Dr. Barbara Turner's presentation from TPR's Think Health Science: Pain Management presentation, 6/9/16 at UT Health Science Center.

1. Barbara J Turner MD, MSED, MA
Director, Center for Research to Advance Community
Health
James D and Ona I Dye Professor of Medicine

3. What is chronic pain?
 Pain lasting at least 3 months or past the
normal time for tissue healing*
 Pain disrupts everyday activities and often
affects sleep
 Does not have to be constant to be a
significant problem
*Chou et al. Ann Intern Med. 2015:162:276-86

4. Many tragedies

6. Huge impact on health
 1 in every 3 Americans will have chronic
pain at some point in their lives
 When it starts, it usually lasts
 60% of older adults reporting pain still have pain
after one year.
Institute of Medicine. Relieving Pain in America: A Blueprint for
Transforming Prevention, Care, Education, and Research, 2011

7. How common is it?
Condition # people in U.S. Source
Chronic Pain Over 25 million with
moderate to severe pain
Institute of
Medicine, NIH
Diabetes 26 million (including
not yet diagnosed)
American Diabetes
Association
Heart disease
Stroke
16.3 million
7.0 million
American Heart
Association
Cancer 11.9 million American Cancer
Society

8. Chronic pain has many effects
 Report fair or poor health: 25–33%
 Unable to work: 15–22%
 Sleeping <6 hours: 12–17%
 Daily mental distress/strain: 6–13%

9. What is the most
common reason
people see a
doctor in the USA?
Pain!

11. Huge demand for health care
 Adults with joint pain
 11,000,000 physician office visits,
 >1,100,000 outpatient hospital visits,
 1,500,000 emergency department visits
 177,ooo inpatient hospitalizations
 Adults with back pain
 700,000 physician office visits,
 762,000 outpatient hospital visits,
 >1,500,000emergency department visits
 227,ooo inpatient hospitalizations
Source: NIH

12. Economic burden
Pain costs an
estimated $100 billion
annually in lost
workdays, medical
expenses, and other
benefit costs.
NIH Evidence Review,
2015

14. What about obesity and
chronic pain?

15. Arthritis prevalence and BMIBody weight and arthritis

16. Chronic pain and body weight

17. Who has severe pain?

18. Women more likely to have pain
if overweight or obese

20. Drugs for pain
 Used for centuries
 No prescription needed
 Used mostly by Caucasian
woman

22. Opioids still the norm

23. NIH America’s Addiction to Opioids: Heroin and Prescription Drug Abuse
Opioid prescriptions from retail pharmacies—
US, 1991–2013

25. • Use of oral opioids for at least 4 weeks versus placebo or other pain
medication
• Fifteen trials (5540 participants)
• Generally lower quality studies
• Small to moderate efficacy for short-term treatment (< 15 weeks)
• The effectiveness and safety of long-term opioid therapy unproven
• Remember these studies only involve pills for back pain

26. Are there problems with these
drugs?

27. Overdose from prescription drugs

28. Drug overdose deaths by major drug type
U.S. 1999–2010
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
NumberofDeaths
Year
Opioids Heroin Cocaine Benzodiazepines
CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.

29. Heroin deaths skyrocketing
Source CDC

31. 206,869 privately insured patients aged 18 to 64 with non-cancer
pain and at least 2 filled prescriptions for Schedule II or III opioids
from 1/2009 to 7/2012. Opioid therapy examined in 6-month
intervals including 6 months before a drug overdose

32. Daily opioid dose and overdose
Drug overdose in 1,385 (.67%) subjects

33. Total opioid dose/6 months and
drug overdose

34. JAMA. 2016;315(15):1624-1645

36. Hypothesis: Opioids and other drugs used to treat
chronic pain are associated with an even greater
risk for overdose in all patients but especially
those with mental health disorders
J Gen Intern Med, in press

37. Risks of combining opioids with
other drugs
 In a patient with depression, treatment with a
moderately high opioid dose (e.g. 60 mg/d) plus
benzodiazepines (e.g. Xanax) for >1 month
increased the likelihood of drug overdose by 12
times (vs none of these drugs and not depressed)
 Co-treatment with zolpidem (e.g., Ambien) increased
the likelihood of overdose by 14 times

38.  High dose opioids even more risky for men than women
 Men also have greater risks from long-term
benzodiazepines
 But women have greater risks from zolpidem (Ambien)

40.  Blue Cross Blue Shield of Texas enrollees with diabetes
 Significantly less likely to be checked for diabetes control
with higher dose or longer term opioids
 Higher dose and duration of opioids associated with 6 to 8
times higher odds of being hospitalized and over 3
times greater odds of going to the emergency room

42. Restrictions on opioid prescribing

43. Governmental response

44. N Y Times editorial: March 2, 2015

45. CDC guidelines 2016
 Nonpharmacologic therapy preferred
 Do not use only opioids, use with nonpharmacologic
therapy and/or non-opioid therapy
 Establish realistic goals for pain and function in an
agreement
 Discuss risk/benefits and physician/patient
responsibilities
 Initiate with short-acting not long-acting opioids
 Prescribe lowest effective dosage, avoid >50 MME/d

46. CDC guidelines 2016, cont.
For acute pain, <=3 days of short-acting opioids, rarely >7
days – at lowest effective dose
Review benefits/harms 1-3 weeks after start, then every 3
mos. if benefits < harms, focus on alternatives and tapering
Consider naltrexone if increased risk of overdose
Avoid opioids with benzodiazepines
Urine drug testing before starting and at least annually
Buprenorphine or methadone with behavioral therapies for
patients with opioid use disorder

47. Where are we heading with
chronic pain management?

48. Chronic pain and the brain
 Chronic pain engages brain
regions critical for
cognitive/emotional
assessments
 Neuroimaging studies also
highlight impact of environment
and genetics in chronic pain
 These features of chronic pain
may be a distinctive vs acute
pain
 Chronic pain appears to be less
related to ongoing tissue
damage
J Clin Invest. 2010;120:3788-97

49. Evidence-based non-drug treatment
of chronic low back pain
 Exercise
 Physical therapy
 Spinal manipulation
 Massage
 Yoga
 Acupuncture
 Cognitive behavioral therapy
 Progressive relaxation
Chou et al. Ann Intern Med, 2007

50. There are alternatives!

52. ARCH INTERN MED/VOL 171 (NO. 22), DEC 12/26, 2011
Rowland Disability Questionnaire

53. Walking for low back pain
ITT analysis found significant improvements at 12 mos. in the Oswestry Disability Index
(Primary Outcome), Numerical Rating Scale, Fear Avoidance-PA scale, and EuroQol
Weighted Health Index (P<0.05), but no significant between-group differences

54. Value of an active lifestyle

55. Body’s reward for exercising

56. Trial of multi-modality non-drug
treatment for chronic pain
 Setting lifestyle goals to live better beyond pain
 Walking
 Safe exercises
 Stretching
 Self- or partnered-massage
 Mind-body skills
 Improve sleep habits
 Eat healthier and smarter
 Dealing with set backs

57. Not the kind of water exercise we
are looking for!