2. +/- Opioid Management Kristen Zeller, M.D. Interventional Pain Management Specialist

4. Pain – “Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” *1994 International Association for the Study of Pain

5. Basic Neuroanatomy of Pain

6. Biochemical mediators of the Dorsal Horn Excitatory Neuromediators -Excitatory amino acids-glutamate and aspartate -Neuropeptides-substance P (SP) and calcitonin gene-related peptide (CGRP) -Growth Factor-brain-derived neurotrophic factor (BDNF) Inhibitory Neuromediators -Endogenous opiods, such as enkephalin and B-endorphin -Gamma-aminobutyric acid (GABA) -Glycine

7. Yin/Yang 1.Excitation occurs in an injury 2.A patient needs counter balance or pain can be out of control 3.Patients have natural inhibition 4.Opioids particularly in an acute injury function as inhibition in the pain pathway

8. Target Sites for Pain Therapies

9. Individual Pain Experience Nociception Perception of Pain Suffering Pain Behavior Fear Secondary Gain Cancer Depression

10. Nociception Perception of Pain Suffering Pain Behavior

11. Nociception Perception of Pain Suffering Pain Behavior Fear Secondary Gain Depression

12. High Pathology ACUTE PAIN CHRONIC PAIN Low Pathology

13. OPIOID MANAGEMENT PAIN OPIOIDS DIAGNOSIS

14. OPIOID MANAGEMENT DIAGNOSIS ? SOMATIC (Acute post-op, Fractured bone, Cancer metastasis to the bone, etc) NEUROPATHIC ( RSD, Neuroma, Peripheral Neuropathy, Radiculopathy, etc. VISCERAL (Distention of hollow viscous, SBO, etc. Very Helpful ? Utility

15. OPIOID MANAGEMENT AGE ? - Is tolerance going to be an issue Pathology ? - Chronic benign pain with low pathology Chemical Dependency ? – Denial - Urine Screen Functional ability ? – Coach Potatoes Long Term Goals ? – Briefly use opioids to facilitate rehabilitation and then taper off Personality Disorders/Psychiatric issues/Psychosocial issues ?

16. OPIOID MANAGEMENT Difficult medications to manage - Utility Physical Dependence Hyperalgesia state with withdrawal Potential for a paradoxical effect with chronic use

17. Education 1. If rapid tolerance develops unlikely to be a long-term solution to the patients pain state. 2. If the patient has an injury that needs time to heal if they take opioids they may not get the proper feedback on biophysical pain mechanisms. 3. Opioids are typically not a solution to a pain state, so to use opioids ONLY without other treatments will likely lead to tolerance and increasing doses……..poor pain control 4. Long-term use seems to loose its efficacy and the side effects of opioid remain. (cognitive delay, constipation) 5. I do not want to see you suffer and I will treat your pain, but I want you to understand the risks and limitations of these medications.

18. Rehabilitation Middle Road of Activity Over Activity Under Activity PAIN TIME

19. Urine Drug Screen Needs to be random Test temperature of urine Most Urine Drug screens were developed for illicit use of drugs More challenges and more variables when testing for compliance of narcotic use (hydration, dosing, metabolism, body mass, urine pH, duration of use, drug’s pharmacokinetics)

20. Urine drug screen Opiates Codiene Hydrocodone Hydromorphone Morphine Semi-synthetic opiates Oxycodone Oxymorphone Synthetic-methadone, Fentanyl, Tramadol Benzodiazapines-Alprzolam, Nordiazepam Illicit Drug-Methamphetamine, Cocaine metabolites, THCA/marijuana, Heroin metabolite

21. Urine Drug Screen Immunoassay Susceptible to false positives Gas Chromatography-Mass Spectrometry (GC/MS) When a positive result is on Immunoassay then need to go to GC/MS. GC/MS is an confirmation assay that is highly reliable and specific test with rare interferences.