1. Opioids for Chronic Pain: Course Overview William Morrone, D.O., M.S. Medical Director, Hospice of Michigan Assistant Director, Family Medicine Synergy Medical Education Alliance, Saginaw, Michigan Consulting Liaison Addictionologist, Wolverine Human Services

3. PUBLIC DOMAIN NOTICE Material presented in this document – except the quoted passages, tables, photos, figures, and graphs from copyrighted sources – is in the public domain and may be reproduced or copied without permission. Citation of the source is appreciated.

4. There is a long cultural tradition of seeking relief from pain through medication “to lull all pain and anger and bring forgetfulness of sorrow…” Homer: The Odyssey JWF: The Vintage Image Gallery

5. The challenge is that “treating pain is neither an absolute science nor risk-free” Scott M. Fishman, MD - Anesthesia & Analgesia. 2007;105:8-9 Michigan Prescribers Allopathic Physicians 31,695 Osteopathic Physicians 6,550 (15.4%) Michigan had 3,208 students enrolled in a public medical school –allopathic (2,461 students) –osteopathic (747 students) Dentists7800+ Podiatrists 1200+ 2008 survey of physicians in Michigan, about 34 percent identified themselves as primary care doctors, that is, their primary specialty is family practice, general medicine, internal medicine, or general pediatrics

6. Use of all prescription opioids is increasing

7. Trend data: Distribution of prescription opioids, U.S., 2000–2007 Source: DEA, ARCOS system, 2007 GRAMS PER 100K POPULATION * Includes OTPs

8. Problems related to opioid use are rising in tandem with distribution

9. Deaths per 100,000 related to unintentional overdose and annual sales of prescription opioids by year, 1990 - 2006 Source: Paulozzi, CDC, Congressional testimony, 2007

11. Unintentional drug overdose deaths are rising faster for prescription opioids than for illicit drugs Source: CDC, National Vital Statistics System, 2006

12. Emergency department mentions and admissions to addiction treatment related to use of prescription opioids also are rising Emergency department mentions and admissions to addiction treatment related to use of prescription opioids also are rising Source: CDC, National Vital Statistics System, 2006

13. Non-medical use of prescription opioids by adolescents and young adults is a particular concern

14. Source: SAMHSA, OAS, NSDUH data, July 2007

15. This course will address the balance between providing optimal pain relief and preventing inappropriate use of opioid analgesics.

16. What is the Physician’s Role?

17. Total Chronic Pain Population Aberrant Medication Use Behaviors: A spectrum of patient behaviors that may reflect misuse Prescription Drug Misuse Addiction Abuse/Dependence Adapted from Passik. APS Resident Course, 2007

18. Opioid treatment of chronic pain Adapted from Katz NP. Patient Level Opioid Risk Management. PainEDU.org Manual. 2007 Initial Patient Assessment Trial of Opioid Therapy Setting Goals Patient Reassessment Monitoring

19. Steps to be covered: Assess for pain, function, risk Set realistic goals Use agreements and informed consents Monitor, monitor, monitor… Not all aberrant medication taking is addiction Patients with addiction lose control Reassess, reassess, reassess.. Make needed adjustments Document, document, document…