44th Annual CME Conference for Physician Assistants. Alexander Bautista, MD Assistant Professor Anesthesiology and Pain Medicine

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1 44th Annual CME Conference for Physician Assistants Alexander Bautista, MD Assistant Professor Anesthesiology and Pain Medicine

2 Fifth Vital Sign: 15 years later Opioid Epidemic

3 Relevant Disclosure and Resolution Under Accreditation Council for Continuing Medical Education guidelines, disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months. Commercial Interest Alexander Bautista, MD Nature of Relevant Financial Relationship What was received? None None None For what role? The conflict was resolved by

4 Relevant Disclosure and Resolution Under Accreditation Council for Continuing Medical Education guidelines, disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months. Alexander Bautista, MD I have no relevant financial relationships or affiliations with commercial interests to disclose.

5 Experimental or Off-Label Drug/Therapy/Device Disclosure I will NOT be discussing experimental or off-label drugs, therapies and/or devices that have not been approved by the FDA.

6 Learning Objectives Upon completion of this session, participants will improve their competence and performance by being able to: 1. Highlight the magnitude of the opioid crisis in the US 2. Discuss strategies to decrease the use of opioids in patients with chronic pain 3. Discuss the role of interventional pain physicians in assisting primary physicians in helping patients with chronic pain

7 Background Opioids include typical pain killers such as oxycodone, hydrocodone, codeine, morphine, fentanyl, and heroin. Overdose is the leading cause of accidental death and opioid addiction is responsible for the largest number of those overdoses. In 2015, > 20,000 deaths related to prescription painkillers and nearly 13,000 related to heroin overdose. 91 Americans die every day from an opioid overdose.

8 Background Over the past decade, new admissions to substance abuse clinics have increased by six-fold. 259 million opioid prescription were filled in 2012 a bottle for every adult in the US.

9 What are the most common myths surrounding opioid prescription?

10 #1 The opioid epidemic is mostly a street drug problem. CDC states that half of all opioid overdose deaths involve prescription of opioid. 4 out of 5 new users of heroin say that they began by abusing prescription painkillers.

11 #2 Opioid use during surgery is unlikely to cause addiction. Elective surgeries can increase the risk of chronic opioid use in the opioid-naïve patients. Increased risk if they have history of alcohol/drug abuse, taking anti-depressants and benzodiazepines.

12 #3 The optimal number of pills to prescribe after surgery is 30. Surplus prescription Diversion 71% reports using drugs through diversion. 55% received pills from family members or friends % did not take opioids after surgery Average opioid pills taken was 5-15.

13 #4 Discarding unused opioids is cumbersome. Four ways to dispose unused opioids: 1. As part of national or state take-back programs 2. At locally DEA-authorized collectors 3. Flush down the toilet 4. Mix uncrushed medicines or capsules with unpalatable substances

14 #5 Prescriptions drug monitoring programs are not helpful.

15 #6 There are limited educational resources available. Education is the key. Treat pain safely and effectively. Screen patients for opioid use disorder. Talk about and treat addiction as chronic illness.

16 CDC Guidelines

17 CDC Guidelines

18 CDC Guidelines

19 CDC Guidelines

20 What can we do?

21 The No Opioid Policy Non-opioid pain relievers Downside: low customer service ratings as a result of its no-opioid policy.

22 Interrupting the Addiction Cycle Use of partial agonist and antagonists Buprenorphine Naltrexone

23 Pre-surgery Pain Management Adequately treating acute pain Multimodal analgesia

24 Community Involvement The project Lazarus Program, UNC at Chapel Hill Educating the community responsibility on one s own health and every drug overdose is preventable Nonprofit organization Provides training and technical assistance

25 Interventional Pain Management

26 Interventional Pain Management Conditions that we can help treat: 1. Chronic headache/facial pain 2. Low back pain 3. Muscle or bone pain 4. Neck pain 5. Cancer pain 6. Neuropathic pain

27 Injections Epidural injections : Most common Facet injections Selective nerve root blocks Sacroiliac joint injections

28 Radiofrequency Ablation Neck pain Low back pain SI joint pain Knee pain Provides relief for 6-12 months

29 Sympathetic Blocks Stellate ganglion block: CRPS of the arm Celiac plexus blocks: Cancer pain, visceral hyperalgesia Lumbar sympathetic block: CRPS of the lower extremity Superior hypogastric block/ganglion impar block: pelvic cancer/ functional pelvic pain

30 Intrathecal Pump Decreased reliance to oral pain medications Cancer pain Failed low back or neck surgeries Spasticity for chronic spinal cord injury

31 Spinal Cord Stimulation Failed back surgery Peripheral vascular disease Diabetic peripheral neuropathy Chronic regional pain syndrome Chronic angina

32 8 th Sin: Care without Compassion

33 Conclusion and Clinical Pearls Opioid-associated adverse effects can be preventable Offer alternatives to our patient Set expectations Multidisciplinary team should be involved in the treatment of patients with chronic pain.

34 Thank You for Listening!