Pain & Opioid Epidemic 2018 Charles P. O Brien, MD, PhD University of Pennsylvania No financial conflicts, patents, speakers bureaus
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)
Inadequate treatment of cancer pain 1940-1990 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
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)
Ethical Question Adequate treatment of pain may hasten death in terminal patient Family and medical personnel may object if patient appears groggy
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
Dependence (normal) Anti hypertension Anti depressants (some) Anti-anxiety Opiates for pain
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
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
Short acting v. long acting opioids Hydromorphone (Dilaudid) Hydrocodone (Vicodin) Oxycodone (Percodan) Meperidine (Demerol) Fentanyl (patch) Methadone MS Contin OxyContin (IR,SR,Crush)
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
Street Opioids Parallel epidemic Heroin price and potency Fentanyl 50 x potency Diversion of Suboxone, methadone
Chronic pain (avoid opioids) Headache (various types) Backache (various etiologies) Reflex sympathetic dystrophy Diabetic Neuropathy Fibromyalgia Tic douloureux Shingles Ulcerative colitis
Multi-disciplinary diagnostic evaluation Diagnosis of pain etiology Psychological evaluation Family and other supports Quality of life measures
Non- opiate options Acetominophen Ibuprophen Cox 2 inhibitors Aspirin Combinations - caffeine adjuvant Tramadol (weak opioid)
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)
Non medication strategies Biofeedback Hypnosis Group and individual psychotherapy Cognitive therapy Family therapy Exercise Acupuncture TENS and related stimulation
Interventions for pain relief Depends on etiology of pain Nerve blocks Neurosurgical intervention TENS, acupuncture
Addiction Neuroscience Valid, predictive animal models Role of reward system Conditioned craving Conditioned DA release Anti-relapse medications New meds developed from basic research
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
Opioid Use Disorder FDA Medications Methadone Buprenorphine (Suboxone, + naloxone) Naltrexone, oral, depot (Vivitrol) Lofexidine (Lucemyra) Buprenorphine depot Sublocade (monthly injection) Probuphine implant (6 months)
Methadone Maintenance Heroin 0 6 12 18 24 Time (Hours)
Intrinsic Activity: Full Agonist (Methadone), Partial Agonist (Buprenorphine), Antagonist (Naloxone) 100 90 80 Full Agonist (Methadone) 70 60 50 40 Partial Agonist (Buprenorphine) 30 20 10 0 Antagonist (Naloxone) -10-9 -8-7 -6-5 -4 Log Dose of Opioid
Induction Success (%) X Site 24
Opioid overdose deaths 2017-72,000 in USA Most due to fentanyl, China origin Fentanyl: 50-100 times more potent than morphine Cocaine/Fentanyl combinations Tobacco: 450,000 deaths per year
Pain and depression Pain as a depressive equivalent Depression secondary to pain Circular relationship
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
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
Goals of Medication Think about the clinical picture Education level, Job skills Motivation Detoxification, naltrexone OR Transfer directly from heroin to agonist Suboxone Methadone