This document discusses effective pain management and the challenges of treating chronic pain with opioids. It provides an overview of pain management principles, the risks of addiction, and approaches to assessing patients and monitoring opioid treatment. While opioids can help treat pain in some cases, providers must consider the risks and benefits for each patient due to the potential for abuse, addiction and undertreatment of pain.

1. Effective Pain Management Ann Connolly, ACNP Jennifer Reidy, MD Suzana Makowski, MD May 19, 2011

2. Declarations There has been no commercial sponsorship or support for this program. The planners and presenters have declared that no conflict of interest exists. The MARN CE Committee does not endorse any products in conjunction with any educational activity.

3. Overview

4. Objectives Participants will: Gain an understanding of the principles of effective pain management Have the knowledge and/or resources to assist in indentifying patients at high risk for substance abuse, and Gain an awareness of the importance of counseling patients about the side effects, addictive nature and proper storage and disposal of prescription medications.

5. The challenge It is true that untreated and undertreated pain is a major public health issue, so is addiction.

6. Approach Pain Policy #2012 Ask (screen) Assess (comprehensively) Manage (treat) Re-assess (modify plan prn) Educate (patient/family) Educate (clinicians) Monitor (effectiveness) Pain Web Site (OurNet) PAIN

7. Case Presentation 59 y.o. man presents to his primary care physician for chronic foot pain

8. Types of pain

9. Pain It is common It is often undertreated There are many barriers to treating pain Clinical, Patient-related System-related Racial and ethnic barriers exist Language Perceptions

10. Is his pain real? Woolf CJ. Lancet 1999

11. Treatment of pain Pharmacotherapy Rehabilitative Approaches Psychologic Interventions Anesthesia/Interventional Pain Approaches Neurostimulatory Techniques Radiotherapy Surgery Complementary/Alternative Approaches Lifestyle Changes

12. Overview of Pharmacology

13. Opioid Pharmacology

14. Opioid pharmacology Conjugated by liver 90-95% excreted in urine Dehydration, renal failure, severe hepatic failure Decrease interval/dosing size If oliguria/anuria STOP routine dosing (basal rate) of morphine Use ONLY PRN

15. Opioid Pharmacology What is the half life (range) for opioids? 2-4 hours How many half lives to get to steady state? 4-5 What do you base your scheduled dosing on: Cmax or T1/2? T1/2 What do you base your breakthrough dosing on: Cmaxor T1/2? Cmax

16. A few words on methadone Methadone Rises as a Painkiller With Big Risks By ERIK ECKHOLM and OLGA PIERCE Published: August 16, 2008 [Methadone] is implicated in more than twice as many deaths as heroin, and is rivaling or surpassing the tolls of painkillers like OxyContin and Vicodin. “This is a wonderful medicine used appropriately, but an unforgiving medicine used inappropriately,” said Dr. Howard A. Heit, a pain specialist at Georgetown University. www.pcssmentor.org - find a mentor on use of methadone in pain management

18. OxyIR 10mg PO q2 hours PRN– up to 6 per day

20. Gabapentin 600mg PO TIDOxycodone 80mg+60mg = 140mg/day 140mg PO oxy x (5mg IV morphine/10mg PO oxy) = 60 mg IV morphine/day 60mg IV morphine ÷ 24 hours = 2.5 mg/hour PCA basal rate 2mg/hour, bolus 0.5 or 1mg with 15 minute lockout

21. Case: In the ER Patient goes to the ER … He has been doubling his oxycodone dose on his own at home – “my foot pain is terrible!” “I’m out of my medication and I need more – help me!”

22. Slides adapted from: “Safe and effective opioid prescribing for chronic pain” Boston University School of Medicine Free online CME www.bumc.bu.edu/cme/educational-opportunities/online-programs/

23. Prescription Drug Abuse Major public health problem Abuse and misuse of opioids more than doubled during 1990s to present Most nonmedical users obtain drug from family or friend (medicine cabinet) Source where family/friend obtained drug: one clinician Source: SAMHSA, OAS, NSDUH data, July 2007

24. From 1997-2006, opioid prescriptions increased sevenfold Unintentional overdoses more than doubled Overall risk of opioid overdose remains very low (0.04%) Sources: 2007 National Vital Statistics System; JAMA 2011;305(13):1315-21 Deaths from prescription drug abuse

26. Difficult to know the difference between inappropriate drug-seeking and appropriate pain-relief seeking behavior

28. Reassure patient that you understand pain severity

29. Reflect on patient strengths (self-efficacy)

31. Pain has significant impact on function

32. Pain has significant impact on quality of life

33. Non-opioid pharmacotherapy has failed

35. Known risk factors:

36. Past cocaine use, hx alcohol or cannabis use

37. Lifetime hx of substance abuse

38. Family hx of substance abuse

39. Tobacco addiction

40. Hx of severe depression or anxietyIves T et al BMC Health Services Research 2006, Reid MC et al JGIM 2002, Michna E et al JPSM 2004, Akbik H et al JPSM 2006 What is the risk of addiction?

42. Compulsive use

43. Continued use despite harm

44. Craving

45. It is NOT physical dependence

47. Complaints about need for medication

48. Drug hoarding

49. Requesting specific pain medication

50. Openly acquiring similar medications from other providers

51. Occasional unsanctioned dose escalation

52. Nonadherence to other recommendations for pain therapyPassik SD Mayo Clin Proc 2009

54. Deterioration in functioning at work or socially

55. Illegal activities – selling, forging, buying

56. Injecting or snorting medication

57. Multiple episodes of “lost” or “stolen” scripts

58. Resistance to change therapy despite adverse effects

59. Refusal to comply with random drug screens

60. Concurrent abuse of alcohol or illicit drugs

62. Self-medication of psychiatric & physical symptoms other than pain

63. Criminal intent - diversion

64. Inadequate analgesia “pseudoaddiction”

65. Disease progression

66. Opioid-resistant pain

67. Opioid-induced hyperalgesia

69. Pain, function and quality of life

70. Assess for harm – use “universal precautions”

71. Agreements/contracts

72. Informed consent

73. Monitor for aberrant medication-taking behavior

74. Urine drug testing, pill/patch counts

75. Monitor for adherence, addiction & diversion

76. Initially small quantities & frequent visits

77. Establish a refill & cross-coverage systemAssessing & monitoring

79. What number best describes how, during the past week, pain has interfered with your enjoyment of life? (does not interfere – completely interferes)

82. Benefit must outweigh observed harms

83. If small benefit, consider increasing dose as a “test”

84. If no effect = no benefit, can stop opioids (taper and reassess)

86. Acknowledge patient’s desire to “never go there” again

87. Openly discuss higher risk

88. Consider using ASA-GI bleed analogy

89. Partner with patient to monitor for risk Patients w/ past substance abuse

91. Give feedback: explain why pt’s behaviors raises your concern for possible addiction

92. Benefits no longer exceed risks

93. “I cannot responsibly continue prescribing opioids as I feel it would cause you more harm than good.”

94. Avoid judging the person

95. Show commitment to continue caring about pt and pain, even without opioids

96. Always offer referral to addiction treatmentExit strategy: discussing lack of benefit

97. MA Online Prescription Monitoring Program Online database of prescriptions filled in MA Oct 2009-Dec 2010: Schedule II January 2011 onward: Schedule II-V Pharmacies report data weekly Up to 4 week lag in uploading data Registered providers may access online Requires patient first and last names, birthday Only provider may access (not nurse, MA) Only for patients for whom you are prescribing

98. Safe Disposal Federal: FDA, White House Office of National Drug Control Policy; US Environmental Protection Agency State: MA DCR; Mass DEP; MA Water Resources Authority Local: Take back programs When no longer needed

100. Use whole-person approach, w/focus on wellness

101. Understand pathophysiology of pain, pharmacology of medications

102. With opioids for chronic pain, use consistent approach but set level of monitoring to match risk

103. If there is benefit in the absence of harm, continue opioids

105. Prevalence & Impact Chronic pain is one of the most common conditions for which people seek medical treatment 35% of Americans suffer from chronic pain >50 million Americans are partially or totally disabled by chronic pain 50 million workdays are lost per year $100 billion is the estimated annual cost in lost productivity, medical costs, and lost income

107. did not take the patient’s pain seriously

108. had inadequate knowledge about pain treatmentUndertreatment of chronic pain

109. Barriers to treating pain Clinician-Related Limited knowledge of pain pathophysiology and assessment skills Biases against opioid therapy and overestimation of risks Fear of regulatory scrutiny/action Patient-Related Exaggerated fear of addiction, tolerance, side effects Reluctance to report pain: stoicism, desire to “please”clinician Concerns about “meaning” of pain (associate increased pain with worsening disease) System-Related Low priority given to pain and symptom control Limits on number of Rxs filled per month & number of refills allowed Reimbursement policies

110. Racial & ethnic barriers Language or cultural differences make pain assessment more difficult Clinicians’ perceptions and misconceptions: minority-group patients have fewer financial resources to pay for prescriptions higher drug-abuse potential among minority groups Patients’ lack of assertiveness in seeking treatment Lack of treatment expertise at many sites at which minority-group patients are treated Relative unavailability of opioids in some communities

112. nerves become resistant to anti-nociceptive systemIf untreated, pain signals will continue even after injury resolves Chronic pain signals become embedded in the central nervous system

113. Common causes of chronic pain

114. Clinician issues Over-prescribing Pts expect medication to solve problems Fear of confrontation and saying “no” to pt Under-prescribing Poor education about opioids Overestimate potency and duration of action Fear of being duped Exaggerated fear of addiction potential

116. Benefit must outweigh observed harms

117. If small benefit, consider increasing dose as a “test”

118. If no effect = no benefit, can stop opioids (taper and reassess)

120. RCTs are short duration (<4 months) and small sample sizes (<300 pts)

121. Mostly industry-sponsored

122. Pain relief modest

123. Limited or no improvement in functioningBalantyne JC, Mao J NEJM 2003, Kalso E et al Pain 2004, Eisenberg E et al JAMA 2005, Martell BA et al Ann Intern Med 2007

125. Mu receptor subtypes

126. Not everyone responds to same opioid in same way

127. Not all pain responds to same opioid in same way

129. ? Neuroadapation to chronic opioids

130. Opioid-induced hyperalgesiaDoverty M et al Pain 2001, Angst MS Clark JD Anesthesiology 2006