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Optimizing Opioids in Pain Management

Optimizing Opioids in Pain Management. Roman D. Jovey, M.D. Physician Director Alcohol & Drug Treatment Program Credit Valley Hospital Complex Pain Consultant Mississauga, Ontario, Canada. April 1, 2003.

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Optimizing Opioids in Pain Management

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  1. Optimizing Opioids in Pain Management Roman D. Jovey, M.D. Physician Director Alcohol & Drug Treatment Program Credit Valley Hospital Complex Pain Consultant Mississauga, Ontario, Canada

  2. April 1, 2003 An 89-year-old man who smothered his 85-year-old wife in her nursing home bed to end her pain will face murder charges, U.S. prosecutors said yesterday. Morris Meyer, who uses a wheelchair, told police his wife had begged him to help her die, so he made his way to her bed and held a pillow over her face.

  3. The Dorsal Horn Synapse Endorphins Enkephalins Baclofen Opioids Clonidine 2-methylserotonin GABAB µ § a2 5-HT3 Nociceptor Midozalam Citalopram GABAA 5-HT1B Dorsal Horn Cell Brookoff, 2000

  4. Pain and Suffering The Importance of Genetics GENETICS Placebo Effect N O C I C E P T I O N P A I N COMT COMT Emotions Cognition (vigilance) MORs Environment 2D6 Codeine SUFFERING

  5. Clinical Significance of the Basic Science of Pain • Not all pains are the same • Not all patients have the same pain sensitivities • Not all patients have the same pain relief from opioids • Not all patients have the same side effects of opioids • Not all opioids are the same • Not all opioid receptors are the same • Not all mu opioid receptors are the same Pasternak, 2001

  6. Why use opioids at all?

  7. Chronic Pain- Treatment Options

  8. Future Pharmacotherapies • CGRP antagonist • NMDA blockers • Cannabinoids • COX inhibitors • Bradykinin antagonists • Glutamamte antagonists • Substance P and Neurokinin antagonists • Tetrodotoxin / Omega conotoxins • CCK blockers • TRPVR1 agonist

  9. Opioids continue to be our most potent pain reliever

  10. Treating Chronic Pain… Pharmacotherapy BENEFIT RISK

  11. Acetaminophen • Used for mild-moderate nociceptive pain • Good evidence in post-op pain • No placebo-controlled evidence in chronic arthritis pain (Case, 2003)

  12. Acetaminophen – not a benign drug • Hepatotoxicity • GI bleeding / perforation • Chronic renal failure • Hypertension Zimmerman, 1995, 2000; Bromer, 2003; Garcia Rodriguez, 2001; FDA 2004; Health Canada Feb. 2003; Curhan 2002.

  13. U.S. Mortality Data, 1997 Singh G. Am J Med 1998 Wolfe M. NEJM, 1999

  14. If you take an NSAID > 2 mo… • 1/5 chance of an endoscopic ulcer • 1/70 chance of a symptomatic ulcer • 1/150 chance of a bleeding ulcer • 1/1200 chance of dying Henry McQuay 10th World Congress on Pain, 2002 http://www.jr2.ox.ac.uk/bandolier/booth/painpag/nsae/nsae.html

  15. Approximately 1900 Canadians die annually due to NSAID-related adverse effects * Canadian Arthritis Society www.arthritis.ca * more than the total number of deaths due to MVCs, fires and gunshot wounds combined

  16. COXIBs • Concurrent ASA nullifies the GI protective effect • Increased cardiovascular risk (Vioxx) Howard PA, 2004 Topol E, NEJM 2004 • Delayed fracture healing in animalsSimon AM. 2002 Gerstenfeld LC, 2004

  17. NSAIDs and COXIBs • 10-17% of patients develop increased BP Cheng HF. Hypertension, 2004 • Acute and chronic kidney toxicity DeMaria AN. JPSM 2003 • Double the risk of hospitalization for CHF Garcia-Rodriguez LA. Epidemiology 2003 • Increased miscarriage riskLi DK. BMJ 2003

  18. Adjuvant AnalgesicsToxicity • Carbamazepine – liver, hematological • Valproic Acid – liver, hematological • Gabapentin – liver • Tricyclics – cardiac, anticholinergic • Mexiletine – cardiac, liver, hematological • Topiramate - kidney stones

  19. Opioids have never been shown to cause organ damage when taken therapeutically.

  20. Opioids are physically the safest pain reliever available.

  21. Opioids can cause harm when they are misused.

  22. Prescription Opioid AbuseDAWN Data – United States

  23. New Users of Illicit Drugs in the Past Year U.S. National Household Survey on Drug Abuse, 2001

  24. Past Year Abuse or Dependence (DSM IV) on Alcohol or Illicit Drugs by Age U.S. National Household Survey on Drug Abuse, 2001

  25. Prescription Opioid AddictionTreatment Episode Data System, TEDS Percent of total admissions

  26. It really comes down to a question of balance

  27. Appropriate Use vs Abuse:Maintaining the Balance • The FEW who misuse prescribed opioids should not penalize the OVERWHELMING MAJORITY who use opioids appropriately • Treat pain sufferers + minimize drug diversion • Assess for risk factors • Prescribe carefully • Monitor behaviours suggestive of misuse/abuse, or addiction

  28. Can we predict who will misuse prescribed opioids?

  29. Risk factors for misuse / addiction • Family history • Previous history of alcohol abuse / addiction • Previous history of drug abuse / addiction • Serious untreated psychiatric problems • Previous criminal behaviour • High risk home environment

  30. Opioidology 101 Optimizing opioid use for pain

  31. When to Consider Opioid Therapy for Chronic Pain … Failure of usual treatments Unrelieved pain + Decreased QoL +

  32. Opioids work best when dosed to effect

  33. Dosing to effect means… Reasonable pain relief or Unmanageable and persistent side effects

  34. Some people respond to a small dose. Others require a much higher dose to adequately treat their pain.

  35. Each patient responds uniquely to a given opioid at a given dose with an individual side effect response.

  36. Opioid Side Effects • Nausea/constipation • Sedation during titration (driving, work) • Pruritis/sweats • Dysphoria/psychotomietic effects • Dry mouth/urinary retention • Hyperalgesia/myoclonus • Opioid-induced edema • Hormonal effects • Reflux symptoms • (Immune dysfunction)

  37. Stable dose, titrated, scheduled, LTO does not cause clinically significant cognitive impairment: • Hendler N. et al. Amer J Psychiatr 1980 • Zacny JP. Exp Clin Psychopharmacol 1995 • Vainio A. et al. Lancet 1996 • Zacny JP. Addiction 1996 • Lorenz J. et. al. Pain 1997 • Haythornthwaite JA, et al. JPSM 1998 • Sjogren P,et al. Pain; 2000 • Galski T, et al. JPSM 2000 • Chapman S. Clin J Pain 2002 • Sabatowski R. et al. JPSM 2003 • Tassain V. et al. Pain; 2003 • Fishbain DA. Et al. JPSM 2003

  38. The response to an excess of side effects vs. pain relief is to switch opioids

  39. Optimizing Opioid Therapy “In short, we need to move beyond inadequate trials of single opioids at fixed doses to sequential opioid trials, titration for individual patients, and management of side effects.” K. Foley, M.D. NEJM 2003; 348(26):2688-9

  40. Treatment Goals • Decrease pain • Improve function • Minimize adverse effects

  41. Opioids are not magic ! • Not all pains in all patients will respond. • Opioids have side effects - like any other medication • High risk patients on therapeutic opioids can manifest abuse / addiction. • Prescribed opioids can be diverted.

  42. We have a responsibility to society to prescribe and monitor carefully to minimize as much as possible the harm due to misuse and diversion

  43. BUT… Opioids are our most potent pain reliever They do not cause organ damage They are underutilized due to exaggerated fears of addiction One cannot predict response without a trial of therapy They work best as part of a multi-modal treatment approach

  44. “Men stumble over the truth from time to time, but most pick themselves up and hurry off as if nothing happened.” Winston Churchill

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