The document discusses chronic pain and addiction. It notes that while all pain is real, emotions drive the experience of chronic pain. Opioids are often ineffective in treating chronic pain and can actually make pain worse. The goals of pain management should be to maintain or improve function rather than just reducing pain. Non-medication treatments like exercise, massage, and mindfulness can be effective alternatives or supplements to medication for chronic pain.

2. Mel Pohl, MD, DFASAM
Chief Medical Officer
Las Vegas Recovery Center
Chronic Pain and Addiction:
How We Missed the Boat

4. 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.

5. 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

6. Chronic pain is associated
With decreased prefrontal
And thalamic gray matter
density.
Apkarian AV, 2004, 2009, 2011, 2015

7. Pain Switchboard – Lower Threshold
P
A
I
N
N
O
C
I
C
E
P
T
I
O
N
GENETICS
COMT
TRAUMA

8. NORMAL PAIN RESPONSE

9. CENTRAL SENSITIZATION

10. 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.

11. Pain Assessment Scale: Clinical definition of pain:
“Whatever the patient says it is...
unless proven otherwise”

12. Reasonable Goals of Pain Management:
Enhance Quality of Life!!
• Maintain function.
• Improve function.
• Reduce discomfort by 50%.

13. Pharmacologic Non-Opioid
• NSAIDs.
• Tricyclics and SNRIs.
• Anti-convulsants.
• Muscle Relaxants— (AVOID
SOMA/carisoprodol).
• Topicals.

14. 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.”

15. Treating Chronic Pain with Opioids
• Clinical Trial.
• Ongoing Assessment.
• Need exit strategy.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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

21. 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%

23. Problems with Opioids
• Side Effects.

25. Problems with Opioids
• Side Effects.
• Tolerance and physical dependence.
• Loss of function.
• Perceive emotional pain as physical pain
(chemical copers).
• Hyperalgesia.

26. NEJM, Ballantyne & Mao
Nov 2003

27. Pendulum Swings

29. OxyContin 80mg

30. New Oxycontin® Formulation to
Mitigate Abuse April 2010
So, by 2012:
1. Freeze Oxy or
2. Opana®
Oxycodone
Oxymorphone

31. Emergence of an Epidemic

32. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

33. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

34. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

35. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

36. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

37. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

38. Source: CDC

39. 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

40. 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.

41. 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.”

42. N Engl J Med. 1980 Jan 10;302(2):123.

44. FDA used to permit drug manufacturers to advertise
opioids as safe and effective for chronic pain.

45. Photo taken at the 7th International Conference on
Pain and Chemical Dependency, June 2007

46. Heroin: making a big comeback
since 2010!
Black Tar heroin
Texas “Cheese Heroin”:
Black Tar Mixed with Tylenol PM

47. Source: CDC

49. Medication Assisted Treatment
• Methadone.
• Buprenorphine.
• Naltrexone.
• Naloxone.

51. 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

52. 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.

53. 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…

54. 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.

55. Research confirms that
drugs give the same benefits
as yoga !!!

56. Halasana
Excellent for back pain and insomnia.

57. Balasana
Position that brings the sensation of peace and calm.

58. Savasana
Position of total relaxation.

59. QUESTIONS?
Mel Pohl, MD, DFASAM
702-271-1734
mpohl@centralrecovery.com
drmelpohl.com

60. 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.

63. THANK YOU
Mel Pohl, MD, DFASAM
702-271-1734
mpohl@centralrecovery.com
Drmelpohl.com