Duke Division of Physical Therapy, Department of Orthopaedics. Disclosures. Research funding from NIH, Foundation for PT (Magistro), and DoD

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1 The Duplicity of Opioids How they Work, A Dubious History, and Person-Level Characteristics Chad Cook PhD, PT, MBA, FAAOMPT Program Director and Professor Duke Division of Physical Therapy, Department of Orthopaedics Duke Clinical Research Institute Disclosures Research funding from NIH, Foundation for PT (Magistro), and DoD Receive Royalties from MedBridge Education and Pearson Education Special Topics Editor for JOSPT Senior Associate Editor for the British Journal of Sports Medicine Learning Objectives Evaluate the physiological mechanisms associated with opioids pain relief and euphoria; Compare and contrast the benefits and the complications associated with opioids use; Synthesize the key historical triggers that led to increased opioid use within North America;

2 Recognize the person-level characteristics associated with opioid abuse Table of Contents How Opioids Work How Opioids are Useful and Harmful What are Recommended Management Approaches? How has History Influenced the use of Opioids Person Level Factors associated with Opioid Use, Misuse, and Abuse How Opioids Work Opioids are medications that act on opioid receptors Act by attaching to and activating opioid receptor proteins (found on nerve cells in the brain, spinal cord, gastrointestinal tract, and other organs in the body). Inhibition of Pain When these drugs attach to their receptors, they inhibit the transmission of pain signals. Opioid Receptors Opioid Receptors Short Term Changes Reduction of Pain

3 Reduce Diarrhea Reduce coughing Overall calming effect Neuroplastic changes: Diminished Gray Mater volume in areas of the brain responsible for the regulation of cravings, pain, and emotions. Slowing of the central nervous system which leads to depressed respiration Long Term Changes Neuroplastic changes (reduced gray matter was observed in the right amygdala) Physical dependence Tolerance to analgesic effects Increased gray matter seen areas high in MOR receptors such as the cingulate (middle, dorsal posterior, and ventral posterior), the inferior pons, and hypothalamus. Euphoric Element When one takes synthetic opioids, their reward system feels an extreme rush of something called dopamine (plays a major role in reward-motivated behavior).

4 Dopamine signals the neurons of the body in a way that creates a very high level of pleasure or excitement often referred to as a high. Opiates gain access to a major component of the circuitry mediating opiate physical dependence through opiate receptors in the periaqueductal gray matter. How Opioids are Useful and Harmful Acute pain after surgery - Injury or trauma - Cancer pain - Breakthrough pain (severe pain that erupts while a patient is already medicated with a long-acting painkiller-usually associated with cancer) How Opioids are Useful and Harmful Common Nausea Sedation Confusion Sweats Dry mouth Constipation

5 More Serious/Less Common Death Myoclonus Hyperalgesia Respiratory Depression Delirium Tolerance/Addiction What are Recommended Management Approaches? Guidelines Analgesic Step Ladder Long-term: Who Benefits? Selected patients with osteoarthritis Diabetic neuropathy Selected patients with chronic pain syndromes How has History Influenced the use of Opioids Severe Diarrhea Dysentery: Initial treatment 1805 Hypodermic Invented-1857 Desire to disassociate pain and addiction have led to a number of synthetic opioids

6 Types of Opioids Addiction or Dependence? Addiction: Characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal Dependence: Reflects physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal) World War II: Heroin Addiction Vietnam War: Heroin Addiction Oops. In 1969, the World Health Organization (WHO) abandoned the belief that the medical use of morphine led inevitably to dependence. The WHO clarified that tolerance and physical dependence did not in itself constitute drug dependence, a diagnosis characterized by typical behaviors, including difficulty in controlling the assumption of drugs, compulsive use of the substance and inappropriate social behaviors. th American Pain Society-The 5 Vital Sign

7 In the early 90s, the American Pain Society opined that there was a national epidemic of untreated pain in our nation s hospitals and announced that pain should be classified as the fifth vital sign. In 2001, the Joint Commission rolled out its Pain Management Standards, which helped grow the idea of pain as a "fifth vital sign." 2016-We are Starting to Sort this Out In December, 2015 CDC announces opioid crisis in North America In June 2016, the American Medical Association (AMA) removed pain as a vital sign. In September 2016 the American Academy of Family Physicians (AAFP) voted to drop pain scores as the fifth vital sign. October 30th, 2017 President Trump announces public health emergency associated with opioids Person Level Factors associated with Opioid Use, Misuse, and Abuse Person Level Characteristics and Opioid Abuse The Screening Instrument for Substance Abuse Potential The Prescription Abuse Checklist

8 The Prescription Drug Use Questionnaire The Pain Assessment and Documentation Tool The Pain Medication Questionnaire The Screener and Opioid Assessment for Patients with Pain (SOAPP) Demographics (Narrative) Younger > older (18-26 greatest increases) Men > Women (15.9% vs. 11.2% for abuse) Men more likely to take/steal prescription opioids Fewer women pursue substance abuse treatment 625 Individuals with Chronic Non-Cancer Pain History of illicit drug use (OR=5.45, 95%CI ) Insomnia (Every 1-h decrease in average hours of nightly sleep increased the risk of opioid misuse by 20% > 1 Million Non-cancer Patients who Received Opioids who were Opioid Naive Characteristics of the first opioid prescription: High dosages, and high morphine equivalents Duration of the prescription Chronic pain diagnosis

9 Inpatient admission All were significant predictors of continued opioid use irrespective of the indication for an opioid prescription. >36K with Minor Surgical Procedures Risk factors independently associated with new persistent opioid use included preoperative tobacco use (adjusted odds ratio [aor], 1.35; 95% CI, ), Alcohol and substance abuse disorders (aor, 1.34; 95% CI, ), Mood disorders (aor, 1.15; 95% CI, ), Anxiety (aor, 1.25; 95% CI, ), Preoperative pain disorders (back pain: aor, 1.57; 95% CI, ; neck pain: aor, 1.22; 95% CI, ; arthritis: aor, 1.56; 95% CI, ; >10 million Opioid Prescription Recipients 1.5-fold for prior attention-deficit/hyperactivity disorder medication prescriptions (hazard ratio [HR] = 1.53; 95% confidence interval [CI], ) 3-fold for prior nonopioid substance abuse diagnoses (HR = 3.15; 95% CI, )

10 9-fold for prior opioid use disorder diagnoses (HR = 8.70; 95% CI, ). Psychiatric conditions. Our work LBP N=732 Military Summary Data References Atkinson, TJ et al. The damage done by the war on opioids: the pendulum has swung too far. Journal of Pain Research; 2004, 7: Brownstein, MJ. A brief history of opiates, opioid peptides, and opioid receptors. Proc Natl Acad Sci. 1993;90(12): Brummett et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg Jun 21;152(6):e Coambs, et al. The SISAP: A new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain within general medical practice. Pain Res Manag. 1996, 1,

11 Chabal, et al. Prescription opiate abuse in chronic pain patients: Clinical criteria, incidence, and predictors. Clin J Pain 1997, 13, Compton, et al. Screening for addiction in patients with chronic pain and problematic substance use: Evaluation of a pilot assessment tool. J Pain Symptom Manag. 1998, 16, Hah et al. Factors associated with prescription opioid misuse in a crosssectional cohort of patients with chronic non-cancer pain. J Pain Res May 3;10: McDonald and Lambert. Continuing Education in Anaesthesia, Critical Care & Pain Volume 5 Number Passik, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin Ther. 2004, 26, Portenoy, R.K.; Farrar, J.T.; Backonja, M.-M.; Cleeland, C.S.; Yang, K.; Friedman, M.; Colucci, S.V.; Richards, P. Long-term use of controlledrelease oxycodone for noncancer pain: Results of a 3-year registry study. Clin. J. Pain 2007, 23, Shah et al. Factors Influencing Long-Term Opioid Use Among Opioid Naive Patients: An Examination of Initial Prescription Characteristics and Pain Etiologies. J Pain Nov;18(11):

12 Quinn et al. Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims. Pain Jan;158(1): Now on to Dr. Dan Rhon

13 12/13/ The Duplicity of Opioids Downstream Implications and Proposed Provider Roles Dan Rhon PT, DPT, DSc, OCS, FAAOMPT Assistant Professor Army-Baylor University, Doctoral Programs in PT (entry-level DPT and DSc) ORISE Research Fellow G 3/5/7 Physical Performance Service Line Office of the Army Surgeon General Disclosures Research funding from NIH and CDMRP Owner, Clinically Relevant Technologies, LLC (apps for clinicians and patient care) Receive royalties/payments for education/teaching from Medbridge, Inc and Evidence in Motion, LLC. Disclaimer Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Baylor University, Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense, Department of Energy, the Defense Health Agency, or the U.S. Government. Learning Objectives Understand the downstream influence of opioids on whole health Understand the relationship between opioids, comorbidities and musculoskeletal health Summarize intervention strategies to help mitigate risk of opioid dependency relevant to providers managing musculoskeletal disorders Table of Contents Downstream Effects 1

14 12/13/17 Downstream Effects Chronic pain prevalence A rare convergence of federal priorities Direction of recent clinical guidelines Relationship with Comorbidities The pain experience individually The pain experience broadly Intervention Strategies How we can help manage these patients True Health Impact of Opioid Medication Aside from aberrant behaviors and addiction True Health Impact of Opioid Medication Opioids and Sleep and Musculoskeletal Injuries The role of sleep in overall health The role of sleep in recovery from MSK disorders The interaction between sleep, pain, and opioids Sleep and Health Meeting sleep guidelines (7-9 hours) is associated with decreased risk of all-cause morbidity and better health-related quality of life. Better quality sleep also promotes daytime physical activity, and poor sleep could adversely influence exercise performance, as well as the physiological and cognitive benefits of exercise Decreased sleep quality is associated with higher rates of healthcare utilization in patients with low back pain. Sleep and Pain There is a bidirectional relationship between sleep and pain 2

15 12/13/ Sleep and Pain As severity of insomnia increases, pressure pain threshold decreases Insomnia is an independent risk factor for developing chronic pain Disrupted sleep is associated with musculoskeletal pain in adults. Poor sleep quality has been shown to induce generalized hyperalgesia, increase anxiety, and affect one s ability to regulate cortisol in response to stress Opioids and Sleep Opioids are a major contributor to nocturnal hypoxemia and sleepdisordered breathing (apnea) Sleep architecture can be altered after one single dose of oral opioids in healthy adults Acute use of opioids can increase REM latency, decrease REM sleep time, decrease overall sleep time and decrease sleep efficiency Opioids and Sleep Opioids and Mental Health and Musculoskeletal Injuries The role of mental health Adjusted OR based on having 3+ opioid prescriptions during the 2-year follow-up after hip surgery for FAI Opioids and Comorbidities Comorbidities as adverse events and complications Opioids and Comorbidities Complex Relationship 3

16 12/13/ How do Physical Therapists Make a Difference? POLL The physical therapist appears to be an important link PT Referrals in Medicare Patients w/ New Onset of Low Back Pain Odds of long-term opioids use in cohort of patients with low back pain Cohort of 1049 subjects receiving both Physical Therapy and Opioids after FAI Surgery Dichotomized based on timing of each Rhon et. al. PTJ, 2018 (in press) Patients are open non-pharmaceutical options Is there true informed decision making? Is the patient an informed and active stakeholder in the care management plan? Focus on empowering patients IDEAL vs REALITY 4