Opioids, Pain and Addiction Project Echo June 21, 2018

The Team Addiction team: Pain Team: Paula Cook MD Elizabeth Howell MD Addiction Psychiatry and Medicine Fellows: Lauren Prest DO, David Crabtree MD and Patrick Bell MD Tiffany Love PhD (Neuroscience) Rae Murphy Pharm.D Anthony May Pharm. D Pain Team: Jill Sindt MD Robert Jenkinson, MD Pain Fellows

Objectives Discuss chronic pain pain, opioid prescribing and risk mitigation for opioid use disorder Learn how to identify and manage the chronic pain patient with opioid use disorder Identify pharmacological and non-pharmacological methods to treating chronic pain Discuss special topics in pain and addiction including cannabis Review pain and addiction in special populations

Format Short didactic presentation (20 minutes) Case presentations (2 per session) Q&A

cases Learner based cases Goal of Project Echo is to provide specialty care to many patients via learners Form is on line Welcome questions about patient or practice based care along the way (informal)

Schedule, Modules 1 & 2

Schedule, modules 3 & 4

Introduction Chronic Pain Addiction >116 million Americans have chronic pain (30-40%) Total costs $560-635 billion/year Higher than costs combined of cancer, CV disease, and diabetes About 21-29% of persons receiving chronic opioids MISUSE them Between 8-12% develop OPIOID USE DISORDER About 4-6% of people abusing prescription opioids transition to heroin 80% of heroin users started out with Rx opioids Why is this such a hot topic?

Deaths from heroin increased 3x from 2010-2015 but LARGEST increase in overdose deaths in 2015 was from synthetic opioids which doubled from 5,544 to 9,580 in 2015. Heroin use is on the rise too, 3 out of 4 new heroin users report abusing Rx opioids prior (inc availablilty, lower price and inc purity lead to more use).

Why? Opioids bind to mu receptors Affect pain perception Affect emotional response Affect the brain’s reward system = analgesia and euphoria Pavlovian-type conditioning can occur Volkow and McClelland: Affect pain perception in the periaquaductal grey, thalamus, cingulate cortex and insula. Emotional response un the amygdala Brain reward system: ventral tegmental area and nucleus accumbens = analgesia and euphoria

use despite Consequences What is addiction? “Addiction is a primary chronic disease of brain reward, motivation, memory and related circuitry…is characterized by an inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships”. (ASAM short definition) The 3 C’s lack of Control Craving use despite Consequences

Dopamine projections into (LIMBIC system) code for salient reward which can lead to diminishing the value of natural reward

Neuroadaptations in addiction Neuroadaptations in brain reward, stress, habit formation, and executive function systems drive continued alcohol/drug intake despite negative consequences Neuroadaptation Result Decreased dopamine and GABA in ventral striatum Decreased reward Enhancement of corticotrophin-releasing factor (CRF) in the extended amygdala Increased negative emotional state Blunting of HPA axis Decreased response to stress Engagement of dorsal striatum Solidified habitual behaviors Prefrontal cortex damage/impairment Poor inhibitory control Poor executive functioning Poor decision-making Mesolimbic circuit (NAc, amygdala, hippocampus) adaptations Enhanced saliency of drugs/drug stimuli Decreased sensitivity to natural reinforcers Insula dysfunction Impaired ability to evaluate internal states Lateral habenula impairments Compromised ability to process and learn from disappointment Disrupted mood

Chronic pain & addiction misconceptions Physical dependence/tolerance are not addiction Pain protects from addiction Only long term use of opioids leads to addiction Only certain people are at risk for addiction Medication assisted treatment is a substitute for a drug Taken from Volkow paper in NEJM march 2016.

The chronic pain dilemma The “Opioid epidemic is HOT right now Many patients have chronic pain but not addiction Chronic opioids may be appropriate for patients with NCP but still have risks Guidelines exist to help with utilization Patients with both pain and addiction need aggressive treatment of both Addiction, opioids, trauma (emotional pain) and mental illness can complicate chronic pain. *Psychological adjustment, personality traits and emotional responsiveness, circumstances surrounding onset and persistence of pain, ACEs

What echo can do Discuss and demystify – Pain and it’s emotional complexities Tips and tools on management Talk a lot about addiction, especially opioid use disorder How to screen and diagnose How to manage this in primary care settings Help with the management of your patients! Submit cases please!

references PCSS: Management of Chronic Pain: A core curriculum for primary care providers Volkow, N D, McClellan Thomas D. Opioid Abuse in Chronic Pain- Misconceptions and Mitigation Strategies. N Eng Journ Med. March 31, 2016; 374:1254-1263 Management of Chronic Pain and Opioid Misuse: A Position Paper from the AAFP. American Family Physician. 2017: 95(7). 458-459 ASAM National Practice Guideline CDC Opioid Prescribing Guidelines for Chronic Pain. March 2016 ASAM Pain & Addiction Conference. Common Threads Course. April 2018