Pain Management and  Opioid Addiction  Mel Pohl, MD, FASAM        Medical Director   Las Vegas Recovery Center
Disclosure of Relevant FinancialRelationships Name      Commercial          Relevant         Relevant      No Relevant    ...
Objectives●    Review addiction as brain disease.●    Describe chronic pain.●    Discuss pain treatment in the context of ...
AddictionCharacterized by: ●   Compulsive use ●   Loss of Control ●   Continued use despite harm ●   Craving
Neurobiology          Addiction is a Brain               Disease                  Cortex                 Midbrain         ...
Limbic System         Brain Stem
Addiction is Similar to other Diseases                  Both:                   ●                       disrupt normal, he...
Dopamine Transporters   (A) Control Group with no history of drugs   J. Shi et al. / European Journal of Pharmacology 579 ...
Dopamine Transporters  (B) Methadone maintenance group – 6 months       J. Shi et al. / European Journal of       Pharmaco...
Dopamine Transporters   (C) Prolonged Abstinence Group – 6 months       J. Shi et al. / European Journal of       Pharmaco...
5 Key Facts About ChronicPain:•   All pain is real.•   Emotions drive the experience of pain.•   Opioids often make pain w...
Pain Definitions“An unpleasant sensory and emotionalexperience associated with actual orpotential tissue damage ….”The Int...
Patient with Pain             n             ai             P‘Injury’
Patient with Pain             Suffering               n               ai               P              ‘Injury’
“…When touched with a feeling of pain, the ordinaryuninstructed person sorrows, grieves, and laments, beats            his...
Chronic Pain Syndrome• Pain > 6 months• Depression, anxiety, anger, fear• Restriction in daily activities• Excessive use o...
Pain Assessment Scale Clinical definition of pain: “Whatever the patient states it is unless proven   otherwise.” No      ...
Reasonable Goals of Pain Management:      Enhance Quality of Life!!• Maintain function• Improve function• Reduce discomfor...
Pharmacologic Non-Opioid• NSAID’S, COX 2S• Tricyclics, SNRI’S• Anticonvulsants• Muscle Relaxants— (AVOID  SOMA/carisoprodo...
Treating Chronic Pain with Opioids• Clinical Trial• Ongoing Assessment• Need exit strategy
Problems with Opioids• Side Effects• Tolerance and physical dependence• Loss of function• Perceive emotional pain as physi...
NEJM, Ballantyne & Mao                  Nov 2003
Emergence of an Epidemic
Primary non-heroin opiates/synthetics admission rates, by State          (per 100,000 population aged 12 and over)
Primary non-heroin opiates/synthetics admission rates, by State          (per 100,000 population aged 12 and over)
Primary non-heroin opiates/synthetics admission rates, by State          (per 100,000 population aged 12 and over)
Primary non-heroin opiates/synthetics admission rates, by State          (per 100,000 population aged 12 and over)
Samsha Oxycodin.jpg
Rates of prescription painkiller sales, deathsand substance abuse treatment admissions(1999-2010) SOURCES: National Vital ...
Sleep DisturbancePhysical Problems                                           Substance                                    ...
Sleep DisturbancePhysical Problems                                         Substance                                      ...
Sleep DisturbancePhysicalProblems                             Substance                                       Abuse       ...
Emotional Intensifiers•   Guilt•   Anger – Resentments•   Loneliness•   Helplessness•   Fear
Pain Pearls• Conditioning Increases Pain.• Pain Patients Are A Pain.• Secondary Gain Prevents Getting Well.
Treatment Implications•   Surrender•   Utilize body awareness•   Develop “relaxed attention”•   Involved with others•   Pa...
Pain Recovery – Develop Balance•   Mental•   Emotional•   Physical•   SpiritualRESULTING CHANGES    – Relationships    – P...
Non-Medication Treatments at LVRC•   Exercise – Physical Therapy•   Chiropractic Treatments•   Therapeutic Massage•   Reik...
THANK YOU Mel Pohl, MD, FASAM      702-515-1373mpohl@centralrecovery.com  adaywithoutpain.com
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Pohl presentation

  1. 1. Pain Management and Opioid Addiction Mel Pohl, MD, FASAM Medical Director Las Vegas Recovery Center
  2. 2. Disclosure of Relevant FinancialRelationships Name Commercial Relevant Relevant No Relevant Interests Financial Financial Financial Relationships: Relationships: Relationships What Was For What Role with Any Received Commercial InterestsMel Pohl Las Vegas Salary Medical Director Recovery Center
  3. 3. Objectives● Review addiction as brain disease.● Describe chronic pain.● Discuss pain treatment in the context of opioid addiction.
  4. 4. AddictionCharacterized by: ● Compulsive use ● Loss of Control ● Continued use despite harm ● Craving
  5. 5. Neurobiology Addiction is a Brain Disease Cortex Midbrain PositronPET = Emission Tomography
  6. 6. Limbic System Brain Stem
  7. 7. Addiction is Similar to other Diseases Both: ● disrupt normal, healthy functioning of the underlying organ ● have serious harmful consequences ● are chronic preventable, and treatable
  8. 8. Dopamine Transporters (A) Control Group with no history of drugs J. Shi et al. / European Journal of Pharmacology 579 (2008) 160-166
  9. 9. Dopamine Transporters (B) Methadone maintenance group – 6 months J. Shi et al. / European Journal of Pharmacology 579 (2008) 160-166
  10. 10. Dopamine Transporters (C) Prolonged Abstinence Group – 6 months J. Shi et al. / European Journal of Pharmacology 579 (2008) 160-166
  11. 11. 5 Key Facts About ChronicPain:• All pain is real.• Emotions drive the experience of pain.• Opioids often make pain worse.• Treat to improve function.• Expectations influence outcomes.
  12. 12. Pain Definitions“An unpleasant sensory and emotionalexperience associated with actual orpotential tissue damage ….”The International Association for the Study of Pain (Mesky,1979)
  13. 13. Patient with Pain n ai P‘Injury’
  14. 14. Patient with Pain Suffering n ai P ‘Injury’
  15. 15. “…When touched with a feeling of pain, the ordinaryuninstructed person sorrows, grieves, and laments, beats his breast, becomes distraught. So he feels two pains, physical and mental. Just as if they were to shoot a man with an arrow and,right afterward, were to shoot him with another one, so that he would feel the pains of two arrows…” The Buddha
  16. 16. 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
  17. 17. Pain Assessment Scale Clinical definition of pain: “Whatever the patient states it is unless proven otherwise.” No Moderate Worst Pain Pain Pain 0 1 2 3 4 5 6 7 8 9 10
  18. 18. Reasonable Goals of Pain Management: Enhance Quality of Life!!• Maintain function• Improve function• Reduce discomfort by 50%
  19. 19. Pharmacologic Non-Opioid• NSAID’S, COX 2S• Tricyclics, SNRI’S• Anticonvulsants• Muscle Relaxants— (AVOID SOMA/carisoprodol)• Topicals
  20. 20. Treating Chronic Pain with Opioids• Clinical Trial• Ongoing Assessment• Need exit strategy
  21. 21. Problems with Opioids• Side Effects• Tolerance and physical dependence• Loss of function• Perceive emotional pain as physical pain (chemical copers)• Hyperalgesia
  22. 22. NEJM, Ballantyne & Mao Nov 2003
  23. 23. Emergence of an Epidemic
  24. 24. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  25. 25. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  26. 26. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  27. 27. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  28. 28. Samsha Oxycodin.jpg
  29. 29. Rates of prescription painkiller sales, deathsand substance abuse treatment admissions(1999-2010) SOURCES: National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009
  30. 30. Sleep DisturbancePhysical Problems Substance Abuse Addiction Depression Functional Anxiety Disability Increased StressesSeddon Savage, M.D.
  31. 31. Sleep DisturbancePhysical Problems Substance Abuse Chronic Pain Depression Functional Anxiety Disability Increased Stresses
  32. 32. Sleep DisturbancePhysicalProblems Substance Abuse Pain AddictionDepression Functional Anxiety Disability Increased StressesSeddon Savage, M.D.
  33. 33. Emotional Intensifiers• Guilt• Anger – Resentments• Loneliness• Helplessness• Fear
  34. 34. Pain Pearls• Conditioning Increases Pain.• Pain Patients Are A Pain.• Secondary Gain Prevents Getting Well.
  35. 35. Treatment Implications• Surrender• Utilize body awareness• Develop “relaxed attention”• Involved with others• Pain Recovery – Develop Balance
  36. 36. Pain Recovery – Develop Balance• Mental• Emotional• Physical• SpiritualRESULTING CHANGES – Relationships – Positive actions and behaviors
  37. 37. Non-Medication Treatments at LVRC• Exercise – Physical Therapy• Chiropractic Treatments• Therapeutic Massage• Reiki• Acupuncture• Individual + group therapy• Mindfulness-Based Stress Reduction (Kabat-Zinn)• Yoga - Chi Gong
  38. 38. THANK YOU Mel Pohl, MD, FASAM 702-515-1373mpohl@centralrecovery.com adaywithoutpain.com

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