1. Finding Balance When Managing Chronic Pain Maximizing function – minimizing harm Dan Berland, MD, ABAM, FACP Departments of Medicine and Anesthesiology

2. UM Class of 1952

3. The CDC Guideline

4. Super Bowl 2016 Ad

5. Outline For The Day The discussion about opioids – Guidelines, REMS, CDC How we got where we are now Making the right diagnosis Psychology of pain; recognizing addiction What to say and do for patients Having “the talk”and management pearls

6. What You Need to Take Away All roads do not lead to opioids. Opioids often don’t work and should not be a first or a last resort. Iatrogenic addiction does not help pain. Take a history. You’ll get the answers. Med reduction and psychology work. It’s hard, but rewarding.

8. How Our Training Was Wrong The WHO Pain Ladder is our guide Follow pain scores All paths lead to opioids There is no ceiling for opioid treatment We are docs. We must “help” and…

9. Acute And Chronic Pain Are Different Acute Pain – a defense Acute Pain – a defense Is a symptom Has identifiable source and physical findings Has a protective function in response to disease or injury Associated with autonomic response (HR, BP changes, distress) Resolves with treatment or recovery of underlying process Chronic Pain - learned Is a diagnosis Often without clear source or physical findings Is often maladaptive and becomes the disease itself Usually no observable physiologic changes After 3 months, is associated with physical, affective, behavioral and interpersonal consequences

10. Chicago Tribune, 2001

11. WSJ, December, 2012

14. What have I done? Bridge on the River Kwai, 1957

15. Journal of Pain, 2009 Sent to Michigan prescribers

16. UM, 2009, rev 2011

17. 0.1 0.2 0.6 0.7 0.6 2.0 6.2 14.6 0 0 1 1 3 3 5 5 7 7 9 9 11 13 15 LSD Heroin Inhalants Meth Ecstasy Crack Cocaine Prescription Drugs Marijuana (incl. crack) Past Month Users, Ages 12 and Older (in Millions) SAMHSA, 2002 National Survey on Drug Use and Health Non-medical Use of Prescription Drugs, Non-medical Use of Prescription Drugs, Reported by 6.2 Million Persons in 2002 Reported by 6.2 Million Persons in 2002 -- Second Only to Marijuana Use -- Second Only to Marijuana Use Non-medical Use of Prescription Drugs, Non-medical Use of Prescription Drugs, Reported by 6.2 Million Persons in 2002 Reported by 6.2 Million Persons in 2002 -- Second Only to Marijuana Use -- Second Only to Marijuana Use Millions of Americans Misuse Prescription Drugs

19. Well Meaning Doc or Serial Killer?

20. NEJM, Jan. 2015

23. Prescription Drug Abuse 1 death : 10 admissions : 32 ED visits : 825 non-medical use

24. Prescription Drug Abuse The Drugs All DEA # requiring drugs are abused locally, have a street value, and are sought by some patients Street value depends on the dopamine surge Onset of action—fast Intensity of effect—high Duration of action—short Potential route of administration— IV/pulmonary Trade name > generic

25. BRAIN

27. Are Opioids Indicated? Effective? Are Opioids Indicated? Effective? Trial funding and duration

30. Are Opioids Indicated? Effective? Are Opioids Indicated? Effective? Trial funding and duration Norwegian trial – 500 on high dose 3 yr prospective trial of 69,000 10 year outcome: increased burden of illness Opioid induced hyperalgesia

31. The Meaning of Pain The Meaning of Pain “Good” pain vs a bodily defense Pain vs. suffering. fMRI studies: sensation vs. emotion Anxiety predicts level of pain > pain predicts level of anxiety Pain scores select the wrong patients for chronic opioids

33. Twelve-Month Prevalence of DSM-IV Independent Mood and Anxiety Disorders Among Respondents with DSM-IV Substance Use Disorders Who Sought Treatment in the Past 12 Months DisorderRespondents, % (SE) Those With Any Drug Use Disorder (13.10%)* Any mood disorder60.31(5.86) Major Depression44.26(6.28) Dysthymia25.91(5.19) Mania20.39(5.17) Hypomania2.48(1.67) Any anxiety disorder42.63(5.97) Panic disorder With agoraphobia5.92(2.19) Without agoraphobia8.64(3.05) Social phobia12.09(3.48) Specific phobia22.52(4.99) Generalized anxiety disorder22.07(5.18) Any alcohol use disorder55.16(6.29) *Data in parentheses are the percentages of respondents with the substance use disorders who sought treatment in the past 12 months. Grant B, JAMA 2004

35. Sleuthing the Real Story or There’s no substitute for a good history!

37. Create Timelines

38. The PQRSTs of the Patient’s Pain Exact nature of the original injury, timing of pain onset Degree of pain (really 27 / 10?) Initial evaluation Prior pain syndromes Coincident and prior life events Some diagnoses need to be undiagnosed, especially when no objective findings

39. Creating a Pain Timeline How the nature/location/timing have changed Medications tried o Non-opioid o Opioid Non-invasive treatments o TENS, PT, acupuncture, chiropractic Invasive procedures o Blocks, injections, surgery

40. Medication Use – Current & Past Opioids: How started and why escalated MED = morphine equivalent dose Pill numbers; fentanyl patch refills at 48 hrs Sedatives; “VED” Muscle relaxants, sedatives, sleepers, Soma Adjuvant trials (TCA, α-2 δ ligands, SNRIs) Total number of psychoactive medications

41. Was the Patient at Risk to Transition From Acute to Chronic Pain? Severity of initial pain and disability MMPI scores of distress and denial Pending Workers Compensation or personal injury actions Female sex, history of abuse FHx of chronic pain JAMA 2010; 303(13): 1295-1302. Jl of Pain 2010; 11(12): 1320-28.

42. Was the Patient at Risk to Transition From Acute to Chronic Pain? Job type, availability of light duty Low job satisfaction Low socioeconomic or educational status Maladaptive coping behaviors – avoiding recommended activities, unreasonable fear Prior poor general health or functional status Prior psychopathology or substance abuse?

43. The Background Matters Family history o Chronic pain syndromes o Psychopathology / learned behaviors o Substance abuse

44. Psychosocial History It’s much more than substance use Current living arrangements Work history / current employment Insurance status / seeking disability/ law suits Raised where, with whom in the household Hx of bullying, violence, neglect, abuse Psych history – anxiety, depression, suicidality, “bipolar,” assessments, therapy

45. Psychology for the Primary Doc Take a “real” psychosocial history Uncover anxiety back to childhood, PTSD, current stresses, pending litigation Substance abuse vs. chemical coping Therapy is hard Finding a qualified therapist (and payment) is harder Detoxification (benzos, too) is essential !

46. Substance Use / Abuse History

49. M A P S

50. Toxicology Testing Basics Origins of Urine Testing The SAMHSA “5” GCMS What test to use: Depends on what you are looking for – know your lab Serum methadone levels

51. Case Vignettes

52. Essential Reading CDC Opioid Guideline 2016CDC Opioid Guideline 2016 www.cdc.gov UM Chronic Pain/Opioid GuidelineUM Chronic Pain/Opioid Guideline available at guidelines.gov HEATHER ASHTON MANUALHEATHER ASHTON MANUAL benzo.org.uk THE BODY KEEPS THE SCORE – van der KolkTHE BODY KEEPS THE SCORE – van der Kolk My email: danielbe@umich.edu