Analgesia and the Pain Pathway Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84. Descending modulation Dorsal horn Ascending signals input Spinothalamic tract Dorsal root ganglion Peripheral nerve Peripheral nociceptors Pain Trauma Local anesthetics Opioids 2 agonists Opioids 2 agonists Centrally acting analgesics COX-2–specific inhibitors Traditional NSAIDs Local anesthetics AEDs Local anesthetics Corticosteroids Traditional NSAIDs Cox-2–specific inhibitors Substance P inhibitors Opioids Baclofen Clonidine Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84. Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84. Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84. Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84.
Opioid Dependence (DSM-IV) – AKA Addiction (3 or more within one year)
Larger amounts/longer period than intended
Inability to/persistent desire to cut down or control
Increased amount of time spent in activities necessary to
Social, occupational and recreational activities given up or reduced
Opioid use is continued despite adverse consequences
… a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing the development and manifestations. It is characterized by behaviors that include one or more of the following:
What is the Risk of Addiction and Aberrant Behavior?
Boston collaborative Drug Surveillance Project: Porter and Jick, 1980. NEJM.
4 cases of addiction in 11,882 patients with no prior history of abuse who received opioids during inpatient hospitalization.
Dunbar and Katz, 1996, JPSM .
20 patients with both chronic: pain and substance abuse problems on chronic opioid therapy
Nine out of 20 abused medication
Of the 11 who did not abuse the medications, all were active in recovery programs with good family support
Spectrum of Risk of Addiction or Aberrant Behavior <1 % ~ 45% LOW Short-term Exposure to Opioids in Non-addicts Porter and Jick HIGH Long-term Exposure to Opioids in Addicts, Dunbar and Kafz Where is your patient ?
Differential Diagnosis of Aberrant Drug-Taking Attitudes and Behavior
Prescription Opioid Abuse Is a Significant and Costly Public Health Problem Birnbaum HG et al. Clin J Pain . 2006;22:667-676. Total cost of prescription opioid abuse in the United States was $8.6 billion in 2001 and continues to grow. Health Care 30% Workplace 53% Criminal Justice 17% $4.6 billion $1.4 billion $2.6 billion
Annual Numbers of New Nonmedical Users of Pain Relievers, by Age at Initiation: 1965-2003, SAMHSA
Drug Mortality Rate, Source, and Misuse of Prescription Drugs: Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health, SAMHSA
Increase in New Starts of Prescription Opioid Abuse Among Teenagers Adapted from Manchikanti L. Pain Physician . 2006;9:287-321. 700 600 500 400 300 200 100 0 Percent Increase 1992 2003 542% —Incidence of new starts of prescription opioid abuse among teenagers 150% —Prescriptions written for controlled substances 14% —US population 212% ----Number of 12-17 year olds abusing CS 81% ---Adults abusing controlled substances
Past Year Users of Selected Drugs (Prevalence), Including Nonmedical Users of Prescription Psychotherapeutic Drugs: Annual Averages Based on 2002-2004 SAMHSA
Past Year Initiates (Incidence) of Illicit Drug Use, by Drug: Annual Averages Based on 2002-2004 (12 or older, 2002-2004) SAMHSA
Annual number of new non-medical users of Oxycontin
Drug-Related Emergency Department Visits With Nonmedical Use of Opioid Analgesics (DAWN) Adapted from the Drug Abuse Warning Network. DHHS Publication No. 07-4256, 2007. Total = 598,542 Narcotic analgesics alone = 160,363
1 out of 3 visits were from nonmedical use of opioid analgesics in 2005.
Of these, oxycodone and hydrocodone account for about 60%.
Methadone has been used as an effective analgesic agent for decades. New information about NMDA receptor antagonist actions, combined with its relatively low cost, has generated increasing interest for use in pain management.
The use of methadone as a treatment for addiction has complicated efforts to appropriately position the drug for analgesic therapy. For example, some physicians erroneously believe that a special license is required to prescribe methadone as an analgesic agent. This concern is particularly strong when the patient is receiving MMT and the use of methadone is being considered for pain.
Federal law prohibits physicians from prescribing methadone (or other DEA Schedule II medications) for maintenance therapy or opiate addiction* EXCEPT in a federally licensed opiate treatment program (OTP) (this includes methadone maintenance).
* There is a difference between detoxification and tapering a non addicted patient off opiates once pain is resolved.