Opioids for Chronic Pain:

Course Overview

William Morrone, D.O., M.S.Medical Director, Hospice of Michigan

Assistant Director, Family Medicine

Synergy Medical Education Alliance, Saginaw, Michigan

Consulting Liaison Addictionologist, Wolverine Human Services

PUBLIC DOMAIN NOTICEMaterial presented in this document – except the quoted passages, tables, photos, figures, and graphs from copyrighted sources – is in the public domain and may be reproduced or copied without permission. Citation of the source is appreciated.

There is a long cultural tradition of seeking relief from pain through medication

“to lull all pain and anger and bring forgetfulness of sorrow…”

Homer: The Odyssey

JWF: The Vintage Image Gallery

The challenge is that“treating pain is neither an absolute

science nor risk-free” Scott M. Fishman, MD - Anesthesia & Analgesia. 2007;105:8-9

Michigan Prescribers• Allopathic Physicians 31,695 • Osteopathic Physicians 6,550 (15.4%)

• Michigan had 3,208 students enrolled in a public medical school

– allopathic (2,461 students)– osteopathic (747 students)

• Dentists 7800+

• Podiatrists 1200+

2008 survey of physicians in Michigan, about 34 percent identified themselves as primary care doctors, that is, their primary specialty is family practice, general medicine, internal medicine, or general pediatrics

Use of all prescription

opioids is increasing

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Methadone* Oxycodone Hydrocodone

Trend data: Distribution of prescription opioids, U.S., 2000–2007

Source: DEA, ARCOS system, 2007

GR

AM

S P

ER

10

0K

PO

PU

LA

TIO

N

* Includes OTPs

Problems related to opioid use are

rising in tandem with distribution

Deaths per 100,000 related to unintentional overdose and annual sales of

prescription opioids by year, 1990 - 2006 Source: Paulozzi, CDC, Congressional testimony, 2007

0

1

2

3

4

5

6

7

8

'90 '91'92 '93'94 '95'96 '97 '98'99 '00'01 '02'03 '04'05 '06

Cru

de

ra

te p

er

10

0,0

00

0

100

200

300

400

500

600

Sa

les

in m

g/p

ers

on

Deaths per 100,000

Opioid sales (mg perperson)

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Welcome to DrMorrone.com. In my world, forensic science, medicine, teaching, law, criminal justice investigation and toxicology explain mystery and discover truth. Universal scientific principles often uncover mystery. What is truth? What is Justice? Sometimes, making complex medical facts simple honest sound bites, is the only true justice. Teaching and knowledge are the only weapons against fear and ignorance.

As a practicing physician, teacher, forensic scientist, research scientist, medical examiner, toxicologist, addictionologist and social advocate, I have sought simple truth to help, heal or comfort others for 24 years. Over that period of time, I have watched medical knowledge undergo exponential &

dramatic growth, most recently in areas of drug development and DNA application. I have attempted to bring natural justice to every level of “complex science and medicine” that has been too long-winded in the past.

This website is to declare my interests as a forensic scientist, toxicologist, real-world practicing physician, and medical-legal consultant. I hope to share this with colleagues and students as well as those who seek my services to explain, teach and investigate.

Bring me your mystery.

Sincerely,

William R. Morrone, DO, MS, ACOFP, CCD

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Unintentional drug overdose deaths are rising faster for prescription opioids

than for illicit drugs Source: CDC, National Vital Statistics System, 2006

0

1000

2000

3000

4000

5000

6000

7000

8000

'99 '00 '01 '02 '03 '04

Year

Nu

mb

er

of

de

ath

s

Prescription opioid

Cocaine

Heroin

Emergency department mentions andEmergency department mentions andadmissions to addiction treatment admissions to addiction treatment

related to use of prescription opioidsrelated to use of prescription opioidsalso are risingalso are rising

Source: CDC, National Vital Statistics System, 2006

1995 1996 1997 1998 1999 2000 2001 200230,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

110,000

Treatment Admissions

Emergency Department Mentions

Non-medical use of prescription opioids

by adolescents and young adults

is a particular concern

Exhibit 2: Past Year Initiation of Non-Medical Use of Prescription-type

Psychopharmaceutics, Age 12 or Older: In Thousands, 1965 to 20051

0

500

1000

1500

2000

2500

3000

New

Use

rs (

x 10

00)

Analgesics Tranquilizers Stimulants Sedatives

Source: SAMHSA, OAS, NSDUH data , July 2007

This course will address the balance between providing

optimal pain relief and preventing inappropriate use of

opioid analgesics.

What is the Physician’s Role?

Total Chronic Pain Population

Aberrant Medication Use Behaviors:A spectrum of patient behaviors

that may reflect misuse

Prescription Drug Misuse

AddictionAbuse/Dependence

Adapted from Passik. APS Resident Course, 2007

Opioid treatment of chronic pain

Adapted from Katz NP. Patient Level Opioid Risk Management. PainEDU.org Manual. 2007

Initial Patient Assessment

Trial of Opioid TherapySetting Goals

Patient Reassessment

Monitoring

Steps to be covered:

• Assess for pain, function, risk• Set realistic goals• Use agreements and informed consents• Monitor, monitor, monitor…• Not all aberrant medication taking is addiction• Patients with addiction lose control• Reassess, reassess, reassess..• Make needed adjustments • Document, document, document…