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Pain Opioids and Addiction PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Pain, Opioids and Addiction" by Daniel P. Alford, MD, MPH.

This medical PowerPoint presentation is about Pain, opioids, and addiction which are all interconnected issues that have received a lot of attention in recent years.

Pain is a common experience that can result from a variety of factors such as injury, illness, or chronic conditions. While pain is a normal response to injury or disease, it can also be a debilitating experience that affects a persons quality of life.

Opioids are a class of drugs that are commonly prescribed to manage pain. They work by binding to opioid receptors in the brain and spinal cord, reducing the perception of pain. While opioids can be effective in managing pain, they also carry a risk of addiction and overdose.

Addiction is a complex disorder characterized by compulsive drug-seeking behavior despite negative consequences. While not everyone who uses opioids will develop an addiction, prolonged use can lead to physical dependence and withdrawal symptoms if use is stopped abruptly.

It is important to understand the risks associated with opioids and to use them only as directed by a healthcare professional. Alternative treatments for pain, such as physical therapy, non-opioid medications, and cognitive-behavioral therapy, should also be considered. Additionally, education and awareness campaigns can help reduce the stigma associated with addiction and encourage individuals to seek help if they are struggling with opioid dependence.

Tags : Pain, Opioids, Addiction, manage pain, pain management

Published on : Jun 23, 2023 | Views : 1721 | Downloads : 1

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Slide 1-

Pain, Opioids and Addiction Immersion Training in Addiction Medicine Programs 2021 May 2021 Daniel P. Alford, MD, MPH Professor of Medicine Associate Dean, Continuing Medical Education Director, Clinical Addiction Research and Education (CARE) Unit
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Chronic Pain is Complex Dzau VJ, Pizzo PA. JAMA. 2014 Walk D, Poliak-Tunis M. Med Clin N Am. 2016 Argoff CE, et al. Pain Med. 2009 Adaptive by eliciting motivation to minimize harm and allow healing Acute Pain Life sustaining symptom Maladaptive, pathologic, disorder of the somatosensory pain signaling pathways influenced by genetic and epigenetic factors Chronic Pain Can be a disease in itself Petrosky E, et al. Ann Intern Med. 2018 Ilgen MA, et al. JAMA Psychiatry. 2013 Tang NK et al. Psychol Med. 2006 * Associated with higher risk of fatal and nonfatal suicide attempts*
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Chronic pain is common Pain is subjective to the patient and the clinician Pain can’t always be visualized Psychiatric co-morbidities are common Significant barriers to adequate pain care Lack of decision support for chronic pain management Financial misalignment favoring use of medications Poor support for team-based care and specialty clinics Many competing priorities in primary care Negative attitudes and disparities in pain care Chronic Pain in Perspective Institute of Medicine. 2011 Relieving Pain in America. Washington DC
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Qualitative study Adults with low back pain Patient and provider themes Buchman DZ et al. Pain Med. 2016
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Patient Theme 1: Threats to Trustworthiness and Iatrogenic Suffering Perceptions that their clinicians have demonstrated a lack of care, empathy, and respect…affecting patients’ assessments of clinician trustworthiness…negative interactions with clinicians caused them further suffering. SUSAN: “You could just tell that he just didn’t believe me that I was in as much pain as I was. He was just very unsympathetic. He would literally walk away while I was in the middle of a sentence.” Buchman DZ et al. Pain Med. 2016
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Patient Theme 2: Motive, Honesty, and Testimony Patients’ doubts that their clinicians believed that they were being honest about their motives for seeking treatment (e.g., drug misuse or drug diversion). Patients described being perceived as untrustworthy by clinicians LUDWIG: “When I was in [hospital] just a couple of weeks ago…the ambulance drivers just took one look at me and it was, like—the look in their eyes was like, ‘Oh, he’s just a junkie looking to get stoned.’ They didn’t believe that I was actually suffering and in pain. They thought I was faking it completely…” Buchman DZ et al. Pain Med. 2016
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Clinician Theme 1: Challenges of the Practice Context Physicians highlighted the challenging context in which chronic pain management is delivered. They recalled several difficult interactions and the impact these interactions had on their approach to care DR. JOHN: “The things that we remember are the times that we got burned, right . . . You may get burned one in 100, but that one in 100 is enough to burn an impression in your mind that makes you wary of all patients potentially.” Buchman DZ et al. Pain Med. 2016
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Clinician Theme 2: Complicated Clinical Relationships Chronic pain management involving opioid analgesics can prohibit or destabilize the development of trusting clinical relationships. Physicians…did not necessarily see their role as a collaborative partner…[they] saw themselves in a defensive role of interrogator DR. HENRY: “In most doctor–patient relationships we learn to listen to the patient and accept their testimony…in some instances, to be quite honest, we are interviewing the patient as if we are a police officer or a lawyer and we’re trying to find flaws in their story…So there is a different relationship here.” Buchman DZ et al. Pain Med. 2016
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Opioid Analgesics Analgesia Turn on descending inhibitory systems Prevent ascending transmission of pain signal Inhibit terminals of C-fibers in the spinal cord Inhibit activation of peripheral nociceptors Variable response (not all patients respond to the same opioid in the same way) >3,000 polymorphisms in the human MOR gene Differences in pharmacokinetics (opioid metabolism) Active the reward pathway McCleane G, Smith HS. Med Clin N Am. 2007 Smith HS. Pain Physician. 2008 Somatosensorycortex Thalamus Ascendingpathways Dorsal Horn Peripheralnerves Descendingpathway Periaqueductalgray area
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www.fda.gov, ONDCP 2019 Since 2011 MME decline by 43% 2018 largest MME decline at 17% Opioid Prescribing Trends
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Source of Prescription Opioid Misused SAMHSA. (2020). 2019 National Survey on Drug Use and Health
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Opioids v placebo (high quality evidence) Statistically significant improvements in pain1,2 and functioning.2 Opioids v placebo (neuropathic pain) (low-mod quality evidence) Clinically relevant pain relief and reduction of disability3 Opioids v nonopioids (low-mod quality evidence) Similar benefits2 RCT4 found opioids not superior to nonopioids for improving musculoskeletal pain-related function over 12 months Study limitations:5 Excluded patients already on long-term opioids 89% of eligible patients declined to be enrolled Two longer term follow-up studies found 44.3% on chronic opioids for chronic pain had at least 50% pain relief 6 1. Meske DS, et al. J Pain Res. 2018 2. Busse JW, et al. JAMA. 2018 3. Sommer C et al. Eur J Pain. 2020 Opioid Efficacy for Chronic Pain 4. Krebs EE, et al. JAMA. 2018 5. Webster L. Pain Med. 2019 6. Noble M, et al. Cochrane Syst Rev. 2010 Meta-analyses (1-6 month follow-up)
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Opioid Risks Allergies are rare Side effects are common Nausea, sedation, constipation, urinary retention, sweating Respiratory depression – sleep apnea Organ toxicities are rare Suppression of hypothalamic-pituitary-gonadal axis Immunosuppression Increased risk of invasive pneumococcal dz and community acquired pneumonia Worsening pain (hyperalgesia in some patients) Addiction (Opioid Use Disorder) Overdose when combined w/ other sedatives and at higher doses Dunn KM et al. Ann Intern Med 2010 Li X et al. Brain Res 2001 Doverty M et al. Pain 2001 Angst MS, Clark JD. Anesthesiology 2006 Wiese AD, et al. Ann Intern Med. 2018
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Problematic Opioid Use Systematic review from 38 studies (26% primary care, 53% pain clinics) Misuse rates: 21% - 29% Misuse: Opioid use contrary to the directed or prescribed pattern of use, regardless of the presence or absence of harm or adverse effects. Addiction rates: 8% - 12% Addiction: Pattern of continued use with experience of, or demonstrated potential for, harm (eg, “impaired control over drug use, compulsive use, continued use despite harm, and craving”). Vowles KE et al. Pain. 2015
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Volkow ND et al. N Engl J Med 2016 Risk Factors: Overdose & Addiction
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Risk Factors: Overdose, Addiction & Misuse Akbik H, et al. J Pain Symptom Manage. 2006 Ives J, et al. BMC Health Serv Res. 2006 Liebschutz JM, et al. J Pain. 2010 Michna E, et al. J Pain Symptom Manage. 2004 Reid MC, et al. J Gen Intern Med. 2002 Volkow ND et al. N Engl J Med 2016
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Craving or strong desire to use opioids Recurrent use resulting in failure to fulfill major role obligations Recurrent use in hazardous situations Continued use despite social or interpersonal problems caused or exacerbated by opioids Continued use despite physical or psychological problems *Tolerance *Withdrawal Use in larger amounts or duration than intended Persistent desire to cut down Giving up interests to use opioids Great deal of time spent obtaining, using, or recovering from opioids American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Mild OUD: 2-3 Criteria Moderate OUD: 4-5 Criteria Severe OUD: >6 Criteria *This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision Does my patient have an OUD?
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A clinical syndrome presenting as… Loss of Control Compulsive use Continued use despite harm Aberrant Medication Taking Behaviors Savage SR et al. J Pain Symptom Manage 2003 Is my patient addicted to the prescription opioid? Addiction is a behavioral maladaptation Physical Dependence is a physiologic adaptation
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Safer Opioid Prescribing for Chronic Pain
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Multidimensional Care for Chronic Pain Studies on all pharmacologic and nonpharmacologic treatments for chronic pain are < 12 m, vast majority are < 12 w Tayeb BO, et al. Pain Med. 2016 Multimodal approaches are more cost-effective than single modality options Flor H, et al. Pain 1992 Roberts AH, et al. Clin J Pain. 1993 Patrick LE, et al. Spine. 2004 Kamper SJ, et al. Cochrane Review. 2014
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Assessing Benefit – PEG scale Krebs EE, et al. J Gen Intern Med. 2009
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Misuse risk assessment Patient Provider Agreements (PPA) Medication Management Opioids should not be 1st line, begin with immediate-release opioids, prescribe the lowest effective dose. (caution with any dose, if possible avoid doses >90 mg MME) Avoid dangerous combinations (e.g., benzodiazepines) Frequent face-to-face visits (Document risks and benefits) Risk mitigation, monitor for adherence, addiction and diversion Urine drug testing (UDT) and pill counts Prescription Drug Monitoring Program (PDMP) data Naloxone co-prescribing Gourlay DL et al. Pain Med 2005 Dowell D et al. MMWR 2016 “Universal Precautions”when Prescribing Opioids (not evidence-based but has become “standard” of care)
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Patient-Provider Agreements (PPA) Survey 430 individuals from 43 states (primary care [64%], pain specialty [18%]) 66% of respondents thought PPAs were “often” or “always” worth the effort Only 28% considered them “often” or “always” effective in reducing opioid misuse 121 PPAs samples similar specialty type as the survey Reading burden surpassed recommended patient education standards, with only 2.5% at or below fifth-grade reading level Focused more on rules and consequences of patients’ noncompliance than on a shared treatment plan Laks J, Alford DP et al. J Gen Intern Med. 2021
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Evidence of therapeutic adherence Evidence of use or non-use of illicit drugs Urine Drug Testing Discuss urine drug testing openly with patient One medical data point to integrate with others Urine drug screens are usually immunoassays (Risk of false negatives and false positives) Unexpected findings can be verified with Gas Chromatography (GC) or Liquid Chromatography (LC) and Mass Spectroscopy (MS) (need to know expected metabolites) Identify a toxicologist for questions regarding unexpected results Objective information that can provide: Argoff CE, Alford DP, Fudin J et al. Pain Med. 2018, Nagpal G et al. JAMA. 2017, Christo PJ, et al. Pain Physician. 2011
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Monitoring: Pill Counts Information on medication adherence Information concerning for diversion Objective data that can provide:
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Prescription data available to prescribers (delegates in some states) and pharmacists Over 60% of states mandate use before prescribing controlled substances PDMP use can change prescriber behaviors (e.g., decreased opioid prescribing) Systematic review* insufficient evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses Monitoring: Prescription Drug Monitoring Programs Haffajee RL. N Eng J Med. 2019 Haffajee RL, et al. JAMA. 2015 Haegerich TM, et al. Drug Alcohol Depend. 2014 Information on harmful polypharmacy Information on multiple provider use Patrick SW, et al. Health Affairs. 2016 *Fink DS, et al. Ann Intern Med. 2018 Objective data that can provide:
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27 Opioids for Chronic PainWhat is the clinician’s role? VS. Nicolaidis C. Pain Medicine 2011 Use a risk-benefit framework Judge the opioid treatment, not the patient
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Continuation of Opioids Before writing the next opioid prescription…you should be convinced that there is… …benefit (pain, function, QOL) and… …absence of harm Despite subjective assessments (benefits/harms), it should be documented at each visit
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Discontinuing (or Decreasing) Opioids Do not have to prove addiction or diversion - only assess and reassess the risk-benefit ratio If patient is unable to take opioids safely or is nonadherent with monitoring then discontinuing opioids is appropriate even in setting of benefits Need to determine how urgent the discontinuation should be based on the severity of the risks and harms Document rationale for discontinuing opioids You are NOT abandoning the patient. You are abandoning the opioid therapy.
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Tapering Opioids No validated protocols in patients on opioids for chronic pain Systematic review found very low quality evidence suggests that several types of opioid tapers may be effective and that pain, function, and quality of life may improve for some patients with opioid dose reduction CDC guideline recommends decrease of 10% per month if patient on opioids for years and decrease of 10% per week if patient on opioids for weeks to months Frank JW et al. Ann Intern Med. 2017 Dowell D et al. MMWR. 2016
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Trends of Opioid Tapering Trends in the rate and rapidity of tapering among 99,874 individuals receiving chronic opioids in a large US claims database (2008-2017) Annual percentage undergoing tapering increased from 13% in 2008 to 23% in 2017 Tapering was significantly more likely among women and patients with higher baseline opioid doses 27% of tapers had a maximum dose reduction rate exceeding 10% per week Fenton JJ, et al. JAMA Netw Open. 2019
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Opioid Discontinuation Risks Oliva EM, Bowe T, Manhapra A, et al. BMJ. 2020 Observational cohort study 1.3 million US veterans with an outpatient opioid analgesic prescription over 2 years Opioid discontinuation was associated with an increased risk of death from overdose or suicide regardless of the length of opioid treatment Risk increased with the longer the patient was prescribed opioids (hazard ratios: 1.67 [≤30 days], 2.80 [31-90 days], 3.95 [91-400 days], and 6.77 [>400 days]) Patients with SUD (HR, 2.48) and mental health diagnoses (HR, 1.54) were at most risk for overdose or suicide
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Patient-Centered Opioid Tapering Study found 62% of 82 patients in a pain clinic remained in a voluntary, patient-centered opioid taper over 4 months Self-help book and a slow, individually designed taper with up to 5% decrease for up to 2 dose reductions in 1st month to minimize negative physical and emotional response, and facilitate confidence in the process Months 2-4, taper as much as 10% per week; but tailored to the patient Median decreases in MME from 288 mg to 150 mg Likelihood of >50% opioid dose reduction was not predicted by starting dose, baseline pain intensity, years prescribed opioids, or any psychosocial variable Neither pain intensity nor pain interference increased with opioid reduction Darnall BD et al. JAMA Intern Med. 2018
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www.scopeofpain.org
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Thank you!Questions? dan.alford@bmc.org