Charles P. O Brien, MD, PhD University of Pennsylvania No financial conflicts, patents, speakers bureaus

Transcription

1 Pain & Opioid Epidemic 2018 Charles P. O Brien, MD, PhD University of Pennsylvania No financial conflicts, patents, speakers bureaus

2 Opioids 3400 BC Mesopotamia, Joy plant 1843 morphine by syringe 1874 Synthesis of Heroin (Hero drug) USA Civil war veterans, Patent medicines, housewives, more addicts than today 1914 Harrison Narcotic Act, physicians imprisoned, Heroin clinics closed 1930s Lexington Narcotic Farm (forerunner, NIH)

3 Inadequate treatment of cancer pain Very restricted opioid prescribing 40-60% oncology patients--inadequate medication Minorities -3 times more likely under treated Women, Elderly also under treated May be related to desire for physician assisted suicide Confusion between Dependence and Addiction Major change: Pain as 5 th vital sign

4 Albert Sabin, MD, example Oral polio vaccine 1957 age 86, disseminated cancer interviewed Nightline, Ted Koppel Severe pain, could not discuss polio My doctors don t trust me. (? Medical malpractice on national TV)

5 Ethical Question Adequate treatment of pain may hasten death in terminal patient Family and medical personnel may object if patient appears groggy

6 Dependence (Normal response) Tolerance - reduced effect from level dose, may begin with 1st dose, euphoria v. analgesia Withdrawal - Characteristic symptoms when drug abruptly stopped, may continue for days, weeks, months 8% of medical schools, course on addiction, 36% cover the material

7 Dependence (normal) Anti hypertension Anti depressants (some) Anti-anxiety Opiates for pain

8 Substance Use Disorder(Addiction) Tolerance DSM-5 Withdrawal Drug craving More use than intended Unsuccessful efforts to cut down Spends excessive time in acquisition Activities given up because of use Use despite negative effects

9 Prescribing opiates Specific diagnosis Acute pain (e.g. dental, limited time) Terminal illness COMFORT Avoid opioids in chronic non-specific pain Patients on chronic opioids rarely can switch to non opioids (one way street) Avoid needles, use low dose, short duration

10 Short acting v. long acting opioids Hydromorphone (Dilaudid) Hydrocodone (Vicodin) Oxycodone (Percodan) Meperidine (Demerol) Fentanyl (patch) Methadone MS Contin OxyContin (IR,SR,Crush)

11 Non- malignant pain Don t begin with opiates Patient already on chronic opiates should ideally be detoxified and transferred to other meds Ideal is rarely achieved Don t drive patient to street sources pseudo-addiction

12 Street Opioids Parallel epidemic Heroin price and potency Fentanyl 50 x potency Diversion of Suboxone, methadone

13 Chronic pain (avoid opioids) Headache (various types) Backache (various etiologies) Reflex sympathetic dystrophy Diabetic Neuropathy Fibromyalgia Tic douloureux Shingles Ulcerative colitis

14 Multi-disciplinary diagnostic evaluation Diagnosis of pain etiology Psychological evaluation Family and other supports Quality of life measures

15 Non- opiate options Acetominophen Ibuprophen Cox 2 inhibitors Aspirin Combinations - caffeine adjuvant Tramadol (weak opioid)

16 Tolerance controversy Analgesic tolerance is rare Curtiss & Schneider, 1999 The ineffectiveness of chronic opiate treatment for pain is its major problem --Streltzer, 1999 Differential tolerance (euphoria, analgesia)

17 Non medication strategies Biofeedback Hypnosis Group and individual psychotherapy Cognitive therapy Family therapy Exercise Acupuncture TENS and related stimulation

18 Interventions for pain relief Depends on etiology of pain Nerve blocks Neurosurgical intervention TENS, acupuncture

19 Addiction Neuroscience Valid, predictive animal models Role of reward system Conditioned craving Conditioned DA release Anti-relapse medications New meds developed from basic research

20 Opioid Use Disorder Treatments Residential, 30 days, group therapy Abstinence, 12 step model Medication only for detox No evidence base for residential programs Use relapse prevention medication Parent: 14 years of paying for my son to be treated in expensive programs and no one told me about medications

21 Opioid Use Disorder FDA Medications Methadone Buprenorphine (Suboxone, + naloxone) Naltrexone, oral, depot (Vivitrol) Lofexidine (Lucemyra) Buprenorphine depot Sublocade (monthly injection) Probuphine implant (6 months)

22 Methadone Maintenance Heroin Time (Hours)

23 Intrinsic Activity: Full Agonist (Methadone), Partial Agonist (Buprenorphine), Antagonist (Naloxone) Full Agonist (Methadone) Partial Agonist (Buprenorphine) Antagonist (Naloxone) Log Dose of Opioid

24 Induction Success (%) X Site 24

25 Opioid overdose deaths ,000 in USA Most due to fentanyl, China origin Fentanyl: times more potent than morphine Cocaine/Fentanyl combinations Tobacco: 450,000 deaths per year

26 Pain and depression Pain as a depressive equivalent Depression secondary to pain Circular relationship

27 Role of anti depressant medication Common association of depression and chronic pain Analgesic properties of tricyclics independent of mood effect Reduction in analgesic dose Increased social activities reduce focus on pain

28 MAT Agonist v. Antagonist Agonist (methadone, buprenorphine) Easy to start Hard to stop, relapse frequent Abuse potential, diversion Antagonist (XR naltrexone, monthly) Detox first (more complicated to begin) Easy to stop (HAPPY ENDING) No abuse potential, but prevents opioid for pain

29 Goals of Medication Think about the clinical picture Education level, Job skills Motivation Detoxification, naltrexone OR Transfer directly from heroin to agonist Suboxone Methadone

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