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

2. 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
National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain.
National Centers of Health, NIH guide: new directions in pain research: 1. Bethesda, MD: National Institutes of Health Sept 4.

3. 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%
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:
Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs 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.
Hojsted J, Sjogren P. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain 2007;11:

4. Problem: expectations

5. Problem: misconceptions
Opioids = Pain Relief therefore: More Pain Relief = More Opioids

6. Steady Increases in Opioid and Stimulant Prescriptions Dispensed by U
Steady Increases in Opioid and Stimulant Prescriptions Dispensed by U.S. Retail Pharmacies,

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

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

9. 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

10. 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???

11. 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.

12. 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.