Brain, Pain, Opioids. John Hart, DO

Transcription

1 Brain, Pain, Opioids CHANGE John Hart, DO

2 4 % Rule

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4 1 UDS Pain score Contract & PMP Ask about addiction Ak Ask about tfunction As long as function increases, there is no upper limit to opioid

5 UDS Pain score Contract & PMP Ask about addiction Ask about function 2 Upper limit 120 mg Morphine Equivilent

6 3 UDS Pain score Contract & PMP Ask about addiction Ask about function Upper limit mg ME

7 UDS Pi Pain score Contract & PMP Ask about addiction Ask about function 1 As long as function increases, there is no upper limit

8 2 UDS Pain score Contract & PMP Ask about addiction Ask about function Upper limit 120 mg ME

9 UDS Pain score Contract & PMP Ask about addiction Ask about function Upper limit it mg ME

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11 How to increase Long Term Disability x 2 Write one opioid script for over 7 days Or Write 2 opioid prescriptions Franklin et al Spine 2008

12 How to keep your patients on opioids for 5 years. (60 office visits) Patients on Chronic Opioid Therapy for 90 days 60% will be on opioids at 5 years. Martin et al 2011 Gen Int Med 2011;26:450 7

13 Previous focus: Decrease pain, increase function Safety New focus: Don t start Don t continue

14 Give patient proper information at the start. t Chronic Opioid Therapy relieves only about 30 % of a persons pain. Do not expect more.

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16 SIMPLE GUIDELINES Post surgery 6 weeks- stop opioids Avoid sub acute Don t exceed 90 days

17 New Guidelines American Academy of Neurology 2014 Do NOT use COT for: 1. Chronic low back pain 2. Headaches 3. Fibromyalgia Dose mg

18 RECCOMENDATIONS O 50 mg ACOEM (American College of Occupational and Environmental Medicine) 50 mg - Virginia Garcia Health Care

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20 Who Overdoses? Over 100 mg = OD rate is x 9 ½ of OD is from intermittent or low dose opioids id

21 Summary Patients not on Narcotics Don t use for Headache, Low Back Pain & Fibromyalgia When COT is used, tell patient to only expect 30 % relief Stay below 50 mg If using long acting opioids, avoid use of breakthrough Rx

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23 Why do we have all of these problems? What do opioids do to the brain? What didn t the drug salesperson tell us?

24 Let s look at this from a Laboratory viewpoint

25 Before entering the lab, we must understand one thing. The brain doesn t care if oxycodone comes from a prescription or the street. The chemical changes in the brain are the same.

26 Dopamine D2 Receptors are Lower DA DA Cocaine Meth DA DA DA DA DA DA DA DA DA DA Reward Circuits Non-Drug Abuser DA DA Alcohol DA DA DA DA Heroin control User Reward Circuits Drug Abuser Adapted from Volkow et al., Neurobiology of Learning and Memory 78: , 2002.

27 Effects of Drugs on Dopamine Release % of Basal Re elease Accumbens AMPHETAMINE DA DOPAC HVA hr Time After Amphetamine % of Basal Rele ease Accumbens COCAINE DA DOPAC HVA hr Time After Cocaine % of Basal Release NICOTINE Accumbens Caudate % of Basal Re elease Accumbens MORPHINE Dose (mg/kg) hr Time After Nicotine hr Time After Morphine Di Chiara and Imperato, PNAS, 1988

28 What do these brain look like? Normal Opioid Exposed Loss of dopamine Receptors

29 Tolerance is dopamine receptor loss BRAIN DAMAGE which in certain people is permanent and irretrievable.

30 So what? Does reduced dopamine activity affect behavior?

31 Effects of Tx with an Adenovirus Carrying a DA D2 Receptor Gene into NAc in DA D2 Receptors Overexpression of DA D2 receptors reduces alcohol self-administration Change in D2R Percent 60 R Vector Rp < st D2 p < R Vector 2nd D2 p < p < p < p < p < p < Thanos, PK et al., J Neurochem, 78, pp , Time (days) Null Vector p < p < 0.001

32 Decreases in Metabolism in Anterior Cingulate Gyrus Orbito Frontal Cortex (OFC) Impulsivity Compulsive Drug Intake control cocaine abuser ACG = rational cognitive, decision making

33 Normal Exposed Brain High Control user The loss of receptors in the orbital frontal cortex reduces self inhibition. Why can t they followthe Pain Contract?. Low Sources: From the laboratories of Drs. N. Volkow and H. Schelbert

34 Effects of a Social Stressor on Brain DA D2 Receptors and Propensity to Administer Drugs Individually Housed Becomes Dominant No longer stressed Group Housed Dominant 50 Subordinate * * Becomes Subordinate Stress remains 10 0 S Cocaine (mg/kg/injection) Morgan, D. et al. Nature Neuroscience, 5: , 174, 2002.

35 Low Dopamine People EAT Opioids

36 Wouldn t it be nice to know who has low dopamine receptors?

37 Know who has low dopamine and you may have a view of the future!

38 Ask 4 simple questions

39 1. Previous history of drugs or alcohol?

40 2. Genetics How Important? t? 50%

41 The Development of Addiction: Genetics 2. Details of Genetics: Parents, Grand Parents, Siblings? Inheritability has been found to range from 40-60% Some variability between: gender and substances Specifically: 4-fold increased risk in 1st degree relatives 4-fold increased risk also in adopted away children

42 Selective Breeding Originating gpopulation (a genetically diverse sample) 1 st selected generation 2 nd selected generation 3 rd selected generation

43 3. At what age did they start smoking?

44 Smoking before e brain reaches maturity results in: Increased use of substances of abuse 4-12 times normal population. If one pack/day before age 16= 100 fld fold increase in cocaine

45 Years of Use 4. How many years and amount of opioid exposure to the brain? Amount of Use Amount of Receptor Loss

46 4 simple questions 1. Previous personal history 2. Genetics 3. Age start smoking 4. Exposure time & amount

47 Forget guidelines by committee And the laboratory. Suggestions for practice.

48 Tell patients THERE HAVE BEEN MAJOR CHANGES IN OPIOID TREATMENT.

49 The new recommendations are Not to use chronic opioids for Low Back Pain, Headache & Fibromyalgia Chronic use of opioids will only help with 30% of their pain. The other 70 % is up to them.

50 Chronic opioids are neurotoxic For the dopamine system.

51 Chronic Opioid Therapy Kappa Receptors Pain and Depression

52 My patients are already on opioids. Now what do I do? Change the dialog Explain about receptor loss

53 Presently on Opioids? Look for a lever, an excuse to start lowering the opioids. This may be an increase in pain, an increase in depression or any side effect that allows you to open a dialogue concerning possible receptor damage.

54 How to get patient s buy in. For their long term health, would they consider a small reduction? This is for their hibrain tissue and In case they get injured and need more opioid in the future

55 Reasonable goals ( The world is not perfect) If above 50 mg, make 50 mg the goal If below 50 mg, make mg the goal If not on opioids, don t continue past the acute stage when the first opioid is given for acute injury set the end date

56 Rule of Thumb 20 to 50 mg is the most for pain Anything above that is due to receptor damage. I want to help you, but I cannot cause further receptor damage.

57 How to Taper Narcotics mg Taper Reduce by 10% per time unit (3 days, weeks or month) Try reducing breakthrough h first. (Produces dopamine spike)

58 2 scripts trick #1 todays dosage (first script) #2 reduced dosage (second script) If aggressive reduction, try clonidine patch TTS 1-2 or gabapentin

59 How to Lower Narcotics 70 mg and higher, if taper is not working: Use Buprenorphine/Naloxone (Suboxone) For Pain & Opioid Dependence combined. (Not discussed at this session)

60 Why do we not start COT and why do we want to reduce the opioid load? Because we care about the long term health of our patient s brain receptors and we do not want to trade short term happiness for long term damage.

61 4 simple questions 1. Previous personal history 2. Genetics 3. Age start smoking 4. Exposure time & amount

62 The new recommendations are NOT to use chronic opioids for Low Back Pain, Headache & Fibromyalgia Chronic use of opioids will only help with 30% of their pain. The other 70 % is up to them.

63 Change can Be Good

64 Additional Resources Available Physicians for responsible opioid prescribing PROP org/resources/ WA Guidelines ACOEM Guidelines (4%)