chronic pain, psychiatry and opioid therapy …anything to ... pain psych n… · primary care...
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Chronic Pain, Psychiatry and Opioid Therapy …Anything To Learn???
March 24, 2017
Robert McCarron, D.O.
Associate Clinical Professor
Pain Medicine / Psychiatry
Internal Medicine
UC Davis, School of Medicine
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Ouch!!!
• 47 Y/O male with a history of B/L knee OA
• “Nothing works and I have no motivation anymore to do my PT or even get out of bed”
• Irritable, depressed, late for appointments, entitled, and requesting an increase to his 100 mcg Fentanyl patch
• “Don’t tell me this is all in my head…I don’t need a shrink…you need a shrink if you think this pain is not real”.
• “20/10” pain level – “you got to help me!”
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The “Difficult Patient Encounter”…
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SHARP INCREASE IN OPIOID PRESCRIPTIONS INCREASE IN DEATHS
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Role of Prescribing Opioids and Overdose Deaths
*Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and Consolidated Orders System
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What’s up with use of opioids…?
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U.S. Department of Health and Human Services -AHCPR 1993 Psychosomatics 41:5 Sept 2000
Psychiatric Services Jan, 2006
Primary Care Setting:The de facto mental health care system
• Primary care physicians – provide over 60% of all psychiatric care in U.S.
• Up to 40% of primary care patients have
primary, active psychiatric problems
• 50% of patients with mental health referrals do not follow up (stigma, poverty, language barriers, paucity of psychiatrists, financial constraints)
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General Hospital Psychiatry 2006
PRIMARY CARE PSYCHIATRYTRAINING ISSUES
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WJM Jan 1999; 170, No.1 Psychosomatics 41:5 Sept 2000
Psychiatric Services Jan 2006
PRIMARY CARE PSYCHIATRYTRAINING ISSUES
• Less than half of primary care patients with mental illness receive any treatment
• 50-70% MDD is not accurately diagnosed or treated in the primary setting
• Roughly 80% of all antidepressants are prescribed by non-psychiatrists (Mark, et. Al 2009)
• More than half of primary care patients on antidepressants do not meet criteria for MDD (Perez-Stable 1990, Tiemens 1999, Klinkman 1998)
• Only 1/3 of internal medicine residents are comfortable treating MDD (JAMA 2002)
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Depression Chronic Pain
Psychosomatic Medicine 68:262–268 (2006)
5,800
Kaiser
patients
surveyed
No Depression Depression
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Chronic Pain and Depression
• Disabling chronic pain present in 41% of those with MDD, versus 10% of those with no MDD.
• Co-morbid depression and chronic pain:
– Decreased overall quality of life
– Greater somatic symptom severity
– Higher prevalence of panic disorder
– Higher chance of opioid use and abuse
Psychosomatic Medicine 68:262–268 (2006)
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Depression and Anxiety
• 85,000 self report
• 17 countries
• Chronic neck or back pain
• 2-3 times more likely to have PDO, GAD or SAD
• Those with fibromyalgia increases risk of anxiety and depression
DEPRESSION AND ANXIETY 26:888–901 (2009)
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Pain and Psychiatric Illness –Closely Linked
Arch Int Medicine Nov 2003
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Pain and Psychiatric Illness –Closely Linked
Arch Int Medicine Nov 2003
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Age-Old Question…
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Depression and Pain
Somatic pre-
disposition
Poor coping
strategies
Low Pain Threshold
Personality Disorder
Primary AMPS
Poor support system
Physically Inactive
Conceptual Model for Pain / Depression Co-occurence
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What Can I Do…?
• Prescribe opioids with caution
• Address poor coping strategies
• Help patient self identify healthy support systems
• Check UDS periodically and connect with a PCP
• Encourage regular physical activity (avoid deconditioning)
• Monitor for AMPS and suicidal risk
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Lippincott’s Primary Care Psychiatry – McCarron, Xiong, et al.
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Screening For Substance Abuse
• CAGE
– Sensitivity: 94%
– Specificity: 70-97%
– Easy to use
– If one or more are positive – probe further
• Audit-C
– WHO --- easy to use
– Score of >4
• Sensitivity: 86%
• Specificity: 72%
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Assessing risk for suicide
• Over 50% of those who kill themselves have seen their primary care doctor within one month of doing so.
• Over 50% of suicides will end up in litigation
• Firearms --- ask about access• Women 45%
• Men 70%
• Make a concluding statement about acute risk
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Ouch!!!
• 47 Y/O male with a history of B/L knee OA
• “Nothing works and I have no motivation anymore to do my PT or even get out of bed”
• Irritable, depressed, late for appointments, entitled, and requesting an increase to his 100 mcg Fentanyl patch
• “Don’t tell me this is all in my head…I don’t need a shrink…you need a shrink if you think this pain is not real”.
• “20/10” pain level – “you got to help me!”
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The “Four A’s” of Opioid Therapy
• Analgesia (does it work)
• Activities of daily living (functionality)
• Adverse effects (including accidental death)
• Aberrant behavior (screen everyone)
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Any Questions???