12 th HIV Nursing Network Conference CHRONIC PAIN Breakout Session May 20, 2016

1. 12th HIV Nursing Network ConferenceCHRONIC PAINBreakout Session May 20, 2016 Jacqueline Tulsky, MD –UCSF Division of HIV, ID & Global Medicine and Bay Area & North Coast AETC Paula Lum, MD, MPH – UCSF Division of HIGM

2. Chronic Pain Learning Objectives 1. Discuss current issues/questions in chronic pain focusing on persons living with HIV2. Increase awareness of medical evidence behind pain management guidance3. Describe future initiatives

3. Pain Management is a Human Right “Regardless of HIV status, the experience of unaddressed chronic pain is demoralizing, decreases quality of life and function and disrupts treatment adherence for other health conditions.” --13th World Congress on Pain, 2010, Int’l Assocfor the Study of Pain WHO 19th List of Essential Medicines includes -- aspirin, ibuprofen, acetaminophen, --codeine and morphine --WHO 19th List of Essential Medications

4. The Pain Medication Conundrum “Undertreating pain, we are admonished, violates the basic ethical principles of medicine. On the other hand, we are lambasted for overprescribing pain medications enabling addicts and creating an epidemic of overdose deaths.” Dr. Danielle Ofri, Assoc Professor NYU and a physician at Bellevue Hospital August 13, 2015 NY Times Op-Ed

5. The Pain Medication Conundrum ‘For patients with chronic pain, esp those with syndromes that don’t fit into neat clinical boxes, being judged by doctors [providers] to see if they “merit” medication is humiliating and dispiriting. It’s equally dispiriting for doctors [providers] . This type of judgment, with its moral overtones and suspicions, is at odds with the [provider]-patient relationship we work to develop.” “As Mr. W. and I sat there sizing each other up, I could feel our reserves of trust beginning to ebb. I was debating whether his pain was real or if he was trying to snooker me. He was most likely wondering whether I would believe him…” Dr. Danielle Ofri, August 13, 2015 NY Times Op-Ed (cont)

6. What Is Pain? • Pain has been defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.3 • The experience of pain is more than a simple sensory process. It is a complex perception involving higher levels of the central nervous system, emotional states, and higher order mental processes.4

7. Processing of Pain Signals • Perception of pain as a 4-step model: • Transduction: Acute stimulation in the form of noxious thermal, mechanical, or chemical stimuli is detected by nociceptive neurons. • Transmission: Nerve impulses are transferred via axons of afferent neurons from the periphery to the spinal cord, to the medial and ventrobasal thalamus, to the cerebral cortex. 7

8. Processing of Pain Signals continued • Perception of pain as a 4-step model: • Perception: Cortical and limbic structures in the brain are involved in the awareness and interpretation of pain. • Modulation: Pain can be inhibited or facilitated by mechanisms affecting ascending as well as descending pathways. 8

9. There Are Multiple Types of Pain5 • Nociceptive • Noxious Peripheral Stimuli • Inflammatory • Inflammation • Neuropathic • Multiple Mechanisms • Noninflammatory/ • Nonneuropathic • Abnormal Central Processing Peripheral Nerve Damage No Known Tissue or Nerve Damage

10. When it becomes Chronic Pain • Chronic pain occurs if the body’s alarm system (pain) does not turn off when it should. • The symptom of pain at that point becomes the disease of pain, or chronic pain. Q. If you have a clear reason for pain (osteoarthritic joint) is it really Chronic Pain in the way its previously been defined? 10

11. Pain Management With Opioids Indications for opioid pain management have evolved • Traditionally limited to: • Acute pain syndromes • Pain associated with malignancy (palliative care) • Current expanded use includes: • Chronic nonmalignant pain (CNMP)

12. Issues That EncourageOpioid Prescribing • 20% of the general population is affected by chronic nonmalignant pain (CNMP) • HIV patients with even higher rates of CNMP and HIV in 80’s, 90’s was a palliative care disease • “There was a belief CNMP deserve pain relief as much as those with cancer” and that sustained pain relief is possible with stable doses of opioids.

13. Use of Opioids in the United States • Estimated 5 to 8 million people use opioids long term. • Opioid prescriptions for pain treatment grew from 76 million in 1991 to 219 million in 2011. • Approx 40% to 70 % with chronic pain may not receive proper medical treatment. • Prevalence of chronic pain and increasing use of opioids have created a “silent epidemic” of distress, disability, and danger. AND STIGMA!

14. Unintentional Injury Deaths, 2013 N=130,557; cause of death rank: 4 http://www.cdc.gov/nchs/fastats/accidental-injury.htm

15. Drug Poisoning Deaths, 2014 Cause of death rank: 4 http://www.cdc.gov/nchs/fastats/injury.htm

17. Number of opioid-analgesic poisoning deaths, by involvement of benzodiazepines: United States, 1999–2011

18. Deaths from overdoses are reaching levels similar to the H.I.V. epidemic at its peak • Death rate from drug overdoses climbing at a much faster pace than other causes of death • Similar to HIV epidemic of late 1980s, early 1990s, which peaked in 1995 • Unlike HIV (mainly urban), drug overdoses cut across rural and urban lines http://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html

19. Perspective on Relative Risk • There is the potential for serious problems related to overuse, misuse, and abuse… but it is important to keep a reasonable clinical perspective. • Although aberrant use or misuse can be relatively common, actual abuse or addiction are fairly uncommon.

20. Relative Frequencies of Aberrant Use, Abuse, and Addiction (1) Total Opioid-Treated Patients Misuse 20–30% Addiction 8–10%

21. Steps in the RationalTreatment of Chronic Pain1 Initial Patient Assessment • Trial of Opioid Therapy • Informed Consent • Functional Goals Adequate Monitoring • Patient Reassessment • Adaptation of Treatment Plan • Intervention When Needed

22. Treatment Goals in Managing Chronic Nonmalignant Pain • Improve patient functioning. • Identify, eliminate, or reduce pain reinforcers. • Increase physical activity. The goal is NOT total eradication of pain!

23. Opioid Risks – Acute Side Effects • Common • Nausea, vomiting • Sedation, respiratory depression • Constipation, urinary retention • Sweating, insomnia, decreased sexual function • Cognitive impairment, psychomotor dysfunction • Opioid-induced delirium

24. Opioid Risks- Adverse Drug Effects • Organ toxicity is rare • Hypothalamic-pituitary-gonadal axis: increased prolactin, decreased LH, FSH, testosterone, estrogen, progesterone • Overdose, especially combined with other sedatives (NALOXONE PEOPLE – Pharmacy dispensed !) • Worsening pain (withdrawal or hyperalgesia) • Risk of opioid dependence – Physical dep nearly universal • Societal toxicity (diversion and trafficking)

25. Opioids Risks – Worse Function? • Study of patients in Washington State Workers’ Compensation system with low back injury • Increased risk of disability at 1 yr in those who received opioids within 6 weeks of injury (adjusted OR 2.2, 95 percent 1.5 to 3.1). 25

26. Opioids Risks – Substance Use Disorder (2) • The strongest risk factor for opioid abuse was personal or family history of substance abuse. • Other risk factors in some studies were depression, younger age, and preadolescent sexual abuse in women. 26

27. Initiating/Continuing Assessment for Chronic Pain • Adequate history and physical exam – Right Dx, Right Rx • What prescribed meds are most appropriate to start? • Has there been an adequate trial of non opioid medications? • Neuropathic pain often seriously under identified and responses well to non opioid pain meds (gabapentin, pregabalin, topical meds) • What meds to continue (if already on)? • Standardized instruments – Baseline Risk and Function • Alcohol, Smoking and Substance Involvement Screening Test (ASSIST); Alcohol Use Disorders Identification Test (AUDIT) • Opioid Risk Tool (ORT); • Pain, Enjoyment, General Activities (PEG)

28. PEG Pain Scale for Longitudinal Assessment Using 1-10 Scale – What number best describes…. 1. …Painon average in the past week. 2. …how, in past how, during the past week, pain has interfered with your Enjoyment 3. ….during the past week, pain has interfered with your GeneralActivities • What does score mean???

29. Initiating/Continuing Assessment for Chronic Pain • Release of Information and contacts with other providers • Treatment Agreements • Prescription Drug Monitoring Program (PDMP) or CURES • Discussion with family or significant other • Plan for follow –up, including stopping points Initial assessments may take several visits Continuation assessments multidisciplinary team

30. Prescription Drug Monitoring Programs (PDMPs) • State-instituted programs • PDMPs (CURES in CA) provide electronic access to history of prescribed (and filled) scheduled drugs • Required pharmacy data reporting • States vary in program design: • Reporting of Schedule II only or II–IV • Real-time or delayed data reporting • Response to inquiries—reactive or proactive • Safeguards for patient confidentiality

31. When Opioid Treatment Fails The vast majority of patients taking opioids for weeks will have physical tolerance to the medications and must be offered a taper or referral to appropriate care to assist in completing treatment. (e.g. methadone or buprenorphine treatment program). “Failing” because of illicit substance use can be a violation of the Pain Agreement plan, but does not end the provider-patient relationship! “”“-DDDDFFFGFRR • What does score mean???

32. What Thoughtful People are Saying… “Given new biological insights [about pain], why are we still reliant on ancient drugs?” --The Translational Scientist , March 2016 “When I think about patients I treated 25 years ago, the reality is that there is little I could offer them now, that I couldn’t back then.” --Roger Fillingim, Past President, American Pain Society

33. Where Do We Go From Here? • .

34. Additional References Used for Slides 1 SAMHSA – Safe and Effective Opioid Prescribing http://www.samhsa.gov/medication-assisted-treatment/training-resources and Boston University – Scope of Pain http://www.opioidprescribing.com/overview 2. CDC Guideline for Prescribing Opioids for Chronic Pain ...www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm, Mar 18, 2016  3Task Force on Taxonomy, International Association for the Study of Pain. (1994). Classification of chronic pain. (2nd ed.). In H. Merskey & N. Bogduk (Eds.). Seattle, WA: IASP Press. 4Institute of Medicine, Committee on Pain, Disability, and Chronic Illness Behavior. (1987). Pain and disability: Clinical, behavioral, and public policy perspectives. M. Osterweis, A. Kleinman, & D. Mechanic (Eds.). Washington, DC: National Academy Press. 5Woolf, C. J. (2004). Pain: Moving from symptom control toward mechanism-specific pharmacologic management. Annals of Internal Medicine, 140(6), 441-451. • What does score mean???

35. And now it’s time for…. CHRONIC PAIN 12th HIV Nursing Network Conference Paula J. Lum, MD, MPH and Jacqueline P. Tulsky, MD