1. Opioids, Pain and Addiction
Project Echo
June 21, 2018

2. 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

3. 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

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

5. 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)

6. Schedule, Modules 1 & 2

7. Schedule, modules 3 & 4

8. Introduction Chronic Pain Addiction
>116 million Americans have chronic pain (30-40%)
Total costs $ 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?

9. Deaths from heroin increased 3x from 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).

10. 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

11. 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

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

13. 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

14. 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.

16. 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

17. 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!

18. 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:
Management of Chronic Pain and Opioid Misuse: A Position Paper from the AAFP. American Family Physician. 2017: 95(7)
ASAM National Practice Guideline
CDC Opioid Prescribing Guidelines for Chronic Pain. March 2016
ASAM Pain & Addiction Conference. Common Threads Course. April 2018