Post on 12-Jun-2015
description
Prevalence of Recurrent and Persistent Pain in the US
• 1 in 4 Americans suffer from recurrent pain (day-long bout of pain/month)
• 1 in 10 Americans report having persistent pain of at least one year’s duration
• 1 in 5 individuals over the age of 65 report pain persisting for more than 24 hours in the preceding month
– 6 in 10 report pain persisting > 1 year
• 2 out of 3 US armed forces veterans report having persistent pain attributable to military service
– 1 in 10 take prescription medicine to manage pain
American Pain Foundation. http://www.painfoundation.org. Accessed March 2010.
National Institutes of Health. New Directions in Pain Research. Sept 1998. PA-98-102.
DAWN 2009 Heroin 213,118 visits Narcotic Pain Relievers: 397,160 visits
Oxycodone/combinations – 175,949 visits Hydrocodone/combinations – 104,490 visits Fentanyl/combinations – 22,143 visits Buprenorphine/combinations – *12,544 Alcohol involvement: 32% of visits Source: Drug Abuse Warning Network, National Estimate, 2010; The Drug Abuse Warning Network
(DAWN) is a public health surveillance system that monitors drug-related morbidity and mortality. DAWN uses a probability sample of hospitals to produce estimates of drug-related emergency department (ED) visits for the United States and selected metropolitan areas annually. DAWN also produces annual profiles of drug-related deaths reviewed by medical examiners or coroners in
selected metropolitan areas and States.
*estimate may be low because buprenorphine is not specifically queried
The majority of unintentional overdose deaths were related to opioid use including oxycodone, hydrocodone, and methadone, often in combination with other drugs and/or alcohol. Source: Methadone Mortality Conference, CSAT/SAMHSA, July 2010 http://www.cdc.gov/HomeandRecreationalSafety/pdf/poision-issue-brief.pdf
A Common Dilemma in Medicine
Lithium Stimulants Antipsychotics Beta-blockers
O Antidepressants Anticonvulsants Alpha blockers BZDs
NSAIDS Opioids Acetominophen Steroids
A-delta (myelinated) and C (unmyelinated) afferents with cell bodies in dorsal root ganglion act as nociceptors: sensitive to noxious stimuli: heat, mechanical, irritating chemicals Sensitization in local tissue with release of prostaglandins, bradykinins, leukotrienes Nociceptors can cause release of Substance P resulting in further local inflammation
Axons of primary afferent nociceptors enter spinal cord via the dorsal root terminating in dorsal horn of spinal gray matter
Spinal neurons then transmit pain signals to brain: thalamus which projects to somatosensory cortex (ascending transmission)
Projections to cortical regions (cingulate and frontal lobe) linked to emotional responses resulting in unpleasant emotional perceptions
Pain can be modulated via a descending circuit that has links in hypothalamus, medulla, and midbrain. Selectively controls spinal pain transmission neurons; contains endogenous opioids
Anatomy of Pain
Pain
Diet/Exercise/PT Anticonvulsant
s
Surgery
Chiropractic Treatment
Acupuncture
TENS
Cognitive Behavioral Therapy
Massage/Yoga
Nerve Block
Trigger Point Injections
Opioid Risk Tool (ORT) • Administration • On initial visit • Prior to opioid therapy
• Scoring • 0-‐3: low risk (6%) • 4-‐7: moderate risk (28%)
• > 8: high risk (> 90%)
Webster & Webster. Pain Med. 2005;6:432.
Opioids for Pain Management
Passik SD, Kirsh KL. J Supportive Oncology, 2005.
Clinical Support Systems Sponsored by Center for Substance Abuse Treatment/SAMHSA
References