Opioid analgesic therapy in pain management: how we got here from there

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1 National Organization of Alternative Programs March 17, 2016 Opioid analgesic therapy in pain management: how we got here from there Gary M. Reisfield, M.D. Divisions of Addiction Medicine and Forensic Psychiatry University of Florida College of Medicine

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5 91 st Annual Session of AMA June 12, 1940

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7 If you re over 50 and you wake up in the morning without pain, you might not be alive anymore. Russian saying

8 John J. Bonica, M.D.

9 Cicely Saunders, M.D.

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11 New Engl J Med 1980;302(2):123

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13 Portenoy: n = 24 receiving Rx opioids n = 3 with abuse/addiction n = 1 refused to answer questions

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22 Van Zee A. The promotion and marketing of OxyContin: commercial triumph, public health tragedy. Am J Public Health 2009;99(2):

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26 Retail sales of prescription opioids 732% 244% 196% 1177% Graph: Manchikanti L. Singh A. Pain Physician 2008;11:S63-S88 Data:

27 Morphine, distribution of consumption, 2013 International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2015

28 Fentanyl: distribution of consumption, 2013 International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2015

29 Hydrocodone: global consumption, U.S. accounted for 99+% of world hydrocodone consumption in 2013 International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2015

30 Oxycodone: global consumption, U.S. accounted for 78% of world oxycodone consumption in 2013 International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2015

31 Methadone: global consumption, U.S. accounted for 51% of world methadone consumption in 2013 International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2015

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33 Deaths from unintentional drug overdoses in U.S., Okie S. A flood of opioids, a rising ride of deaths. New Engl J Med 2010;363(21):

34 Deaths from unintentional drug overdoses in U.S. by drug type Okie S. A flood of opioids, a rising ride of deaths. New Engl J Med 2010;363(21):

35 Prescription opioid deaths Source: National Center for Health Statistics, CDC Wonder

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39 Florida Fun Facts In 2010: 98/100 top oxycodonedispensing physicians in U.S. practice in Florida By far, more oxycodone is dispensed in Florida than in the remaining 49 states combined

40 Top 10 reasons why your pain clinic may be a pill mill

41 Number 10

42 Number 9

43 #8

44 Number 7

45 Number 6

46 Number 5

47 Number 4

48 Number 3

49 Number 2

50 Number 1

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52 Dec. 17, 2012 Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did. We didn t know then what we know now. I gave innumerable lectures in the late 1980s and 90s about addiction that weren t true.

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56 Shifting patterns of opioid abuse Cicero TJ, et al. N Engl J Med 2015;373:

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70 Multidisciplinary pain management redux Medical Management Lifestyle changes Interventional Techniques Psychiatry Psychology Complementary & Alternative Therapies Physical & Rehabilitative Therapies

71 Risks Benefits

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73 Primary care management Opioid risk stratification Low risk Moderate risk High risk Primary care management with specialist support Specialist management ORT score: 0-3 ORT score: 4-7 ORT score: 8 No Past/current SUD No FH of SUD No Major/untreated ψ Mild-moderate pain and/or disability Consistent UDT Consistent PDMP ± past SUD ± FH SUD ± past or current ψ Moderate pain and/or disability Consistent UDT Consistent PDMP Active SUD ± FH SUD Major untreated ψ Mod-severe pain and/or disability Inconsistent UDT Inconsistent PDMP Poor social support Adapted from: Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients. Pain 2005;6: Gourlay DL, Heit HA. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med 2005;6:

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76 New York Times, December 11, 2015

77 Доверяй, но проверяй

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81 What is (and isn t) in the urine Michna E, Jamison RN, Pham LD, et al. Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings. Clin J Pain 2007; 23:

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83 Passik SD, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin Ther 2004;26:

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