david borsook, "opioids for chronic pain: where is the science for the clinician?"
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Opioids for Chronic Pain Where is the Science for the
Clinician David Borsook MD PhD
Professor HMS
1 MGH Center for Law Brain and Behavior
2 MGH Center for Law Brain and Behavior
Relative Status (Addiction and Pain) No Good Treatment for Chronic Pain
3 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Drug War FAIL Drugs Now Kill More People Than Car Accidents httpthefreethoughtprojectcomopiates-killing-people-car-accidents
4 MGH Center for Law Brain and Behavior
Addi
ctio
n Pr
oble
m
MGH Center for Law Brain and Behavior 5
Pain
Pro
blem
25 Mill with severe pain 100 million with chronic pain 2 Mill on opioid addicts
6 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Chronic pain costs US up to $635 billion Prescription Opioid Epidemic $78 billion
Depression chronic pain and suicide by overdose on the edge Cheatle MD Pain Med 2011 Jun12 Suppl 2S43-8
Pain and suicidality insights from reward and addiction neuroscience Elman I Borsook D Volkow ND Prog Neurobiol 2013 Oct1091-27
Ilgen et al 2013
HR how often a particular event happens in one group compared to how often it happens in another group over time
The lifetime prevalence of suicide
attempts was between 5 and 14
in individuals with chronic pain with the prevalence of suicidal
ideation being approximately 20
(Tang and Crane 2006)
7 MGH Center for Law Brain and Behavior
Suic
ide
Common Brain Mechanisms of Chronic Pain and Addiction Elman I Borsook D Neuron 2016 Jan 689(1)11-36
8 MGH Center for Law Brain and Behavior
Neu
ral S
yste
ms
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
2 MGH Center for Law Brain and Behavior
Relative Status (Addiction and Pain) No Good Treatment for Chronic Pain
3 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Drug War FAIL Drugs Now Kill More People Than Car Accidents httpthefreethoughtprojectcomopiates-killing-people-car-accidents
4 MGH Center for Law Brain and Behavior
Addi
ctio
n Pr
oble
m
MGH Center for Law Brain and Behavior 5
Pain
Pro
blem
25 Mill with severe pain 100 million with chronic pain 2 Mill on opioid addicts
6 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Chronic pain costs US up to $635 billion Prescription Opioid Epidemic $78 billion
Depression chronic pain and suicide by overdose on the edge Cheatle MD Pain Med 2011 Jun12 Suppl 2S43-8
Pain and suicidality insights from reward and addiction neuroscience Elman I Borsook D Volkow ND Prog Neurobiol 2013 Oct1091-27
Ilgen et al 2013
HR how often a particular event happens in one group compared to how often it happens in another group over time
The lifetime prevalence of suicide
attempts was between 5 and 14
in individuals with chronic pain with the prevalence of suicidal
ideation being approximately 20
(Tang and Crane 2006)
7 MGH Center for Law Brain and Behavior
Suic
ide
Common Brain Mechanisms of Chronic Pain and Addiction Elman I Borsook D Neuron 2016 Jan 689(1)11-36
8 MGH Center for Law Brain and Behavior
Neu
ral S
yste
ms
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
3 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Drug War FAIL Drugs Now Kill More People Than Car Accidents httpthefreethoughtprojectcomopiates-killing-people-car-accidents
4 MGH Center for Law Brain and Behavior
Addi
ctio
n Pr
oble
m
MGH Center for Law Brain and Behavior 5
Pain
Pro
blem
25 Mill with severe pain 100 million with chronic pain 2 Mill on opioid addicts
6 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Chronic pain costs US up to $635 billion Prescription Opioid Epidemic $78 billion
Depression chronic pain and suicide by overdose on the edge Cheatle MD Pain Med 2011 Jun12 Suppl 2S43-8
Pain and suicidality insights from reward and addiction neuroscience Elman I Borsook D Volkow ND Prog Neurobiol 2013 Oct1091-27
Ilgen et al 2013
HR how often a particular event happens in one group compared to how often it happens in another group over time
The lifetime prevalence of suicide
attempts was between 5 and 14
in individuals with chronic pain with the prevalence of suicidal
ideation being approximately 20
(Tang and Crane 2006)
7 MGH Center for Law Brain and Behavior
Suic
ide
Common Brain Mechanisms of Chronic Pain and Addiction Elman I Borsook D Neuron 2016 Jan 689(1)11-36
8 MGH Center for Law Brain and Behavior
Neu
ral S
yste
ms
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
Drug War FAIL Drugs Now Kill More People Than Car Accidents httpthefreethoughtprojectcomopiates-killing-people-car-accidents
4 MGH Center for Law Brain and Behavior
Addi
ctio
n Pr
oble
m
MGH Center for Law Brain and Behavior 5
Pain
Pro
blem
25 Mill with severe pain 100 million with chronic pain 2 Mill on opioid addicts
6 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Chronic pain costs US up to $635 billion Prescription Opioid Epidemic $78 billion
Depression chronic pain and suicide by overdose on the edge Cheatle MD Pain Med 2011 Jun12 Suppl 2S43-8
Pain and suicidality insights from reward and addiction neuroscience Elman I Borsook D Volkow ND Prog Neurobiol 2013 Oct1091-27
Ilgen et al 2013
HR how often a particular event happens in one group compared to how often it happens in another group over time
The lifetime prevalence of suicide
attempts was between 5 and 14
in individuals with chronic pain with the prevalence of suicidal
ideation being approximately 20
(Tang and Crane 2006)
7 MGH Center for Law Brain and Behavior
Suic
ide
Common Brain Mechanisms of Chronic Pain and Addiction Elman I Borsook D Neuron 2016 Jan 689(1)11-36
8 MGH Center for Law Brain and Behavior
Neu
ral S
yste
ms
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
MGH Center for Law Brain and Behavior 5
Pain
Pro
blem
25 Mill with severe pain 100 million with chronic pain 2 Mill on opioid addicts
6 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Chronic pain costs US up to $635 billion Prescription Opioid Epidemic $78 billion
Depression chronic pain and suicide by overdose on the edge Cheatle MD Pain Med 2011 Jun12 Suppl 2S43-8
Pain and suicidality insights from reward and addiction neuroscience Elman I Borsook D Volkow ND Prog Neurobiol 2013 Oct1091-27
Ilgen et al 2013
HR how often a particular event happens in one group compared to how often it happens in another group over time
The lifetime prevalence of suicide
attempts was between 5 and 14
in individuals with chronic pain with the prevalence of suicidal
ideation being approximately 20
(Tang and Crane 2006)
7 MGH Center for Law Brain and Behavior
Suic
ide
Common Brain Mechanisms of Chronic Pain and Addiction Elman I Borsook D Neuron 2016 Jan 689(1)11-36
8 MGH Center for Law Brain and Behavior
Neu
ral S
yste
ms
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
25 Mill with severe pain 100 million with chronic pain 2 Mill on opioid addicts
6 MGH Center for Law Brain and Behavior
Rela
tive
Stat
es
Chronic pain costs US up to $635 billion Prescription Opioid Epidemic $78 billion
Depression chronic pain and suicide by overdose on the edge Cheatle MD Pain Med 2011 Jun12 Suppl 2S43-8
Pain and suicidality insights from reward and addiction neuroscience Elman I Borsook D Volkow ND Prog Neurobiol 2013 Oct1091-27
Ilgen et al 2013
HR how often a particular event happens in one group compared to how often it happens in another group over time
The lifetime prevalence of suicide
attempts was between 5 and 14
in individuals with chronic pain with the prevalence of suicidal
ideation being approximately 20
(Tang and Crane 2006)
7 MGH Center for Law Brain and Behavior
Suic
ide
Common Brain Mechanisms of Chronic Pain and Addiction Elman I Borsook D Neuron 2016 Jan 689(1)11-36
8 MGH Center for Law Brain and Behavior
Neu
ral S
yste
ms
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
Depression chronic pain and suicide by overdose on the edge Cheatle MD Pain Med 2011 Jun12 Suppl 2S43-8
Pain and suicidality insights from reward and addiction neuroscience Elman I Borsook D Volkow ND Prog Neurobiol 2013 Oct1091-27
Ilgen et al 2013
HR how often a particular event happens in one group compared to how often it happens in another group over time
The lifetime prevalence of suicide
attempts was between 5 and 14
in individuals with chronic pain with the prevalence of suicidal
ideation being approximately 20
(Tang and Crane 2006)
7 MGH Center for Law Brain and Behavior
Suic
ide
Common Brain Mechanisms of Chronic Pain and Addiction Elman I Borsook D Neuron 2016 Jan 689(1)11-36
8 MGH Center for Law Brain and Behavior
Neu
ral S
yste
ms
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
Common Brain Mechanisms of Chronic Pain and Addiction Elman I Borsook D Neuron 2016 Jan 689(1)11-36
8 MGH Center for Law Brain and Behavior
Neu
ral S
yste
ms
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
9
Decrease in Gray Matter Volume in
DLPC
Altered Brain Network
Connectivity
Structural Changes in
Nerve Tracts
Altered Brain Chemistry
Normal Brain
Chronic Pain Brain
Altered Behaviors Sensory (eg spontaneous pain at rest)
Affective (eg anxiety depression suicide addiction) Cognitive (eg decreased attention) Emotional (eg reward deficit state)
MGH Center for Law Brain and Behavior
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
00014
00012
00010
Amyg
dala
Vol
ume
(Nor
mal
ized)
Left Right
Opioid-Dependent Patients
Controls
p lt 005
Amygdala
Upadhyay at al 2010 Brain
10
1
MGH Center for Law Brain and Behavior
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
Stria Terminalis
p lt 005
p lt 0005
Corona Radiata
Opioid-Dependent Subjects
Control Subjects
Mean FA (Opioid-Dependent Subjects) Mean FA (Control Subjects)
FA
Whole Brain White Matter
03 06
123456789
10
Subj
ects
03 05
123456789
10
Uncinate Fasciculus
Subj
ects
FA
Single Subject DTI Data
Upadhyay at al 2010 Brain
11
2
MGH Center for Law Brain and Behavior
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
12
Interoception Fc with Anterior Insula
Reward Circuitry Fc Nucleus Accumbens
Upadhyay at al 2010 Brain
3
MGH Center for Law Brain and Behavior
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
Problem 1 No good treatment Problem 2 A suffering group (~ 100 million Americans) Problem 3 No Good Science that helps pain management CDC Guidelines Problem 4 Politics over Societal Well-being
13 MGH Center for Law Brain and Behavior
The
Clin
icia
ns D
ilem
ma
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
A patient long before becoming the subject of medical scrutiny is at first simply a storyteller a narrator of suffering-a traveler who has visited the kingdom of the ill To relieve an illness one must begin then by understanding the story The Emperor of All Maladies Siddhartha Mukherjee Prescription opioid addiction and chronic pain More than a feeling Ling W Drug Alcohol Depend 2017 Apr 1173 Suppl 1S73-S74
14 MGH Center for Law Brain and Behavior
I will apply for the benefit of the sick all measures which are required avoiding those twin traps of overtreatment and therapeutic nihilism
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
Cochrane Reports
Lynch and Watson 2006
Drug
Effi
cacy
15 MGH Center for Law Brain and Behavior
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
-
MMWR Morb Mortal Wkly Rep 2017 Mar 1766(10)265-269 doi 1015585mmwrmm6610a1 Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States 2006-2015 Shah A Hayes CJ Martin BC Because long-term opioid use often begins with treatment of acute pain (1) in March 2016 the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2) However data quantifying the transition from acute to chronic opioid use are lacking The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy the second prescription 700 morphine milligram equivalents cumulative dose and first prescriptions with 10- and 30-day supplies By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics these findings might inform opioid prescribing practices
Drug
Dat
a
16 MGH Center for Law Brain and Behavior
The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
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The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction abuse or other serious side effects However the evidence supporting these conclusions is weak and longer-term studies are needed to identify the patients who are most likely to benefit from treatment
Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function Evidence supports a dose-dependent risk for serious harms
The effectiveness and risks of long-term opioid therapy for chronic pain a systematic review for a National Institutes of Health Pathways to Prevention Workshop Chou R Turner JA Devine EB Hansen RN Sullivan SD Blazina I Dana T Bougatsos C Deyo RA Ann Intern Med 2015 Feb 17162(4)276-86
Opioids compared with placebo or other treatments for chronic low back pain an update of the Cochrane Review Chaparro LE Furlan AD Deshpande A Mailis-Gagnon A Atlas S Turk DC Spine (Phila Pa 1976) 2014 Apr 139(7)556-63
Drug
Dat
a
17 MGH Center for Law Brain and Behavior
Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
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Miti
gatio
n St
rate
gies
18 MGH Center for Law Brain and Behavior
3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
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3 to 4 of the adult population (96 million to 115 million persons) were prescribed longer-term opioid therapy
In 2014 alone US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers
More than a third (37) of the 44000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids heroin accounted for an additional 19
Rela
tive
Stat
es
19 MGH Center for Law Brain and Behavior
1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
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1 Do opioids produce addiction in all pain patients 11 If yes what are the consequences 12 If no how do we deal with these patients
2 Data Data Data Where is it 21 Epidemiologic Data (doing better) 22 Research Data (doing better) 33 Public Policy (doing better)
3 What are the cost-benefit issues 31 pure drug free society - billions spent on the drug war 32 suffering in chronic pain 4 A National Imperative 41 What are the realistic timelines to new non-addictive medications for symptomatic Rx the clinic
20 MGH Center for Law Brain and Behavior
Reso
lutio
ns
- Opioids for Chronic Pain Where is the Science for the Clinician
- Slide Number 2
- Slide Number 3
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