Elinore McCance Katz-b

Prevalence of Recurrent and Persistent Pain in the US •  1 in 4 Americans suffer from recurrent pain (day-long bout of pain/month) •  1 in 10 Americans report having persistent pain of at least one year s duration •  1 in 5 individuals over the age of 65 report pain persisting for more than 24 hours in the preceding month – 6 in 10 report pain persisting > 1 year •  2 out of 3 US armed forces veterans report having persistent pain attributable to military service – 1 in 10 take prescription medicine to manage painAmerican Pain Foundation. http://www.painfoundation.org. Accessed March 2010.

National Institutes of Health. New Directions in Pain Research.Sept 1998. PA-98-102.

DAWN 2009  Heroin 213,118 visits  Narcotic Pain Relievers: 397,160 visits  Oxycodone/combinations – 175,949 visits  Hydrocodone/combinations – 104,490 visits  Fentanyl/combinations – 22,143 visits  Buprenorphine/combinations – *12,544 *estimate may be low because buprenorphine is not  Alcohol involvement: 32% of visits specifically queriedSource: Drug Abuse Warning Network, National Estimate, 2010; The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related morbidity and mortality. DAWN uses a probability sample of hospitals to produce estimates of drug-related emergency department (ED) visits for the United States and selected metropolitan areas annually. DAWN also produces annual profiles of drug-related deaths reviewed by medical examiners or coroners inselected metropolitan areas and States.

The majority of unintentional overdose deaths were related to opioid use including oxycodone, hydrocodone, and methadone, often in combination with other drugsand/or alcohol.Source: Methadone Mortality Conference, CSAT/SAMHSA, July 2010http://www.cdc.gov/HomeandRecreationalSafety/pdf/poision-issue-brief.pdf

A Common Dilemma in Medicine

NSAIDSLithium O Antidepressants OpioidsStimulants Anticonvulsants AcetominophenAntipsychotics Alpha blockers SteroidsBeta-blockers BZDs

A-delta (myelinated) and C (unmyelinated) afferentsAnatomy of Pain with cell bodies in dorsal root ganglion act as nociceptors: sensitive to noxious stimuli: heat, mechanical, irritating chemicals Sensitization in local tissue with release of prostaglandins, bradykinins, leukotrienes Nociceptors can cause release of Substance P resulting in further local inflammation Axons of primary afferent nociceptors enter spinal cord via the dorsal root terminating in dorsal horn of spinal gray matter Spinal neurons then transmit pain signals to brain: thalamus which projects to somatosensory cortex (ascending transmission) Projections to cortical regions (cingulate and frontal lobe) linked to emotional responses resulting in unpleasant emotional perceptions Pain can be modulated via a descending circuit that has links in hypothalamus, medulla, and midbrain. Selectively controls spinal pain transmission neurons; contains endogenous opioids

Diet/ Trigger Point Exercise/PT Anticonvulsant Injections s Surgery Nerve Block Pain Chiropractic Treatment Massage/Yoga Cognitive Acupuncture Behavioral Therapy TENS

Opioid Risk Tool (ORT) •  Administration •  On initial visit •  Prior to opioid therapy •  Scoring •  0-‐3: low risk (6%) •  4-‐7: moderate risk (28%) •  > 8: high risk (> 90%) Webster & Webster. Pain Med. 2005;6:432.

Opioids for Pain Management

Passik SD, Kirsh KL. J Supportive Oncology, 2005.

Clinical Support SystemsSponsored by Center for Substance Abuse Treatment/SAMHSA

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Elinore McCance Katz-b

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