This document discusses pain management and opioid addiction. It begins with introductions and disclosures from the presenter, Dr. Mel Pohl. The objectives are then outlined as reviewing addiction as a brain disease, describing chronic pain, and discussing pain treatment in the context of opioid addiction. Key facts about chronic pain and definitions of pain and addiction are provided. The neurobiology of addiction and how it is similar to other diseases is examined through PET scan images. Issues with using opioids to treat chronic pain like side effects, tolerance, and hyperalgesia are covered. The emergence of the opioid epidemic in the US is shown through various graphs and charts. Non-opioid and non-medication treatment options at Las Vegas Recovery Center are

1. Pain Management and
Opioid Addiction
Mel Pohl, MD, FASAM
Medical Director
Las Vegas Recovery Center

2. Disclosure of Relevant Financial
Relationships
Name Commercial Relevant Relevant No Relevant
Interests Financial Financial Financial
Relationships: Relationships: Relationships
What Was For What Role with Any
Received Commercial
Interests
Mel Pohl Las Vegas Salary Medical Director
Recovery Center

3. Objectives
●
Review addiction as brain disease.
●
Describe chronic pain.
●
Discuss pain treatment in the context of opioid addiction.

4. Addiction
Characterized by:
●
Compulsive use
●
Loss of Control
●
Continued use despite harm
●
Craving

5. Neurobiology
Addiction is a Brain
Disease
Cortex
Midbrain
Positron
PET =
Emission
Tomography

6. Limbic System
Brain Stem

7. Addiction is Similar to other Diseases
Both:
●
disrupt normal, healthy
functioning of the
underlying organ
●
have serious harmful
consequences
●
are chronic preventable,
and treatable

8. Dopamine Transporters
(A) Control Group with no history of drugs
J. Shi et al. / European Journal of Pharmacology 579
(2008) 160-166

9. Dopamine Transporters
(B) Methadone maintenance group – 6 months
J. Shi et al. / European Journal of
Pharmacology 579 (2008) 160-166

10. Dopamine Transporters
(C) Prolonged Abstinence Group – 6 months
J. Shi et al. / European Journal of
Pharmacology 579 (2008) 160-166

13. 5 Key Facts About Chronic
Pain:
• All pain is real.
• Emotions drive the experience of pain.
• Opioids often make pain worse.
• Treat to improve function.
• Expectations influence outcomes.

14. Pain Definitions
“An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage ….”
The International Association for the Study of Pain
(Mesky,1979)

16. Patient with Pain
n
ai
P‘Injury’

17. Patient with Pain
Suffering
n
ai
P
‘Injury’

18. “…When touched with a feeling of pain, the ordinary
uninstructed person sorrows, grieves, and laments, beats
his breast, becomes distraught.
So he feels two pains, physical and mental.
Just as if they were to shoot a man with an arrow and,
right afterward, were to shoot him with another one, so
that he would feel the pains of two arrows…”
The Buddha

19. 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

20. Pain Assessment Scale
Clinical definition of pain:
“Whatever the patient states it is unless proven
otherwise.”
No Moderate Worst
Pain Pain Pain
0 1 2 3 4 5 6 7 8 9 10

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

22. Pharmacologic Non-Opioid
• NSAID’S, COX 2S
• Tricyclics, SNRI’S
• Anticonvulsants
• Muscle Relaxants— (AVOID
SOMA/carisoprodol)
• Topicals

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

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

25. NEJM, Ballantyne & Mao
Nov 2003

26. Emergence of an Epidemic

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

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

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

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

31. Samsha Oxycodin.jpg

32. 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

33. Sleep Disturbance
Physical Problems
Substance
Abuse
Addiction
Depression Functional
Anxiety Disability
Increased Stresses
Seddon Savage, M.D.

34. Sleep Disturbance
Physical Problems
Substance
Abuse
Chronic
Pain
Depression Functional
Anxiety Disability
Increased Stresses

35. Sleep Disturbance
Physical
Problems Substance
Abuse
Pain Addiction
Depression Functional
Anxiety Disability
Increased Stresses
Seddon Savage, M.D.

36. Emotional Intensifiers
• Guilt
• Anger – Resentments
• Loneliness
• Helplessness
• Fear

37. Pain Pearls
• Conditioning Increases Pain.
• Pain Patients Are A Pain.
• Secondary Gain Prevents Getting Well.

38. Treatment Implications
• Surrender
• Utilize body awareness
• Develop “relaxed attention”
• Involved with others
• Pain Recovery – Develop Balance

39. Pain Recovery – Develop Balance
• Mental
• Emotional
• Physical
• Spiritual
RESULTING CHANGES
– Relationships
– Positive actions and behaviors

40. Non-Medication Treatments at LVRC
• Exercise – Physical Therapy
• Chiropractic Treatments
• Therapeutic Massage
• Reiki
• Acupuncture
• Individual + group therapy
• Mindfulness-Based Stress Reduction (Kabat-Zinn)
• Yoga - Chi Gong

41. THANK YOU
Mel Pohl, MD, FASAM
702-515-1373
mpohl@centralrecovery.com
adaywithoutpain.com