Post on 26-Dec-2015
• 30% of patients prescribed opioids chronically become addicted.
• 0.19-3.7% demonstrating observed signs of addiction (Fishbain DA, et.al. Pain Medicine 2008;9(4):444–459.)
January 4, 2011
Maine plagued by painkiller habitA growing epidemic of abuse is behind an addiction treatment rate that is eight times the national average.
By John Richardson jrichardson@mainetoday.comState House Bureau
• 26% for purposeful oversedation • 39% for increasing dose without prescription • 8% for obtaining extra opioids from other doctors• 18% for use for purposes other than pain • 20% for drinking alcohol to relieve pain• 12% for hoarding pain medications
Michael Von Korff, ScD, Annals of Internal Medicine, 6 September 2011
Perspective
A Flood of Opioids a Rising Tide of Deaths
Susan Okie, M.D.N Engl J Med 2010; 363:1981-1985 November 18, 2010
• No end organ toxicity• No ceiling dose• Safer and more effective than OTCs
• Addiction• Respiratory depression and overdose death• Endocrinologic dysfunction• Immune dysfunction• Opioid induced hyperalgesia
• There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks.
Major Study Limitations• Used placebo comparators• Invariably excluded patients at high risk of serious
adverse events • Trials that have been completed were generally short
term (<16 weeks)
• There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks.
• The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients.
Ten-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life
and health care utilization
Opioid Users had:•Higher pain levels•Poorer self-rated health•Higher unemployment•Greater use of the healthcare system•More maladaptive coping skills •Lower health-related quality of life (SF-36)
Ten-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life
and health care utilization
Study Limitations•Denmark has the highest use of opioids in the world•Cross-sectional epidemiological research, cannot be established a causal relationships
Ten-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life
and health care utilization
“It is remarkable that opioid treatment of long-term/chronic noncancer pain does not seem to fulfill any of the key outcome opioid treatment goals…"
Ten-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life
and health care utilization
“It is remarkable that opioid treatment of long-term/chronic noncancer pain does not seem to fulfill any of the key outcome opioid treatment goals: pain relief, improved quality of life, and improved functional capacity."
A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with
opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission
•At admission patients using opioids reported significantly greater pain severity and depression.•Significant improvement was found on all outcome variables following treatment and six-month posttreatment regardless of opioid status at admission.
Outcome Variable Non Showing Differences•Depression •Pain catastrophizing •Pain interference •Perceived control over pain/life •General activity •Health perception •Physical functioning •Social functioning•Role limitations related to physical problems•Role limitations from emotional factors
A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with
opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission
•At discharge, patients taking higher doses continued to report significantly greater pain severity than the non-opioid group. •Patients in the opioid cohort who completed rehabilitation and opioid withdrawal maintained treatment gains comparable to those in the non-opioid cohort.
A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with
opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission
Study Limitations•Self-selection bias•Methodology of this study precluding causal inferences suggesting patients’ functioning improved because of the opioid withdrawal
Chronic Noncancer Pain Rehabilitation With Opioid Withdrawal: Comparison of Treatment
Outcomes Based on Opioid Use Status at Admission
•No significant pretreatment differences were found between the opioid and nonopioid group regarding demographics, pain duration, treatment completion.•No significant differences were found regarding all outcome variables, including pain severity, between the opioid and nonopioid group.
Multidisciplinary rehabilitation for chronic low back pain: systematic review
•Twelve randomized comparisons of multidisciplinary treatment and a control condition.•Strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments.•Moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain.
1. Confirm diagnosis2. Exhaust interventional options
3. Functional rehabilitationa. Physical therapy/exerciseb. Cognitive behavioral therapyc. Adaptive equipmentd. Lifestyle changee. Medication management
1. Patient selection evaluationsa. Physiatry/pain medicine evaluationb. Psychiatry/psychology evaluationc. Addiction medicine evaluation
1. Patient selection evaluations2. Treatment program
a. 2 ½ hour treatment daysI. 1 hour of cognitive behavioral therapy
(Health and Behavior codes)II. ¼ hour mindfulness exerciseIII. 1 hour of physical exercise
(Group Medical Visit coding)IV. ¼ hour homework assignment
1. Patient selection evaluations2. Treatment program
a. 2 ½ hour treatment daysb. 12 week program
I. Orientation/foundational training weekII. Treatment weeks
i. 5-week opioid taperii. 5-week opioid free
III. Discharge planning weekc. Open ended aftercare program
Treatment Team:1.Patient2.Family3.Physiatrist/pain physician4.Psychiatrist5.Psychologist6.Addiction medicine provider7.Nurse Practitioner8.Registered nurse9.Physical therapy assistant/exercise instructor10.Medical assistant11.Support staff
Medically Managed Opioid Withdrawal
•Pretreatment detox•Supported progressive taper (5-weeks)
• Adjuvant medication management• Suboxone induction and rapid taper
•Suboxone induction and maintenance
MJ Christie, Cellular neuroadaptations to chronic opioids: tolerance, withdrawal and addiction. British Journal of Pharmacology (2008) 154, 384–396