This document summarizes a presentation on alternatives to opioids in pain management. It includes: 1) Disclosures from the three presenters stating they have no financial conflicts of interest. 2) Learning objectives which are to identify opioid alternatives, advocate avoiding opioids for acute pain, and teach counseling strategies to decrease pain and addiction. 3) A presentation by Dr. Don Teater on alternatives to opioids for pain management, the opioid epidemic, and the limited evidence for opioids' effectiveness in chronic pain. He advocates prescribing opioids less and using policy to reduce prescribing.

1. Clinical Track:
Alternatives to Opioids
in Pain Management
Presenters:
• Don Teater, MD, Medical Advisor, National Safety
Council
• Heidi H. Allespach, PhD, Director of Behavioral
Medicine, Family Medicine and Internal Medicine
Residency and Subspecialty Fellowship Programs,
University of Miami Miller School of Medicine
Moderator: John J. Dreyzehner, MD, MPH, FACOEM,
Commissioner, Tennessee Department of Health, and
Member, Rx Summit National Advisory Board

2. Disclosures
• Don Teater, MD, has no relevant, real or apparent personal or
professional financial relationships with proprietary entities
that produce health care goods and services.
• Heidi H. Allespach, PhD, has no relevant, real or apparent
personal or professional financial relationships with
proprietary entities that produce health care goods and
services.
• John J. Dreyzehner, MD, MPH, FACOEM, has disclosed no
relevant, real or apparent personal or professional financial
relationships with proprietary entities that produce health
care goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Identify alternatives to opioids for pain
management.
2. Advocate that physicians avoid opioids when
treating acute pain.
3. Prepare physicians to use counseling
strategies to decrease pain perceptions and
addictive behaviors.

5. Alternatives to opioids in pain
management
Don Teater MD
National Safety Council

6. Disclosure
I, Don Teater MD, have no relevant, real or
apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.

7. Why this is important
• 100 million people with pain in the U.S.
• Over 16,000 die every year from opioid
overdose.
– Also consider
• Addiction
• Crime
• Neonatal abstinence syndrome
• Societal monetary costs
• Workplace and traffic injuries/death

8. Rates of opioid overdose deaths, sales and
treatment admissions, US, 1999-2010
Year
National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS
7
6
5
4
3
2
1
0
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Rate
Opioid Sales KG/10,000
Opioid Deaths/100,000
Opioid Treatment Admissions/10,000

9. Opioid increase
Centers for Disease Control and Prevention. CDC grand rounds: Prescription drug overdoses – a U.S. epidemic. MMWR Morb
Mortal Wkly Rep 2012; 61:10-13
96
700
1997 2007
Mg per person
Mg per person

10. Is it possible…
To reduce pain while at the same time
reducing the use of opioids???
Yes!!

11. 20 year experiment
• 20 years ago we made an honest effort to
treat pain better….
• We have not succeeded.

12. The State of US Health
Years lived with disability (in thousands)
0
500
1000
1500
2000
2500
3000
3500
Low back pain Other MS
disease
Neck pain Osteoarthritis
1990
2010
Murray, C. (2013). The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.
JAMA : The Journal of the American Medical Association, 310(6), 591–608.

13. Institute of Medicine
Relieving Pain in America 2011
“Pain affects millions of Americans; contributes
greatly to national rates of morbidity, mortality,
and disability; and is rising in prevalence.”
IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
Washington, DC: The National Academies Press.

14. Pain
An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described
in terms of such damage.
International Association for the Treatment of Pain

15. Pain
• Acute pain: Pain < 3 months
• Chronic pain: Pain > 3 months

16. Efficacy of pain mediations
0
5
10
15
20
25
30
35
40
45
Ibuprofen 200
mg
Acetaminophen
500 mg
Ibuprofen 400
mg
Oxycodone 15
mg
Oxy 10 + acet
1000
Morphine 10 mg
IM
Percent with 50% pain relief
Percent with 50% pain relief

17. Severity does not matter!
A 2005 Cochran review of the treatment of renal colic
concluded:
NSAID medications and opioids have equal effectiveness
in treatment of acute renal colic…
but opioids have more side-effects.
Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDS) versus opioids for acute renal colic. Cochrane Database of Systematic Reviews 2004,
Issue 1. Art. No.: CD004137. DOI: 10.1002/14651858.CD004137.pub3.

18. Side effects
• NSAIDs
– GI
– Renal
– Cardiac
• Acetaminophen
– Liver

19. Opioid side effects
• Mentally impairing
• Delay recovery
• Increase medical costs
• Opioid hyperalgesia
• Double the chance of disability
• Increase falls (and fractures)
• Cardiac. GI?
• Addiction

20. Opioid side effects
• Brain effects
– Impairing
– Calming
– Antidepressant effects
– Stimulate dopamine
– Cause neuroplastic changes
– Epigenetic changes?

21. Chronic pain
• No evidence that opioids are effective for long-
term treatment of chronic pain.
• “Safe and effective” use of opioids for chronic
pain is an invalid concept.
– No evidence that these can be used safely
– No evidence that they can be used effectively
• Epidemiologic studies have shown that those on
chronic opioid therapy have worse quality of life
than those with chronic pain who are not1.
(1) Eriksen, J., Sjøgren, P., Bruera, E., Ekholm, O., & Rasmussen, N. K. (2006). Critical issues on opioids in
chronic non-cancer pain: an epidemiological study. Pain, 125(1-2), 172–9. doi:10.1016/j.pain.2006.06.009

22. Efficacy of pain mediations
0
10
20
30
40
50
60
70
Ibuprofen 200
mg
Acetaminophen
500 mg
Ibuprofen 400
mg
Oxycodone 15
mg
Oxy 10 + acet
1000
Ibu 200 + acet
500
Percent with 50% pain relief
Percent with 50% pain relief

23. Takeaways
• These are brain medications more than they
are pain medications.
– They do have a role but it is limited.
• Medical and dental providers: We should be
prescribing much less of these.
• Policymakers: By making laws and rules to
reduce prescribing, we will improve the
treatment of pain.

24. “To write prescriptions is easy,
but to come to an understanding with
people is hard.”
-- Franz Kafka, “A Country Doctor”

25. Don Teater MD
don.teater@nsc.org
White papers:
Evidence on the efficacy of pain medications:
nsc.org/painmedevidence
The Psychological and Physical Side Effects of
Pain Medications:
safety.nsc.org/sideeffects

26. Helping Our Patients, Helping Ourselves: Physician-
Administered Counseling Strategies to Decrease
Pain Perceptions & Addictive Behaviors
Heidi H. Allespach, PhD
University of Miami Miller School of
Medicine

27. Faculty Disclosure
Heidi H. Allespach, PhD has no
relevant, real or apparent personal or
professional financial relationships
with proprietary entities that produce
health care goods and services
27

28. Learning Objectives
1.Identify alternatives to opioids for pain
management.
2. Advocate that physicians avoid opioids
when treating acute pain.
3. Prepare physicians to use counseling
strategies to decrease pain perceptions and
addictive behaviors

29. Since we are talking about
addictive behaviors………..

30. Questions
• What types of thoughts do you have when
you see an alcoholic/addicted pt? What types
of feelings do these thoughts create?
• How do these thoughts/feelings differ
depending on whether your pt is male or
female? Black or White? Young or old?

31. Questions
• Think about your own personal life
experiences w/ an alcoholic/addict (family
member, friend, self). How do you think
these past experiences contribute to the
ways you think/feel about your addicted pts?
• How might these reactions influence your Rx
of these type of pts?

32. Brief Points: Pain and Addiction
• Not all patients who use and even misuse
opioids are “addicts”
• Addiction is a chronic disease
• Tolerance, dependence, pseudoaddiction
• Pain affects every aspect of the individual
• Cannot separate “emotional” pain from
“physical” pain (mind/body)

34. Teaching Patients
Cognitive Restructuring
to Decrease Pain &
Addictive Behaviors

35. Question
How confident are you in your ability to
provide brief counseling to your patients with
pain?
A. Extremely confident
B. Very confident
C. Neutral
D. Not very confident
E. Not at all confident

36. Cognitive Behavioral Therapy (CBT)
• CBT is the most widely used & studied
psychotherapeutic modality in the medical
setting
• Aaron Beck, MD
• Time limited and focused
• Helps you and your patients to feel more “in
control”….and it works too!!!
• Wealth of literature on the efficacy of utilizing
CBT to decrease pain

37. Cognitive Restructuring
• Levy RL, Langer SL, Walker LS, Romano JM, Christie DL, Youssef N,
DuPen MM, Ballard SA, Labus J, Welsh E, Feld LD, Whitehead WE.
Twelve-month follow-up of cognitive behavioral therapy for
children with functional abdominal pain. JAMA Pediatr. 2013
Feb;167(2):178-84.
• Castro MM, Daltro C, Kraychete DC, Lopes J. Cognitive behavioral
therapy causes an improvement in quality of life in patients with
chronic musculoskeletal pain. Arq Neuropsiquiatr. 2012
Nov;70(11):864-8.
• Friebe H. Cognitive restructuring in chronic pain. Help your
patients understand their pain in a new light. Pain Therapy Series,
3: Active pain coping works. Fortschr Med. 1999 Feb 20;117(5):53.

38. Cognitive-Behavioral Model
“We feel what we
think”
--Albert Ellis

40. We also see what we
EXPECT to see!

42. Negative Self-Talk or
“The Dis-Ease”
• An automatic thought or “self-talk” statement
that is distorted and creates distress.
• Fear-based, critical
• For those with addiction, part of themselves that
wants to drink/use again

43. Negative/”Reactive” Self-Talk
• Only by becoming aware of their negative self-talk can
our pt change the way s/he feels &, for addicted pts,
avoid relapse.
• Only by actively listening to our pts negative statements
will we gain insight into what is going on with them
• It is actually GOOD to tell your pts to “lose their minds”
(good for you too!)

44. “The Monkey”
• Future=Anxiety (The
“What Ifs”?)
• Past=Depression,
Guilt, Regrets (The
“Would’ve’s,
Could’ve’s &
Should’ve’s)

46. The Relationship Between
Thoughts and Feelings
Automatic Feeling
Negative
Self-Talk
(Thought)

47. Thoughts, Feelings & Behaviors
Automatic Feelings Physical
Thought Sensation
(Self-Talk)
Behaviors

48. Addictive (Reactive)
Cognitions
Automatic Thought Feeling Physical
“I have to get my anxiety INCREASED
meds-I CAN’T LIVE PAIN
WITHOUT THEM!!!
ADDICTIVE
BEHAVIORS

50. Cognitive-Restructuring
• “The Wise Self,” “Rational Non-Reactive Self,”
Higher Power,” “God”,—opposite of
Negative/”Monkey”/Reactive Self-Talk
• “What can you tell yourself (or what would the
“Wise/Higher Power/ God” part of you tell you---
to make you feel less (anxious, angry, sad,
etc)?”
• “What would the Wise/Higher Power, God part
of you say about your drug use?”
Pomm (Allespach) HA, Pomm RM. Management of the
Addicted Patient in Primary Care. 2007; Springer
Publishing.

51. “Nonreactive” Cognitions
Balanced Thought Feeling Physical
I CAN live without taking less anxiety DECREASED
more medication—for PAIN
TODAY. I have to “think this
through”& practice what
my doctor taught me
Tries non-narcotic
strategy instead of opioid

52. WITHOUT & WITH CBT!

53. Some Additional Strategies…
• Diaphragmatic Breathing
• “Think It Through”
• “Act Don’t React”
• “One Day at a Time”
• “Progress, Not Perfection”

54. “Mindfulness”

55. Mindfulness Literature
• F. Zeidan,K.T. Martucci,R.A. Kraft,N.S. Gordon, J.G. McHaffie, R.C.
Coghill. Brain Mechanisms Supporting Modulation of Pain by
Mindfulness Meditation. J Neurosci. 2011 April 6; 31(14): 5540–
5548. J Psychosom Res. 2010 Jan;68(1):29-36.
• Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley
D. Mindfulness-based stress reduction for chronic pain conditions:
variation in treatment outcomes and role of home meditation
practice. J Psychosom Res. 2010 Jan;68(1):29-36.
• Marchand WR. Mindfulness-based stress reduction, mindfulness-
based cognitive therapy, and Zen meditation for depression,
anxiety, pain, and psychological distress. J Psychiatr Pract. 2012
Jul;18(4):233-52.

56. “The Awareness
Exercise”
Demonstration

57. “The Awareness Exercise”
• Present Orientation
• Patients can use the Awareness Exercise to
“disconnect” from The Monkey
• In the beginning, tell patients not to practice
when they are feeling any “hot” emotion &
also to do it out loud
• DO NOT FOCUS ON PAIN OR OTHER INTERNAL
SOMATIC SX!

58. Pain Diary
• To increase awareness that pain is never
constant & is influenced by
thoughts/emotions
• 3 times a Day
• Write down Thoughts, Feelings,
Situation, Pain Level (1-10)

59. Resources for Learning More About
CBT
• The Beck Institute (training for you): http://www.beckinstitute.org/cognitive-
behavioral-therapy/
• WedMD (for patients): http://www.webmd.com/depression/guide/cognitive-
behavioral-therapy-for-depression
• Judith Beck (Book-for you): http://www.amazon.com/Cognitive-Behavior-
Therapy-Second-Edition/dp/1609185048
• The Relaxation & Stress Management Workbook (for patients and for
you!):http://www.amazon.com/Relaxation-Reduction-Workbook-Harbinger-
Self-
Help/dp/1572245492/ref=sr_1_1?s=books&ie=UTF8&qid=1405023778&sr=1-
1&keywords=the+relaxation+and+stress+reduction+workbook+6th+edition

61. Great Resource for Patients!
• Workbook:
“Managing Pain Before It Manages You”
by Margaret A Caudill, MD, PhD, MPH
http://www.amazon.com/Managing-Pain-Before-Manages-
Third/dp/B001TKE4VG/ref=sr_1_2?s=books&ie=UTF8&qid
=1405023980&sr=1-
2&keywords=managing+pain+before+it+manages+you

62. Practice Recommendations
 Before initiating chronic opioid therapy, clinicians should
conduct a history, physical examination and appropriate testing,
including an assessment of risk of substance abuse, misuse, or
addiction
• Primary health care professionals are well-positioned to provide
interventions targeted to all substances irrespective of their
legal status
3. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. American Pain Society-American
Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic
noncancer pain. J Pain. 2009 Feb;10(2):113-30. AHRQ National Guidelines Clearinghouse
http://www.guideline.gov/content.aspx?id=16165
4. WHO http://www.who.int/substance_abuse/activities/assist/en

63. Practice Recommendations
• Psychosocial evaluation: The psychosocial evaluation
should include information about the presence of
psychological symptoms (e.g., anxiety, depression, or
anger), psychiatric disorders, personality traits or states,
and coping mechanisms.
• Cognitive behavioral therapy, biofeedback, or relaxation
training: These interventions may be used as part of a
multimodal strategy for patients with low back pain, as
well as for other chronic pain conditions.
NATIONAL GUIDELINES CLEARINGHOUSE: Practice guidelines for chronic pain management. An updated report by the American Society of
Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.
http://www.guideline.gov/content.aspx?id=23845

64. Contact
• Heidi Allespach, PhD
h.allespach@med.miami.edu

65. Clinical Track:
Alternatives to Opioids
in Pain Management
Presenters:
• Don Teater, MD, Medical Advisor, National Safety
Council
• Heidi H. Allespach, PhD, Director of Behavioral
Medicine, Family Medicine and Internal Medicine
Residency and Subspecialty Fellowship Programs,
University of Miami Miller School of Medicine
Moderator: John J. Dreyzehner, MD, MPH, FACOEM,
Commissioner, Tennessee Department of Health, and
Member, Rx Summit National Advisory Board