine milligram equivalents (MME)/day,
and should avoid increasing dosage to ≥90 MME/day
or carefully justify a decision to titrate dosage to
≥90 MME/day.

19. High Opioid Dose and Overdose Risk
11.18
3.11
1.19
1.00
* 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.

20. CDC: # Day Guideline
Long-term opioid use often begins with treatment of
acute pain.
Clinicians should prescribe the lowest effective dose
of immediate-release opioids
and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.
Three days or less will often be sufficient;
more than seven days will rarely be needed.

21. Eyes open to the risks: Slippery Slope
The longer you use opioids, the greater the risks– and the risks seem to rise fast.
Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269. DOI: 

22. One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of days’ supply* of the first opioid prescription — United States, 2006–2015

23. CDC: #11 Avoid Benzodiazepine-Opioid Combination
Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.

24. CDC: EVIDENCE ABOUT OPIOID THERAPY
• Benefits of long-term opioid therapy for chronic pain not well supported by evidence.
• Short-term benefits small to moderate for pain; inconsistent for function.
• Insufficient evidence for long-term benefits in low back pain, headache, and fibromyalgia.

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

27. NEJM, Ballantyne & Mao Nov 2003

28. Pendulum Swings

29. OxyContin 80mg

30. So, by 2012: New Oxycontin® Formulation to Mitigate Abuse April 2010
1. Freeze Oxy or
2. Opana®
Oxycodone
Oxymorphone

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

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

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

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

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

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

38. Source: CDC

39. 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,

40. 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.

41. “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)

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

43. 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)

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

46. Photo taken at the7th International Conference on Pain and Chemical Dependency, June 2007

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

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

49. Source: CDC

50. Source: CDC

51. Source: CDC

52. Medication Assisted Treatment
Methadone.
Buprenorphine.
Naltrexone.
Naloxone.

53. ASAM Short Definition of Addiction
is reflected in an individual
pathologically pursuing reward and/or relief by substance use and other behaviors...
asam.org

54. 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 VS
“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.

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

56. QUESTIONS? Mel Pohl, MD, DFASAM 702-271-1734 mpohl@centralrecovery.com
thepainantidotebook.com
Drmelpohl.com

57. 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.

58. THANK YOU Mel Pohl, MD, DFASAM 702-271-1734 mpohl@centralrecovery.com
Drmelpohl.com