Paul Snyder MA, LADC - SOPIOIDS AND CHRONIC PAIN

1996 Purdue Pharmaceuticals financed “Pain as the Fifth Vital Sign” campaign to help in the marketing of Oxycontin.

(blood pressure, pulse, temperature, and respiratory rate)

Addition of pain as a vital sign approved by the Joint Commission on Accreditation of Healthcare Organizations in 2000.

PAIN AS THE FIFTH VITAL SIGN

The U.S. equals 4.6% of the world population and consumes:

Over 90% of the global opioid supply 95% of the Hydrocodone produced

There is no ceiling for opioids.

UNITED STATES LIKES PAIN PILLS

“Prescription drug abuse is the nation's fastest-growing drug problem”

White House Office on National Drug Policy

1.3 million emergency room visits in 2010, a 115% increase since 2004

Overdose deaths on opioid pain relievers surpassed deaths from heroin and cocaine for the first time in 2008

RX DRUG USE –AN EPIDEMIC

Every day 2,700 teens try a prescription drug to get high for the first time

Partnership for Drug Free America, 2010

In 2010, nearly 60 percent of the drug overdose deaths (22,134) involved pharmaceutical drugs

Opioid analgesics, such as oxycodone, hydrocodone, and methadone, were involved in about 3 of every 4 pharmaceutical overdose deaths (16,651), confirming the predominant role opioidanalgesics play in drug overdose deaths

Last update February 20, 2013, content source Centers for Disease Control and Prevention

THE RX NATION

Drug overdose deaths increase for 11th consecutive year

6,100 in 1980 16,849 in 1999 (4,030 opioid analgesics) 36,500 in 2008 38,329 in 2010 (16,651 opioid analgesics) 43,982 in 2013 (16,235 opioid analgesics) 47,055 in 2014 (18, 893 opioid analgesics)

In 2012 the number-one cause of death in 17 US states was prescription drug abuse (Source:American Society of Interventional Pain Physicians)

OPIOIDS DRIVE CONTINUED INCREASEIN DRUG OVERDOSE DEATHS

Drug overdoses were responsible for 43,982 in 2013 - 35,663 (81%) of which were unintentional

That's a rate of 120 every day (45 per day for Rx pain relievers)

6,748 people treated every day for the misuse or abuse of drugs

In comparison, in 2010: 33,687 deaths from traffic accidents 31,672 people from firearms 26,852 died as a result of falling

Centers for Disease Control, 2015

MORE PEOPLE ARE DYING FROM DRUG OVERDOSES THANFROM ANY OTHER CAUSE OF INJURY DEATH, INCLUDINGTRAFFIC ACCIDENTS, FALLS OR GUNS

ACCIDENTAL RX OVERDOSES

HYDROCODONE

OxyContin most recognized and abused form Prescribed to relieve pain Twice as strong as morphine Time released (8-12 hours) Pills crushed and snorted or cooked down and

injected to break down time release component Strong, heroin-like, euphoric effects Expensive Other variations: Percocet and Percodan

OXYCODONE

Powerful semi-synthetic opioid analgesic (painkiller)

$25-$30 a pill Doctors begin prescribing it over OxyContin Injecting Opana–according to FDA “abuse

deterrent” coating makes it easier to inject Increased HIV/AIDS cases as a result

You Tube: OP Microwave Method

OXYMORPHONE“OPANA”

High dose hydrocodone narcotic painkiller Zohydro contains as much as 50 mg of

hydrocodone Manufactured as a powder in a capsule,

rather than a pill –easy to abuse 10 times more powerful than Vicodin US presently consumes 99% of worlds

hydrocodone

ZOHYDRO ER, FDA APPROVED

The number of prescriptions written for opioid pain relievers in the U.S. has risen from around 76 million a year in 1991 to nearly 207 million a year in 2013.

In August, 2015, the FDA granted approval to Purdue Pharma to prescribe Oxycontinfor patients as young as 11.

NATIONAL INSTITUTE ON DRUGABUSE(NIDA) 2015

Pure heroin is a white powder with a bitter taste that predominantly originates in South America, Afghanistan and Southeast Asia

South American heroin has become the most prevalent type available in the US

Particularly in the Northeast, South and Midwest “Black tar” heroin is sticky like roofing tar or

hard like coal and is predominantly produced in Mexico and sold in U.S. areas west of the Mississippi River

Dark color from crude processing methods leaving behind impurities

HEROIN

Oxycodone cost up to $1.00 a mg Percocet about $8 a pill Valium about $7 a pill Vicodin about $7 a pill Methadone $10 per dose Fentanyl $65 a patch Heroin $15 per bag (1/10 of a gram)

Source: Nevada HIDTA (High Intensity Drug Trafficking Areas)

$$$$ STREET VALUE $$$$$

CDC new opioid prescribing guidelines:

Initially try nondrug interventions (cognitive behavioral therapy or exercise) or nonopioid medications (anti-inflammatories).

If opioids are used, prescribe the lowest effective dose and start with immediate-release opioids instead of extended-release opioids.

Only provide the quantity needed for the expected duration of the pain.

Monitor patients regularly to make sure opioids are improving pain without causing harm.

These recommendation are not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

PRESCRIBING FOR PAIN – START LOW AND GO SLOW

Mel Pohl, MD, Medical Director for Las Vegas Recovery Center specializes in chronic pain and addiction Recommends distraction, yoga, massage, Reiki, mindfulness,

meditation, food:

Eat foods that reduces inflammation and avoid foods that increases inflammation.

Cherries, blueberries, cranberries, blackberries contain anthocyanins which relieve pain more than aspirin.

HEALTHY ALTERNATIVE TREATMENT

Vitamin C, used by the body to build and repair joint cartilage (good for people with osteoarthritis joint pain)

Vitamin C, antioxidant which can reduce CRP

C-reactive protein (CRP) clinical marker for inflamation

Olive Oil, contains oleocanthol which interferes with COX – 1 and COX -2 enzymes

Omega – 3 fatty acids (salmon, sardines, trout) are potent anti-inflammatory agents

H2O – 8 to 10 glasses a day helps kidney and liver filter toxins and dilutes toxin concentrations in the blood which reduces inflammatory effects.

DIET

All cause the body to produce Advanced Glycation End products (AGE’s) which trigger massive amounts of inflammation

Foods with high glycemic index – simple carbohydrates –white bread, white rice, are quickly converted to glucose during digestion

Alcohol is: converted into sugar almost immediately; and irritates intestinal tissue and allows bacteria to pass into

the blood more readily. The presence of bacteria will increase inflammation.

SUGAR – BAD – CANDY – BAD – SODA – BAD –BAKED GOODS – BAD – ALCOHOL - BAD

“More than one-half of patients who receive continuous opioid therapy for 90 days are still receiving opioids more than four years later.”

“The benefits of short-term opioid therapy is supported by multiple clinical trials. However, the benefit of opioids for managing chronis pain is limited. Chronic visceral or central pain syndromes (e.g. abdominal or pelvic pain, irritable bowel syndrome, fibromyalgia, headache, neuropathic pain) may be especially unresponsive to long-term opioid therapy.”

American Family Physician: Weighing the Risks and Benefits of Chronic Opioid Therapy, Anna Lembke et al. Stanford University School of Medicine

OPIOID MAINTENANCE

“Furthermore, the risks associated with chronic opioid therapy increases in a dose-dependent manner.”

“Patients at increased risk of over-dose include those with medical comorbidities(e.g. sleep apnea, lung disease, heart failure); those reeivingbenzodiazepines or other sedative-hypnotics; those with problematic alcohol use; and those with psychiatric comorbidities (e.g., depression)”

American Family Physician: Weighing the Risks and Benefits of Chronic Opioid Therapy, Anna Lembke et al. Stanford University School of Medicine

OPIOID MAINTENANCE

Discussing why you don’t want to provide another opioidprescription after the patient is accustomed to them.

Takes time – there goes your lunch break.Makes the patient upset.Possible complaint – there goes the bonus.Possible lost patient.

WORKING WITH PATIENTS

Define What Success Looks Like

Agree On An Exit Strategy

6 MINUTE TALK

Addiction is a chronic disease which can be managed, but not cured.

How do you manage it?

Possible medication Counseling Support – family and friends

TREATMENT

You are not alone!

Other providers add insights for optimal care

Qualified expert physicians give different perspectives to medication management

A diverse group of professionals helps the doctor make the correct decision

Time limited staffing weekly or monthly

STAFF COMPLEX CASES

Methadone – Full agonist at the mu opioid receptor, has street $ value, possible overdose, can change cardiac electrical conduction producing prolonged QTc interval, continuous dosing (years),

Buprenorphine – Partial agonist at the mu opioidreceptor and a partial antagonist at the cappa opioidreceptor, will displace other opioids on receptor causing withdrawal, Has street value, can titrate down quickly

Naltrexone – 28 day Mu receptor coverage, no street value

MEDICATION

Cognitive Behavioral Therapy (CBT) – “Is a well-established treatment for pain that involves helping the person improve coping skills, address negative thoughts and emotions that can amplify pain, and learn relaxation methods to help prepare for and cope with pain. It is used for chronic pain, postoperative pain, cancer pain, and the pain of childbirth. Many clinical studies provide evidence for the effectiveness of this form of treatment in pain management.” Defined by the National Institute of Health

COUNSELING

“Counseling can give an individual suffering from pain much needed support, whether it comes from family, group, or individual counseling. Support groups can provide an important supplement to drug or surgical treatment. Psychological treatment can also help people learn about the physiological changes produced by pain.”

Distraction, coping with triggers, music therapy, art therapy, mindfulness, yoga, massage, physical therapy, psycho-education, mind body connection, visioning, support

Provide coping skills and self empowerment to heal spiritually, emotionally, mentally and physically

NIH ON COUNSELING

Education

Communication

Care for the family

SUPPORT – FAMILY AND FRIENDS

Paul Snyder MA, LADC-S775-622-2240

paulsnyder26@yahoo.com

CONTACT

1. Opioids are often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

3. A great deal of time is spent in activities necessary to obtain opioids, use opioids, or recover from its effects.

4. Craving, or a strong desire or urge to use opioids.5. Recurrent opioid use resulting in a failure to fulfill major role obligations

at work, school, or home.6. Continued opioid use despite having persistent or recurrent social or

interpersonal problems caused or exacerbated by the effects of opioids.7. Important social, occupational, or recreational activities are given up or

reduced because of opioid use.8. Recurrent opioid use in situations in which it is physically hazardous.9. Opioid use is continued despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.

10. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of opioids to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of opioids.

THE ELEVEN SYMPTOMS OF OPIOID USE DISORDER

Presence of either of the following: Cessation of (or reduction in) opioid use that has been heavy and prolonged

(i.e., several weeks or longer). Administration of an opioid antagonist after a period of opioid use.

Three (or more) of the following developing within minutes to several days after Criterion A:

Dysphoric mood. Nausea or vomiting. Muscle aches. Lacrimination or rhinorrhea. Pupillary dilation, piloerection, or sweating. Diarrhea. Yawning. Fever. Insomnia.

The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

11. WITHDRAWAL, AS MANIFESTED BY THREE (ORMORE) OF THE FOLLOWING:

Can you identify a patient at risk of opioid misuse? Can you name two alternative methods for treatment of

chronic pain other than opioids? Can you identify two foods that cause inflammation? Can you identify two anti-inflammatory foods? Do you have a standing operating procedure for

prescribing opioids? Do you have a contract for patients to whom you

prescribe opioids? Do you talk to your patient about an exit strategy prior

to prescribing an opioid?

POST TEST QUESTIONS