Slide show from Texas Public Radio and UTHSCSA's Think Health Science: Pain Management program on June 9, 2016.

1. Pain and Addiction:
Minding the Medicine
Cabinet
Jennifer Sharpe Potter, PhD, MPH
Associate Professor of Psychiatry
Associate Dean for Research
Division of Alcohol And Drug Abuse
Department of Psychiatry
School of Medicine
University of Texas Health Science Center San Antonio
Citation available upon request

2. Video

3. Opioid analgesics may
benefit people when
used correctly and under
a medical provider’s care.
But when abused, they can be just as dangerous as illicit drugs,
especially when taken with alcohol or illicit drugs.

4. Pain medicines
Addictive!
Pain!
Safe!
Not safe!It depends…
Addiction?

5. Start at the beginning:
Low back pain (often chronic)

6. Unique characteristics of pain
• Pain is a subjective experience
 Patients experience and “interpret” it differently
 No test for pain (only for unpleasantness)
• Pain tolerance varies from person-to-person
 Genetic and cultural differences
 “Significance” of pain plays a role
• Requires comprehensive clinical evaluation
 Health care providers struggle to treat pain effectively
 Few health care providers are taught adequately how
to diagnose and treat
 Failure to treat/under-treatment common

7. Related Opioid Trends

8. Prescription drug epidemic is
unique
• Prescription drugs are not inherently bad
when use appropriate, under a health
providers supervision, and when they
provide pain relief
• Threat comes from abuse and diversion
• Just because prescription drugs are legal and
are prescribed by an MD, they are not
necessarily safer than illicit substances.

9. Source of Pain Relievers for Most Recent Nonmedical Use
among Past Year Users Aged 12 or Older: 2010-2011
National Survey on Drug Use and Health 2011

11. Weiss, Potter et al. (2011). Adjunctive counseling during brief and
extended buprenorphine-naloxone treatment for prescription opioid
dependence: A 2-phase randomized controlled trial. Archives of
General Psychiatry, 68(12), 1238-46.

12. POATS: Study locations
WA: Providence Behavioral Health Svc
OR: ADAPT, Inc.
CA: SF General Hospital
CA: UCLA ISAP
SC: Behavioral Health Services of Pickens Co
IN: East Indiana Treatment Center
WV: Chestnut Ridge Hospital
NY: Bellevue Hospital Center
NY: St. Luke's Roosevelt Hospital Center
MA: McLean Hospital

13. POATS: Study schema

14. Successful outcomes at 3 time
points
Success
Phase 1 4-week taper + 8 weeks f/u 7%
Phase 2
Week 12 - End of stabilization 49%
Week 24 - 8 weeks post-taper 9%

15. Chronic pain location
Head/face 16.1%
Chest/abdomen 5.5%
Upper extremities 29.6%
Cervical 27.0%
Thoracic 26.3%
Lumbar/sacral 65.0%
Lower extremities 52.9%
Multiple spinal areas 36.1%

16. Primary reason for use:
Past and present
Major reason for first use among CP patients
• pain 83.2%
• get high 13.1%
Major reason for current use among CP patients
whose first reason was pain
• pain 22.6%
• get high 13.9%
• avoid withdrawal 56.5%

17. % of CP Participants with Clinically
Meaningful Reductions in Pain
Reduction at Ph2 wk
12 from baseline
Minimal
(>10% Δ)
Moderate
(>30% Δ)
Substantial
(>50% Δ)
BPI Intensity Scale 69% 51% 35%
Worst pain 66% 51% 34%
Average pain 67% 55% 43%
 BPI – (0-10) worst, least, average, and “right now”
 Results presented for overall sample; no difference between
treatment groups
 n=121 (149 Phase 2 CP participants)
(IMMPACT recommendations, Dworkin et al, Pain, 2008)

18. Clinically meaningful
reductions in pain interference
Reduction at Ph2 wk
12 from baseline
Minimal
(>1 point Δ)
Moderate
(>2 point Δ)
BPI Interference 59.5% 43.0%
 Results presented for overall sample; no difference
between treatment groups
 n=121 (149 Phase 2 CP participants)

20. ACT: Acceptance and Commitment Therapy
Cognitive-behavioral therapy
Mindfulness
Physical activity
Diet
Social support

23. ACT: What we did
• Some patients were randomized to health
education – learning about pain and health –
while other patients were randomized to ACT.
Brain imaging was done before and after the 8-
week treatment program.
• Task - Chronic pain patients who were also
addicted to opiates were exposed to
experimentally induced pain delivered via a
thumb screw.
• Resting state - We also look at their brains at rest

24. Pain region
connections
during resting
state (p<0.05
uncorrected)
Solid cyan = connectivity
ACT pre- > ACT post-
treatment
Dashed cyan =
connectivity ACT post- >
ACT pre-treatment
Solid red = connectivity
HEC post-treatment > ACT
post-treatment
Correlations of clinical variables in
ACT group post-treatment:
Green brackets = Pain intensity correlation
Magenta brackets = Pain interference
correlation
Yellow brackets = AAQ-II correlation
Values = Fisher’s Z
inf
PCC sup
PCC
R
Para
Rlat
Par
R
ITG
R
SFG
vm
PFC
am
PFCL
SFG
L
ITG
Llat
Par
L
Para
B
1.94
[-0.99]
A
Ri
PCC Rs
PCC
Rp
Ins
Rm
Ins
Ra
Ins
R
S2
R
S1
ACC
L
S1
Lp
Ins
R
Thal
R
Amyg
C
Middle frontal
gyrus
Inferior parietal
lobule
Posterior
cingulate cortex
Insula
Anterior
cingulate cortex
Insula
Superior
temporal gyrus
[0.84]
2.19
3.13
2.94
2.75
2.19[0.89][0.94]
2.67
1.68

25. Take home message
•After treatment, the brains of ACT
patients were more resilient at rest,
and less reactive to pain even when it
was deliberately induced. The ACT
patients learned how to carry their
pain is a less entangling way: chronic
pain and induced pain. – Steve Hayes
CAVEATS!!!

26. “The nation's defense rests on the
comprehensive fitness of its service
members ― mind, body, and spirit. Chronic
pain and use of opioids carry the risk of
functional impairment of America's fighting
force.”
-Jonas and Schoomaker

27. PDMPs: Prescription Drug Monitoring Programs:
By State
PDMP Training & Technical Assistance Center

28. Study Aims
 Examine military trends and trajectories in
opioid prescribing
 Build military-specific tools and strategies to
alert clinicians of potential opioid misuse in the
military
 Develop reports and guidelines for addressing
opioid misuse in the military context

29. The road ahead…

32. Nonmedical Use of Pain Relievers in the Past Year among Youths Aged 12 to 17,
by State: Percentages, Annual Averages Based on 2010 and 2011 NSDUHs
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2010 (Revised March 2012) and 2011

33. What do teens say?
Over half of teens (56 percent or 12.8 million) do not see
great risk in trying prescription pain relievers without a
doctor’s prescription
 Prescription drugs are easy to get; 70 percent of kids age 12 and
older say they get them from friends or relatives, often for free
Teens say they abuse prescription painkillers because…
 they believe they are safer to use than illicit drugs (41%)
 there is less shame attached to using them (37%)
 there are fewer side effects than illicit drugs (31%)
 and parents don’t care as much if you get caught (20%)

34. What can parents do?
• Talk with and listen to your kids
• Know what your kids are doing – parental
awareness/monitoring of their kids’ activities is
one of the best predictors of well-being for most
behavioral health issues including drug abuse
• Teens whose parents express disapproval about
drug abuse are less likely to engage in
substance use
• Universal precautions

35. Specific steps parents can take
• Safeguard all drugs at home
 Monitor quantities
 Control access
• TALK-talking to your children is not dangerous
 Set clear rules for teens about all drug and alcohol use,
 INCLUDING not sharing medicine and following the medical
provider’s advice and dosages
• Be a good role model by following these same rules with
your own medicines – don’t share medications
• Properly dispose of old or unneeded medicines
• Ask friends and family to safeguard their prescription drugs
as well

36. Collaborators
Erin Finley, PhD
Mary Jo Pugh, PhD
Don McGeary, PhD
Bill Kazanis, MS
Kangwon Song, PharmD
Don Robin, PhD
Kristen Rosen, PhD, MPH
Suyen Warzinski, MS
Samantha Paniagua
Ashley Garcia
Lt Col (Ret) Vikhyat Bebarta, MD
Maj Josephy Maddry, MD
Lt Col David Carnahan, MD
COL Robert Gibbons
Maj Gen(Ret) Byron Hepburn, MD
LTC Brandon Goff, DO
Lee Ann Zarzabal, MS
Alan Sim, PhD
Sandra Valtier, PhD (program officer, 59th MW)

37. Division of Alcohol and Drug Addiction,
School of Medicine
University of Texas Health Science Center
Questions?