Pain Management: The Provider’s Dilemma D. Andrew Tompkins, M.D. M.H.S., J. Greg Hobelmann, M.D. M.P.H, Peggy Compton, RN, PhD, Baltimore, MD Friday, March 11, 2016
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Objectives • Identify the prevalence and characteristics of chronic pain complaints • Describe the risks and benefits of opioids for chronic vs. acute pain treatment. • Assess the potential for opioid prescriber guidelines to help or hinder pain management.
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What is pain?
• “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” - IASP
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Acute vs. Chronic Pain • Acute: Typically lasts days up to 3 months – Is usually the result of actual tissue damage secondary to injury, surgery or the exacerbation of chronic disease
• Chronic: Persists on a regular (daily to weekly) basis for a month beyond what would be considered necessary to heal the underlying injury – Usually defined as >3 months from beginning of pain – seems to serve no purpose and is much more complex and difficult to manage than acute pain – Divided into cancer/terminal and non-cancer/non-terminal categories March 11th, 2016
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The Many Causes of Pain • • • • • • • •
Injury (trauma, surgery) Disease (pancreatitis, PUD) Neuropathy (diabetic, alcoholic, impingement) Joint degeneration Side effect of drugs Infection (pyelonephritis, abscess) Neurogenic inflammation Unknown???
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The Prevalence of Pain in the United States •
Pain is the number one reason that patients present to their physician or other health care provider
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100 million adults in the United States are affected by a chronic pain condition. – Chronic back pain is the most common condition, followed by severe headaches, arthralgias and neck pain
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The total healthcare costs secondary to pain ranged from $560 billion to $635 billion in 2010 (eclipsing the cost of heart disease, diabetes or cancer) – Patients with chronic pain utilize about twice as many health care resources as the general population
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Prevalence of Pain in Persons with Substance Use Disorders • Substance use disorder and pain are interrelated, with each condition influencing the treatment of the other. • Chronic pain complicates the efforts of many individuals with substance use disorders to enter and sustain recovery • 24% of patients admitted for treatment of addiction experienced severe chronic pain • 37% of patients in methadone maintenance treatment programs (MMTPs) reported severe chronic pain • 80% of MMTP patients and 78% of inpatients reported pain of some type and duration. • These patients are at increased risk of receiving inadequate pain management March 11th, 2016
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What are “effective” pain treatments? Traditional Medical Model
“Less” traditional
• • • • • •
• • • • • • • • •
Medication Surgery Nerve Blocks TENS unit Physical Therapy Cognitive Behavioral Therapy • Comprehensive Program ** Usually covered by insurance. Taught in traditional medical schools. Overseen by FDA. March 11th, 2016
Massage Acupuncture Exercise / stretching Prayer Chiropractic medicine Herbal remedies / homeopathy Self-help Biofeedback Pilates
** Less often covered by insurance. Not taught in traditional medical schools. Not as available. 8
The Swinging Pendulum of Opioid Prescriptions Harrison Narcotic Act in 1914 placed a tax on opium and related practice and specifically stated doctors could not prescribe opiates for the treatment of addiction – net effect, very little opiates prescribed outside acute care setting.
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1980s-1990s saw the W.H.O. popularize pain relief as a right, Drs. Foley and Portenoy advocate for opioids to be used in both chronic cancer and non-cancer pain, and pain seen as the 5th vital sign – net effect, dramatic rise in opioid prescriptions.
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Opioids in Living Color
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Opioid Prescriptions have Skyrocketed in Past Twenty Years
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Who is writing opioid prescriptions?
family practice nurse practitioners 18 16 14 12 10 8 6 4 2 0
internal medicine physician assistants
15.3 12.8
4.1
3.1
Number of schedule II prescriptions written by specialty in 2013 (in millions) March 11th, 2016
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Chen 2016
Don’t forget about other prescribers, e.g. Dentists, anesthesiologists, etc. IR Opioid Prescribers
22.90%
27% 3.20% 3.50% 4.00% 4.50%
4.70%
15.40%
7.40%
7.70%
ER/LA Opioid Prescribers
2.80% 3.60% 4.30% 4.90%
30% 5.70% 9.30% 13.80%
16.80%
GP/FM, DO IM Dentist ortho surg ER med unspecified PA NP anesth others GP/FM, DO IM Anesth pain medicine/rehab NP unspecified PA neuro Other
FDA Approved Indications for the treatment of Pain with Opioids • Pain (Moderate to Severe) • Postoperative pain, short-term management during hospitalization • Pain, chronic, intractable (morphine) • Pain, When opioid analgesics are appropriate • Pain, chronic, In patients requiring daily around-the-clock analgesic (hydrocodone) • Pain, chronic (Severe), In patients requiring a long-term daily around-the-clock opioid analgesic (oxycodone, fentanyl) • Pain (Moderate to Severe), Not responsive to non-narcotic analgesics • Breakthrough cancer pain, In opioid-tolerant patients March 11th, 2016
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The health care provider must… • Often make clinical recommendations based upon insufficient evidence.
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Risks of Untreated or Undertreated Pain • Relapse / new SUD • Mental health symptoms (e.g., depression, anxiety) • Suicide • Exacerbation of cognitive impairment (esp. in elderly) • Functional loss and increased dependency • Loss of Productivity
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• Impaired mobility (increased risk of falls/fractures) • Impaired immune function and healing • Increased health care utilization and costs • Sleep disturbances • Withdrawal and decreased socialization. • ? Legal Problems
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Risks of Opioid Treatment Acute • Constipation (most common problem) • Nausea / vomiting • Overdose, decreased respiratory drive • Urinary retention • Euphoria • Hypotension and bradycardia • Sedation • Confusion March 11th, 2016
Chronic • Physical Dependence • Opioid use disorder • Sleep disruption • Sexual side effects • Immunosuppression • Fractures (especially in women) • MDD • OIH? 17
Risk of SUD Relapse with Pain Treatment • No prospective evidence to suggest increased risk of relapse with pain treatment in persons with history of SUD. • Reductions in pain may actually reduce risk of relapse in patients with alcohol use disorder (Jakubczy et al., 2016)
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Just because an opioid is used for acute pain treatment, persons with an opioid use disorder may still like the drug effect. Buprenorphine Maintained Placebo
Hydromorphone
Methadone Maintained
Buprenorphine
Placebo
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
Hydromorphone
0 Drug Effect
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Like
Good Effects
Bad Desire to Effects Take Again
Drug Effect
Like
Good Effects
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Bad Desire to Effects Take Again
Risk of New Substance Use Disorder with Chronic Opioid Pain Treatment? • The exact rate of OUD in chronic pain patients is not known, but is thought to increase as the daily opioid dose increases and may be as high as 26% among patients prescribed opioids • Persons at higher risk include those with – History of substance use disorder – Co-morbid mental illness
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Risk of Overdose during Chronic Pain Treatment • Patients receiving opioids for chronic non-cancer pain have 5 times greater risk of overdose compared to persons not prescribed opioids. – Increasing dose of opioids was associated with increasing risk of overdose
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Why use Opioids at All? • Very few alternatives available (especially in rural or low SES) • Lack of access to specialty pain treatment • Providers desire to relieve suffering • Legal ramifications of under-treatment of pain March 11th, 2016
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How can the pendulum be shifted back toward more balanced prescriber behavior?
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Opioid Prescribing Guidelines • What is a guideline? – “systematically developed statements aimed at helping people make clinical, policy-related and system-related decisions” http://www.agreetrust.org/
• Who usually writes guidelines? – Professional societies (local, national, international) – Policy makers – Insurance payers
• Audience for guidelines differ – Primary care providers, pain specialists, providers in certain regions or certain specialties, hospital administrators March 11th, 2016
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Opioid Prescribing Guidelines: What do they recommend? • Professional societies: opioids can be prescribed effectively for chronic pain in carefully selected patients • CDC: there is insufficient evidence to support use of opioids for chronic pain in primary care setting. – – – –
Try alternates first If opioids are indicated, start low and go slow Careful and close monitoring Clarify patient expectations at the beginning
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Are guidelines useful in helping manage chronic pain? • Unfortunately, guideline production is flourishing but uptake in community is floundering • Need to consider implementation during guideline development • No evidence that guidelines improve pain treatment OR affect substance use disorder outcomes March 11th, 2016
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Conclusions • Chronic pain is a significant burden to individuals and to society. • The increased reliance on opioids for chronic noncancer pain treatment has been associated with a dramatic rise in persons with opioid use disorder and opioid overdose deaths. • Guidelines designed to inform clinical practice differ in recommendations for opioid use in chronic noncancer pain treatment. • Consensus is needed that balances access to adequate pain management with devastating harms of addiction. March 11th, 2016
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Acknowledgements Resources for Local Pain Treatment
• Johns Hopkins Blaustein Pain Treatment Center • Pain Treatment Program at JHH Dpt. of Psychiatry • George Washington University Pain Center • Father Martin’s Ashley – Pain Recovery Program • University of Maryland – Pain Management Center March 11th, 2016
Grants NIDA K23 DA029609
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