Post on 29-Dec-2015
Prevalence of the Problem
- 116 million people in the US suffer with pain – which is more than diabetes, cancer and heart disease combined
- Annual health care costs – expenses, lost wages, productivity loss estimated to be $600 billion
1. National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain. http://www.cdc.gov/nchs/data/hus/hus06.pdf. 2. National Centers of Health, NIH guide: new directions in pain research: 1. Bethesda, MD: National Institutes of Health. 1998 Sept 4. http://grants.nih.gov/grants/guide/pa-files/PA-98-102.html.
Opioids - Use of opioids has increased substantially over the past 20 years despite limited evidence for efficacy in chronic noncancer pain.
- Rise in opioids utilization corresponds to rise in opioid abuse and dependence – rates of opioid misuse (includes abuse and dependence as well as recreational use) estimated between 18 to 41% and aberrant medication behavior as high as 50%
3. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10:113-30. 4. Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain 2004;109:514-9.5. Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of
opioids. Pain Physician 2008;11:S63-88. 6. 6. Hojsted J, Sjogren P. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain 2007;11:490-518.
6
Steady Increases in Opioid and Stimulant Prescriptions Dispensed by U.S. Retail Pharmacies,
1991-2011
0
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
75,500,98277,560,27380,359,94486,225,85390,783,07395,609,108100,013,912
108,512,184119,817,010
130,598,364138,991,972144,302,410
150,984,759158,300,965
168,866,683179,870,752
192,377,001201,008,960201,727,195
209,557,752219,233,516
Opioids Hydrocodone Oxycodone
IMS’s Source Prescription Audit (SPA) & Vector One®: National (VONA)
Pres
crip
tions
(mill
ions
)
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
3,990,8185,078,9256,701,313
9,158,90712,030,671
13,804,56915,040,81216,382,63618,018,984
19,407,90121,065,820
23,773,02024,047,14026,393,378
29,093,50430,045,64632,775,001
36,307,86239,109,988
44,661,632
51,410,700
Stimulants Methylphenidate Amphetamine
IMS’s Source Prescription Audit (SPA) & Vector One®: Na-tional (VONA)
Pres
crip
tions
(mill
ions
)
Unintentional Overdose Deaths have quadrupled since 1998
Consequences of Rx Drug Abuse are Increasing
15--24 25--34 35--44 45--54 55--64 ≥650
2
4
6
8
10
12
3.7
7.18.3
10.4
5
12.2
4.45.3
6
2.5
0.3
Deaths from Opioid Pain Relievers Ex-ceed Those from Illegal Drugs in all Age
GroupsOpioid pain relievers Illegal drugs
Age Group
Death
s per
100,0
00 p
opula
tion
More Drug Overdose Deaths are Associated with Opioid Pain Relievers than with Illegal Drugs. Data are for 2008. Illegal drug deaths include deaths from overdose of heroin, cocaine, hallucinogens, or stimulants. Source: CDC, Morbidity and Mortality Weekly Report, 60(43): 1489, 2011.
The Problem
• Providers:Addiction providers
uncomfortable treating pain
Pain Management providers uncomfortable treating addiction
PCPs uncomfortable treating both and PCPs prescribe the opioids
• PatientsStigmatization to addictionBelieve pain is primary
problem not addictionFear their pain will not be
addressedMany will agree to
treatment in Primary Care but are reluctant to go to SUD treatment
Ambitious Agenda• Session 1: Overview: Scope of problem- Dr.Pade/Pete List of topics Presenting a case/with essentials Confidentiality • Session 2: Chronic pain: definition, Pathophysiology - Dr. Rzasa lynn• Session 3: Particular types of chronic pain: nocioceptive, neuropathic, central, mixed - Dr. Rzasa lynn• Session 4: Pre visit data collection - Pete/Elizabeth• Session 5: Pharmacology opioids, part 1 focus of short acting – Joe Saseen• Session 6: Pharmacology opioids part 2 focus on long acting – Joe Saseen• Session 7: Aberrant behavior: Pade• Session 8: Addiction: Martin/Pade• Session 9: Narcan: Pade• Session 10: Epic tips: Amber• Session 11: Urine toxicology screening: Lam• Session 12: Weaning and tapering off opioids/rotations: Saseen/Pade• Session 13: Buprenorphine for pain/opioid dependence: Pade• Session 14: Adjunctive pharmacological measures to treating pain: Dr. Rzasa Lynn• Session 15: Adjunctive measures Coping strategies, pain psychology: Brown levey• Session 16: Critical conversations: Pade• Session 17: Psychiatric considerations: Martin
• Any other topics???
Case Presentation• History of Pain: Location, duration, onset, radiations, aggravating factors,
relieving factors.• Prior interventions and therapies• Medications current and past• Aberrant behavior Hx• PMH/Psychiatric Hx• Substance use history: alcohol, opioids, illicit substances, smoking
tobacco (and other substances) and prior treatment(s)• Family Hx including psychiatric and SUD• Social Hx: work, family, support or lack thereof• Pertinent physical findings• PMP, lab data, urine screens• Screening instruments such as SOAPP, DIRE if available.