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iCAAD London 2019 - Mel Pohl - CHRONIC PAIN AND ADDICTION: HOW WE MISSED THE BOAT.

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Chronic Pain occurs as a complicated web of emotions and physical symptoms. The most common way to treat pain is to use opioid medications, which actually complicate the course of chronic pain.

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iCAAD London 2019 - Mel Pohl - CHRONIC PAIN AND ADDICTION: HOW WE MISSED THE BOAT.

  1. 1. Mel Pohl, MD, DFASAM Chief Medical Officer Las Vegas Recovery Center Chronic Pain and Addiction: How We Missed the Boat
  2. 2. Key Points: • All pain is real. • Emotions drive the experience of chronic pain. • Opioids often make pain worse. • Treat to improve function. • Expectations influence outcomes.
  3. 3. Sustained currents Peripheral Nociceptive Fibers Transient Activation ACUTE PAIN Woolf CJ, et al. Ann Intern Med. 2004;140:441-451; Petersen-Felix S, et al. Swiss Med Weekly. 2002;132:273-278; Woolf CJ. Nature.1983;306:686-688; Woolf CJ, et al. Nature. 1992;355:75-78. Surgery or injury causes inflammation How does acute pain become chronic pain? Sustained Activation Peripheral Nociceptive Fibers Sensitization CHRONIC PAIN CNS Neuroplasticity Hyperactivity Structural Remodeling
  4. 4. Chronic pain is associated With decreased prefrontal And thalamic gray matter density. Apkarian AV, 2004, 2009, 2011, 2015
  5. 5. Pain Switchboard – Lower Threshold P A I N N O C I C E P T I O N GENETICS COMT TRAUMA
  6. 6. NORMAL PAIN RESPONSE
  7. 7. CENTRAL SENSITIZATION
  8. 8. 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.
  9. 9. Pain Assessment Scale: Clinical definition of pain: “Whatever the patient says it is... unless proven otherwise”
  10. 10. Reasonable Goals of Pain Management: Enhance Quality of Life!! • Maintain function. • Improve function. • Reduce discomfort by 50%.
  11. 11. Pharmacologic Non-Opioid • NSAIDs. • Tricyclics and SNRIs. • Anti-convulsants. • Muscle Relaxants— (AVOID SOMA/carisoprodol). • Topicals.
  12. 12. Simple Approach to Treating Non-Malignant Pain If it hurts….. If it hurts a lot… If it REALLY hurts… If it still REALLY hurts… If it REALLY hurts for a long time…. If it’s getting worse no matter what I prescribe… • Give ibuprofen • Give hydrocodone • Give Oxycodone • Give more • Keep giving more • Discharge patient “ Hmmm. Something is just not right.”
  13. 13. Treating Chronic Pain with Opioids • Clinical Trial. • Ongoing Assessment. • Need exit strategy.
  14. 14. Appropriate Opioid Prescribing – Utilizing CDC Guidelines Never vs. Always vs. It depends? Should be part of a larger, comprehensive management program based on assessment, trust, relationship, and verification. Conscientious, judicious use. Balance risks and benefits. Informed consent and agreement. Communicate and connect. Assess and Document 5 A’s -- Analgesia, ADL’s, Adverse Side Effects, Aberrancy, Addiction.
  15. 15. CDC: #5 Use lowest effective dosage - carefully reassess dosed of ≥50 morphine milligram equivalents (MME)/day, - avoid increasing dosage to ≥90 MME/day - or carefully justify a decision to titrate dosage to ≥90 MME/day.
  16. 16. High Opioid Dose and Overdose Risk Dunn et al. Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92. 1.00 1.19 3.11 11.18 * Overdose defined as death, hospitalization, unconsciousness, or respiratory failure.
  17. 17. CDC: #6 3-7 Day Guideline Long-term opioid use often begins with treatment of acute pain. Clinicians should prescribe the lowest effective dose of immediate-release opioids . . . Three days or less will often be sufficient; more than seven days will rarely be needed.
  18. 18. Eyes open to the risks: Slippery Slope The longer you use opioids, the greater the risks– and the risks seem to rise fast. Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1
  19. 19. One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of days’ supply* of the first opioid prescription — United States, 2006–2015 22%21%
  20. 20. Problems with Opioids • Side Effects.
  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. Pendulum Swings
  24. 24. OxyContin 80mg
  25. 25. New Oxycontin® Formulation to Mitigate Abuse April 2010 So, by 2012: 1. Freeze Oxy or 2. Opana® Oxycodone Oxymorphone
  26. 26. Emergence of an Epidemic
  27. 27. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  28. 28. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  29. 29. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  30. 30. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  31. 31. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  32. 32. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  33. 33. Source: CDC
  34. 34. Rates of prescription painkiller sales, deaths and 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
  35. 35. Industry-influenced “Education” on Opioids for Chronic Non-Cancer Pain Emphasizes: • Physicians are needlessly allowing patients to suffer because of “opiophobia.” • Opioids are safe and effective for chronic pain. • Opioid therapy can be easily discontinued. • Opioid addiction is rare in pain patients.
  36. 36. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980 Jan 10;302(2):123 Cited 693 times (Google Scholar) “Only four cases of addiction among 11,882 patients treated with opioids.”
  37. 37. N Engl J Med. 1980 Jan 10;302(2):123.
  38. 38. FDA used to permit drug manufacturers to advertise opioids as safe and effective for chronic pain.
  39. 39. Photo taken at the 7th International Conference on Pain and Chemical Dependency, June 2007
  40. 40. Heroin: making a big comeback since 2010! Black Tar heroin Texas “Cheese Heroin”: Black Tar Mixed with Tylenol PM
  41. 41. Source: CDC
  42. 42. Medication Assisted Treatment • Methadone. • Buprenorphine. • Naltrexone. • Naloxone.
  43. 43. ASAM Short Definition of Addiction Addiction … is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors... asam.org
  44. 44. Pain Patients VS “Drug Abusers” 63% admitted to using opioids for purposes other than pain1 35% met DSM V criteria for addiction2 1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy. J Pain 2007;8:573-582. 2. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194. This is a false dichotomy Aberrant drug use behaviors are common in pain patients 92% of opioid OD decedents were prescribed opioids for chronic pain. 3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of Decedents by Next of Kin or Best Contact, Utah, 2008-2009. J Gen Intern Med. 2012 Oct 16.
  45. 45. CDC: NON-OPIOID THERAPIES Use alone or combined with opioids, as indicated: • Non-opioid medications (e.g. NSAID’s, TCA’s, SNRI’s, anticonvulsants, topicals). • Physical treatments (e.g. exercise therapy, weight loss). • Behavioral treatment (e.g. CBT, DBT, ACT, mindfulness). And don’t forget to talk to your patients and believe them…
  46. 46. Non-Medication Treatments at LVRC • Exercise – Physical Therapy. • Chiropractic Treatments. • Therapeutic Massage. • Reiki. • Acupuncture. • Nutrition. • Individual + group therapy. • Mindfulness-Based Stress Reduction (Kabat-Zinn). • Yoga - Chi Gong.
  47. 47. Research confirms that drugs give the same benefits as yoga !!!
  48. 48. Halasana Excellent for back pain and insomnia.
  49. 49. Balasana Position that brings the sensation of peace and calm.
  50. 50. Savasana Position of total relaxation.
  51. 51. QUESTIONS? Mel Pohl, MD, DFASAM 702-271-1734 mpohl@centralrecovery.com drmelpohl.com
  52. 52. Key Points: • All pain is real. • Emotions drive the experience of chronic pain. • Opioids often make pain worse. • Treat to improve function. • Expectations influence outcomes.
  53. 53. THANK YOU Mel Pohl, MD, DFASAM 702-271-1734 mpohl@centralrecovery.com Drmelpohl.com

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