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 ManagementAnn Connolly, ACNPJennifer Reidy, MDSuzana Makowski, MD May 19, 2011

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

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

6. ApproachPain 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 Presentation59 y.o. man presents to his primary care physician for chronic foot pain

8. Types of pain

9. PainIt is commonIt is often undertreatedThere are many barriers to treating painClinical,Patient-relatedSystem-relatedRacial and ethnic barriers existLanguagePerceptions

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

11. Treatment of painPharmacotherapyRehabilitative ApproachesPsychologic InterventionsAnesthesia/Interventional Pain ApproachesNeurostimulatory TechniquesRadiotherapySurgeryComplementary/Alternative ApproachesLifestyle Changes

12. Overview of Pharmacology

13. Opioid Pharmacology

14. Opioid pharmacologyConjugated by liver90-95% excreted in urineDehydration, renal failure, severe hepatic failureDecrease interval/dosing sizeIf oliguria/anuriaSTOP routine dosing (basal rate) of morphineUse ONLY PRN

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

16. A few words on methadoneMethadone Rises as a Painkiller With Big RisksBy ERIK ECKHOLM and OLGA PIERCEPublished: 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

17. Case continuedPatient comes into the hospital ….Pain meds on admission:Oxycontin 40mg PO BID

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

19. Gabapentin 600mg PO TIDPCAs with chronic painPain meds on admission:Oxycontin 40mg PO BID OxyIR10mg PO q2 hours PRN

20. Gabapentin 600mg PO TIDOxycodone 80mg+60mg = 140mg/day140mg PO oxy x (5mg IV morphine/10mg PO oxy) = 60 mg IV morphine/day60mg IV morphine ÷ 24 hours = 2.5 mg/hourPCA basal rate 2mg/hour, bolus 0.5 or 1mg with 15 minute lockout

21. Case: In the ERPatient 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 MedicineFree online CMEwww.bumc.bu.edu/cme/educational-opportunities/online-programs/

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

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

25. Is your patient’s chronic pain real?No objective way to measure

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

27. You need time and a relationship to discover the differenceGeneral PrinciplesMaintain risk-benefit model, not a police-offender model

28. Reassure patient that you understand pain severity

29. Reflect on patient strengths (self-efficacy)

30. Partner with patient by sharing controlWhen are opioids indicated?Pain is moderate to severe

31. Pain has significant impact on function

32. Pain has significant impact on quality of life

33. Non-opioid pharmacotherapy has failed

34. Patient agreeable to have opioid use closely monitoredPublished rates of abuse and/or addiction in chronic pain patients are 3-19%

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 2006What is the risk of addiction?

41. What is addiction?Loss of control

42. Compulsive use

43. Continued use despite harm

44. Craving

45. It is NOT physical dependence

46. Biological adaptation with signs & symptoms of withdrawal if opioid is abruptly stoppedAberrant medication-taking behavior: Yellow flagsLess likely to be predictive of addiction

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

53. Aberrant medication-taking behavior: Red flagsMore likely to be predictive of addiction

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

61. Use of multiple physicians and pharmaciesAberrant medication-taking behaviors: differential diagnosisOpioid-analgesic tolerance

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

68. AddictionAssess for benefit

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

78. Assessment toolPEG (Pain, Enjoyment, General activity) scale (0-10)What number best describes your pain on average in the past week? (no pain – worst pain you can imagine)

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

80. What number best describes how, during the past week, pain has interfered with your general activity? (does not interfere – completely interferes)Standard urine test detects only natural opiates reliably33* Converts to morphine, so can be detected in standard opioid immunoassay

81. Should opioids be continued?You must convince yourself that there is benefit

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)

85. You DO NOT have to prove addiction or diversion – only assess risk-benefit ratioShow admiration for overcoming addiction

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

90. Stress how much you believe/empathize with pt’s pain and impact on life

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 ProgramOnline database of prescriptions filled in MAOct 2009-Dec 2010: Schedule IIJanuary 2011 onward: Schedule II-VPharmacies report data weeklyUp to 4 week lag in uploading dataRegistered providers may access online Requires patient first and last names, birthdayOnly provider may access (not nurse, MA)Only for patients for whom you are prescribing

98. Safe DisposalFederal: FDA, White House Office of National Drug Control Policy; US Environmental Protection AgencyState: MA DCR; Mass DEP; MA Water Resources AuthorityLocal: Take back programsWhen no longer needed

99. SummaryPain management is a core competency of medicine

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

104. If there is no benefit or if there is harm, stop opioidsIn conclusionIt is true that untreated and undertreated pain is a major public health issue, so is addiction.

105. Prevalence & ImpactChronic 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 pain50 million workdays are lost per year $100 billion is the estimated annual cost in lost productivity, medical costs, and lost income

106. >40% to 50% of patients in routine practice settings fail to achieve adequate pain reliefIn a recent study of 805 chronic pain sufferers, >50% had to change physicians to achieve relief because the physician:was unwilling to treat pain aggressively

107. did not take the patient’s pain seriously

108. had inadequate knowledge about pain treatmentUndertreatment of chronic pain

109. Barriers to treating painClinician-RelatedLimited knowledge of pain pathophysiology and assessment skillsBiases against opioid therapy and overestimation of risksFear of regulatory scrutiny/actionPatient-RelatedExaggerated fear of addiction, tolerance, side effectsReluctance to report pain: stoicism, desire to “please”clinicianConcerns about “meaning” of pain (associate increased pain with worsening disease)System-RelatedLow priority given to pain and symptom controlLimits on number of Rxs filled per month & number of refills allowedReimbursement policies

110. Racial & ethnic barriersLanguage or cultural differences make pain assessment more difficultClinicians’ perceptions and misconceptions:minority-group patients have fewer financial resources to pay for prescriptionshigher drug-abuse potential among minority groupsPatients’ lack of assertiveness in seeking treatmentLack of treatment expertise at many sites at which minority-group patients are treatedRelative unavailability of opioids in some communities

111. Un- & undertreated pain can lead to worse chronic painIn chronic pain, the nervous system remodels continuously in response to repeated pain signalsnerves become hypersensitive to pain

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

113. Common causes of chronic pain

114. Clinician issuesOver-prescribingPts expect medication to solve problemsFear of confrontation and saying “no” to ptUnder-prescribingPoor education about opioidsOverestimate potency and duration of actionFear of being dupedExaggerated fear of addiction potential

115. Should opioids be continued?You must convince yourself that there is benefit

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)

119. You DO NOT have to prove addiction or diversion – only assess risk-benefit ratioAre opioids effective in chronic pain?Most studies are uncontrolled case series

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

124. Patients vary in response to opioids>100 polymorphisms in the human mu receptor gene

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

128. Incomplete cross-tolerance between opioidsCan long-term opioid use worsen chronic pain?Methadone maintenance patients with increased pain sensitivity

129. ? Neuroadapation to chronic opioids

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