Trauma, Pain, and Opioids The Pain of Trauma, the Trauma of Pain

Transcription

1 Trauma, Pain, and Opioids The Pain of Trauma, the Trauma of Pain Bennet Davis MD Director, Sierra Tucson Pain Program Medical Director, Weitzman Pain ECHO program President, Integrative Pain Center of Arizona

2 Vital Signs: Changes in Opioid Prescribing in the United States, CDC Weekly / July 7, 2017 / 66(26);

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5 Who are these people who accidentally overdose on prescription opioid, or have moved to illicit opioid and accidentally overdose? Non-addict using prescription opioid obtained from friends, family, and the street who accidentally overdose? People prescribed opioid, suffering a chronic painful illness that responds to opioid, who accidentally overdose? Addicts who accidentally overdose? People using opioids to treat anxiety and depression accidentally overdose?

6 Hypothesis (if correct, we must change our approach to solving the opioid crisis): Many of these people are not addicts, rather they are people using opioid to treat anxiety, PTSD, trauma 51% of the opioid pain killer prescriptions written in the United States go to the 16% of the American population with mental health diagnoses of Anxiety or Depression An American with Depression or Anxiety is 4 x more likely to be prescribed an opioid pain killer than an American without these diagnoses Davis M et al. Prescription Opioid Use Among Adults with Mental health Disorders in the Untied States. J Am Board Family Med 2017; 30:

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9 Developmental trauma: the ACE study >70,000 people given the ACE questionnaire 12.5% had 4 or more ACEs The higher the score, the more adult medical and mental health problems These problems are independent of lifestyle, they are the result of biological brain changes caused by trauma Very few general medical community and pain clinics (and addiction medicine clinics) screen for trauma

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11 How is the trauma epidemic relevant to solving the opioid crisis? Trauma changes brain function These changes lead to symptoms like anxiety that respond to opioid These symptoms are misdiagnosed as pain from tissue injury This is why many pain patients end up on high risk opioid + benzo medication regimens

12 Trauma reorganizes the nervous system Trauma Obesity Nervous Healthy system Nervous reorganization system

13 What evidence is there for this? IPCA experience (interdisciplinary clinic with psychology evaluation for complex patients) ECHO Pain experience (Primary Care pain education telemed program) Addiction medicine experience

14 What evidence is there for this? We realized that many chronic pain patients on chronic opioid and prescription opioid overdose victims have these characteristics: 1. Developmental trauma is there 2. No clear pathology to explain the pain 3. Fatigue, anxiety, depression, pain, insomnia, high level of disability always there 4. Often, no addiction disorder

15 What evidence is there for this? 51% of the opioid pain killer prescriptions written in the United States go to the 16% of the American population with mental health diagnoses of Anxiety or Depression An American with Depression or Anxiety is 4 x more likely to be prescribed an opioid pain killer than an American without these diagnoses Davis M et al. Prescription Opioid Use Among Adults with Mental health Disorders in the Untied States. J Am Board Family Med 2017; 30:

16 Hypothesis (if correct should drastically change our approach to solving the opioid crisis): The majority of our OD victims are not addicts, rather they are people using opioid to treat anxiety, PTSD, trauma

17 The making of a chronic pain patient from a person who chemically copes with the effects of trauma Acute Pain in the context of anxiety, trauma, depression,??? Ahhh, a chronic pain patient Percocet script I feel better, calmer, less anxious, less depressed, so how do I get more? They give me oxycodone if I talk about pain. Pt constantly talks about the pain they have and is prescribed pain meds > 1 year

18 Acute Pain in the context of anxiety, trauma, depression,??? I feel better, calmer, less anxious, how do I get more? Percocet script Patient develops an addiction disorder CRISIS Patient in ER for poisoning from opioid plus benzodiazepine ++ Pt constantly talks about pain and is prescribed pain meds > 1 year

19 Trauma can be easily screened and effectively treated at low cost relative to the cost of treating the consequences of untreated trauma eliminating the need for opioid

20 Treat the root cause, put out the fire in the basement!!! Neurocognitive therapies Obesity Nervous system normalization reorganization

21 Solving the Opioid Crisis: the Missing Piece Acute Pain in a patient with trauma history First Percocet script TREAT THE ROOT CAUSE I feel better, calmer, less anxious, how do I get more? Request for more Percocet SCREEN for trauma and addiction INTERCEPT CRISIS AVERTED Patient NOT in ER for poisoning from opioid, usually plus benzodiazepine and more INTERCEPT Patient who is already on chronic opioids SCREEN for trauma and addiction