Transcript Managing Chronic Pain with Opioids: Best Practice Tools

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
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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
• Podiatrists
7800+
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
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2
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
* Includes OTPs
GRAMS PER 100K POPULATION
Trend data: Distribution of
prescription opioids, U.S., 2000–2007
Source: DEA, ARCOS system, 2007
0
Methadone*
Oxycodone
Hydrocodone
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
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600
500
6
400
5
4
300
3
200
2
100
1
0
0
'90 '91'92 '93'94 '95'96 '97 '98'99 '00'01 '02'03 '04'05 '06
Sales in mg/person
Crude rate per 100,000
7
Deaths per 100,000
Opioid sales (mg per
person)
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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
For Medical/Legal Consulting
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Dr. William R. Morrone
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Phone: 989-928-3566
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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
8000
Number of deaths
7000
6000
5000
Prescription opioid
Cocaine
Heroin
4000
3000
2000
1000
0
'99
'00
'01
'02
Year
'03
'04
Emergency department mentions and
admissions to addiction treatment
related to use of prescription opioids
also are rising
Source: CDC, National Vital Statistics System, 2006
110,000
Emergency
Department
Mentions
100,000
90,000
80,000
70,000
Treatment
Admissions
60,000
50,000
40,000
30,000
1995
1996
1997
1998
1999
2000
2001
2002
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 2005 1
3000
New Users (x 1000)
2500
2000
1500
1000
500
19
65
19
67
19
69
19
71
19
73
19
75
19
77
19
79
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85
19
87
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19
91
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93
19
95
19
97
19
99
20
01
20
03
20
05
0
Analgesics
Tranquilizers
Source: SAMHSA, OAS, NSDUH data , July 2007
Stimulants
Sedatives
This course will address the
balance between providing
optimal pain relief and
preventing inappropriate use of
opioid analgesics.
What is the Physician’s Role?
Addiction
Abuse/Dependence
Prescription Drug Misuse
Aberrant Medication Use Behaviors:
A spectrum of patient behaviors
that may reflect misuse
Total Chronic Pain Population
Adapted from Passik. APS Resident Course, 2007
Opioid treatment of chronic pain
Initial Patient Assessment
Trial of Opioid Therapy
Setting Goals
Monitoring
Patient Reassessment
Adapted from Katz NP. Patient Level Opioid Risk Management. PainEDU.org Manual. 2007
Steps to be covered:
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•
•
•
•
•
•
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•
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…