Opioid analgesic therapy in pain management: how we

got here from there

Gary M. Reisfield, M.D.

Divisions of Addiction Medicine and Forensic Psychiatry

University of Florida College of Medicine

National Organization of Alternative Programs

March 17, 2016

91st Annual Session of AMAJune 12, 1940

“If you’re over 50 and you wake up in

the morning without pain, you might not be alive anymore.”

– Russian saying

John J. Bonica, M.D.

Cicely Saunders, M.D.

New Engl J Med 1980;302(2):123

Portenoy:

n = 24 receiving Rx opioids

n = 3 with abuse/addiction

n = 1 refused to answer questions

Van Zee A. The promotion and marketing of OxyContin: commercial triumph, public

health tragedy. Am J Public Health 2009;99(2):221-227

Retail sales of prescription opioids

↑732%

↑244%

↑196%

↑1177%

Graph: Manchikanti L. Singh A. Pain Physician 2008;11:S63-S88Data: www.deadiversion.usdoj.gov.arcos.retail_drug_summary/index.html

Morphine, distribution of consumption, 2013

International Narcotics Control Board 2014. Narcotic Drugs: Estimated World Requirements for 2015

Fentanyl: distribution of consumption, 2013

International Narcotics Control Board 2014. Narcotic Drugs: Estimated World Requirements for 2015

Hydrocodone: global consumption, 1994-2013

International Narcotics Control Board 2014. Narcotic Drugs: Estimated World Requirements for 2015

U.S. accounted for 99+% of world hydrocodone consumption in 2013

Oxycodone: global consumption, 1994-2013

U.S. accounted for 78% of world oxycodone consumption in 2013

International Narcotics Control Board 2014. Narcotic Drugs: Estimated World Requirements for 2015

Methadone: global consumption, 1994-2013

U.S. accounted for 51% of world methadone consumption in 2013

International Narcotics Control Board 2014. Narcotic Drugs: Estimated World Requirements for 2015

Okie S. A flood of opioids, a rising ride of deaths. New Engl J Med 2010;363(21):1981-1985

Deaths from unintentional drug overdoses in U.S., 1970-2007

Okie S. A flood of opioids, a rising ride of deaths. New Engl J Med 2010;363(21):1981-1985

Deaths from unintentional drug overdoses in U.S. by drug type 1999-2007

Prescription opioid deaths

Source: National Center for Health Statistics, CDC Wonder

Florida Fun Facts

In 2010:

98/100 top oxycodone-dispensing physicians in U.S. “practice” in Florida

By far, more oxycodone is dispensed in Florida than in the remaining 49 states combined

Top 10 reasons why your pain

clinic may be a “pill mill”

Number 10

Number 9

#8

Number 7

Number 6

Number 5

Number 4

Number 3

Number 2

Number 1

“Did I teach about pain management, specifically about opioid therapy,

in a way that reflects misinformation? Well, against the standards of

2012, I guess I did. We didn’t know then what we know now.”

“I gave innumerable lectures in the late 1980s and 90s about addiction

that weren’t true.”

Dec. 17, 2012

Cicero TJ, et al. N Engl J Med 2015;373:1789-1790.

Shifting patterns of opioid abuse

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a3.htm#Tab1

Medical Management

Lifestyle changesInterventional

Techniques

PsychiatryPsychology

Physical&

RehabilitativeTherapiesComplementary

&AlternativeTherapies

Multidisciplinary pain management redux

Risks

Benefits

Opioid risk stratification

ORT score: 0-3 ORT score: 4-7 ORT score: ≥8

• No Past/current SUD

• No FH of SUD

• No Major/untreated ψ

• Mild-moderate pain

and/or disability

• Consistent UDT

• Consistent PDMP

Primary care

management

Primary care management

with specialist support

Specialist management

• ± past SUD

• ± FH SUD

• ± past or current ψ

• Moderate pain and/or

disability

• Consistent UDT

• Consistent PDMP

• Active SUD

• ± FH SUD

• Major untreated ψ

• Mod-severe pain

and/or disability

• Inconsistent UDT

• Inconsistent PDMP

• Poor social support

Adapted from:

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients. Pain 2005;6:432-442.

Gourlay DL, Heit HA. Universal precautions in pain medicine: a rational approach to the treatment of chronic

pain. Pain Med 2005;6:107-112.

Low risk Moderate risk High risk

New York Times, December 11, 2015

Доверяй, но проверяй

What is (and isn’t) in the urine

Michna E, Jamison RN, Pham LD, et al. Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings. Clin J Pain 2007; 23: 173-179.

Passik SD, et al. A new tool to assess and document pain outcomes in

chronic pain patients receiving opioid therapy. Clin Ther 2004;26:552-561.