3212018

1

PRACTICAL PAIN

MANAGEMENT

Anthony Dragovich MD

Blue Ridge Pain

Management

Salem VA

Pain Opioids and the

Quest for the Holy Grail

DISCLOSURE STATEMENT OF FINANCIAL INTEREST

bull I Anthony Dragovich DO NOT have a financial interestarrangement or affiliation with one or more

organizations that could be perceived as a real or apparent conflict of interest in the context of the subject

of this presentation

DISCLOSURE STATEMENT OF UNAPPROVEDINVESTIGATIVE USE

I Anthony Dragovich

DO NOT anticipate discussing the unapprovedinvestigative use of a

commercial productdevice during this activity or presentation

OBJECTIVES

bull Contrast our current thoughts about pain with historical

ideas

bull Recognize risks associated with all pain treatments

bull Understand opioid use in elderly patients

bull Examine ways pharmacists can expand their practice to

provide improved patient care

PAIN MEDICINE

THE TREATMENT OF

HUMAN SUFFERING

How do you balance the treatment of

human suffering versus the very real

risk of causing patient harm

Remember Primum non nocere

THE HOLY GRAIL

Happiness eternal youth or

sustenance in infinite

abundance

Merium-Webster Definition of Holy Grail Merium-

Webster Retrieved December 18 2017

3212018

2

PARADOX IS THE ONLY BOX LARGE ENOUGH TO CONTAIN THE TRUTH

PAIN OVERVIEW

Descartes(1664)

PERIPHERAL AND CENTRAL PATHWAYS FOR PAIN

TransductionModulation

Unmet Needs

RISKS OF MEDICAL TREATMENTS

3212018

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THE TREATMENT OF PAIN IS HIGH RISKLANAS AAM J GASTROENTEROLOGY 2005 AUG100(8)1685-93

A NATIONWIDE STUDY OF MORTALITY ASSOCIATED WITH HOSPITAL ADMISSION DUE TO SEVERE GASTROINTESTINAL EVENTS AND THOSE ASSOCIATED WITH NONSTEROIDAL ANTIINFLAMMATORY DRUG USE

bull 26 general hospitals serving 7901198 people and database

from 197 general hospitals representative of the 269

hospitals in the Spanish National Health System

bull Hospital admission for GI event 1219 events100000

personsyear

bull Mortality rate 153 deaths100000 NSAIDaspirin users

Inflammation and depression combined use of selective serotonin

reuptake inhibitors and NSAIDs or paracetamol and psychiatric outcomesOle Koumlhler12 Liselotte Petersen23 Ole Mors12 and Christiane Ga Brain Behav 2015 Aug 5(8)

A Risk Score for Predicting Long-Term Mortality

Following Coronary Artery Bypass Graft SurgeryChuntao Wu MD PhD1 Fabian T Camacho MS1 Andrew S Wechsler MD2 Stephen Lahey MD3 Alfred T Culliford MD4 Desmond Jordan MD5

Jeffrey P Gold MD6 Robert S D Higgins MD7 Craig R Smith MD8 and Edward L Hannan PhD9 Circulation 2012 May 22 125(20) 2423ndash2430

RISK FACTORS ASSOCIATED WITH MORTALITY AFTER ROUX-EN-Y GASTRIC BYPASS SURGERY

PETER BENOTTI MD G CRAIG WOOD MS DEBORAH A WINEGAR PHDsect ANTHONY T PETRICK MDDagger CHRISTOPHER D

STILL DO GEORGE ARGYROPOULOS PHDdagger AND GLENN S GERHARD MDdagger

ANN SURG 2014 JAN 259(1) 123ndash130Surgery Type No Surgeries No Deaths Within 30 Days ()

Gastric bypass (Roux-en-Y) 81751 123 (15)

Gastric banding adjustable 63669 13 (02)

Sleeve gastrectomy 7323 10 (13)

BPD with duodenal switch 1660 6 (36)

Gastric bypass banded 1407 1 (07)

Other 1749 5

TOTAL 157559 158 (1)

Bariatric Surgical Procedures and 30-Day Mortality Rate

RISKS ASSOCIATED WITH NO PAIN TREATMENT

3212018

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THE TREATMENT OF PAIN IS HIGH RISKLANAS AAM J GASTROENTEROLOGY 2005 AUG100(8)1685-93

A NATIONWIDE STUDY OF MORTALITY ASSOCIATED WITH HOSPITAL ADMISSION DUE TO SEVERE GASTROINTESTINAL EVENTS AND THOSE ASSOCIATED WITH NONSTEROIDAL ANTIINFLAMMATORY DRUG USE

bull 26 general hospitals serving 7901198 people and database

from 197 general hospitals representative of the 269

hospitals in the Spanish National Health System

bull Hospital admission for GI event 1219 events100000

personsyear

bull Mortality rate 153 deaths100000 NSAIDaspirin users

Inflammation and depression combined use of selective serotonin

reuptake inhibitors and NSAIDs or paracetamol and psychiatric outcomesOle Koumlhler12 Liselotte Petersen23 Ole Mors12 and Christiane Ga Brain Behav 2015 Aug 5(8)

A Risk Score for Predicting Long-Term Mortality

Following Coronary Artery Bypass Graft SurgeryChuntao Wu MD PhD1 Fabian T Camacho MS1 Andrew S Wechsler MD2 Stephen Lahey MD3 Alfred T Culliford MD4 Desmond Jordan MD5

Jeffrey P Gold MD6 Robert S D Higgins MD7 Craig R Smith MD8 and Edward L Hannan PhD9 Circulation 2012 May 22 125(20) 2423ndash2430

RISK FACTORS ASSOCIATED WITH MORTALITY AFTER ROUX-EN-Y GASTRIC BYPASS SURGERY

PETER BENOTTI MD G CRAIG WOOD MS DEBORAH A WINEGAR PHDsect ANTHONY T PETRICK MDDagger CHRISTOPHER D

STILL DO GEORGE ARGYROPOULOS PHDdagger AND GLENN S GERHARD MDdagger

ANN SURG 2014 JAN 259(1) 123ndash130Surgery Type No Surgeries No Deaths Within 30 Days ()

Gastric bypass (Roux-en-Y) 81751 123 (15)

Gastric banding adjustable 63669 13 (02)

Sleeve gastrectomy 7323 10 (13)

BPD with duodenal switch 1660 6 (36)

Gastric bypass banded 1407 1 (07)

Other 1749 5

TOTAL 157559 158 (1)

Bariatric Surgical Procedures and 30-Day Mortality Rate

RISKS ASSOCIATED WITH NO PAIN TREATMENT

3212018

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INCREASED MORTALITY DUE TO CHRONIC WIDESPREAD PAIN

Individuals with widespread chronic pain showed an increased mortality

risk (hazard ratio HR = 195 CI 126-303) compared to the group

without chronic pain

Death due to cardiovascular disease accounted for the increased

mortality

Increased mortality among individuals with chronic widespread

pain relates to lifestyle factors a prospective population-based

study Andersson HI1 Disabil Rehabil200931(24)1980-7

Suicidal Ideation 43 times (95 CI 28 67) more likely

Plan Suicide 46 times (95 CI 25 84) more likely

Attempt suicide 65 times (95 CI 35 120) more likely

Chronic Pain and Suicidal Thoughts Plans and

Attempts in the United StatesMark A Ilgen ab Kara Zivinab Ryan J McCammonb and Marcia ValensteinabGen Hosp Psychiatry 2008 30(6) 521ndash527

HEALING IS AN ART

MEDICINE IS A SCIENCE

HEALTHCARE IS A BUSINESS

THOSE WHO CANNOT REMEMBER THE PAST ARE CONDEMNED TO REPEAT IT

GEORGE SANTAYANA REASON IN COMMON SENSE 1905

Harrison Act of 1914

Porter J Jick H Addiction rare in patients treated with narcotics

N Engl J Med 1980 302123

Culture Must be Consideredhellip BREAKING THE NEWS OR FUELING THE EPIDEMIC TEMPORAL ASSOCIATION BETWEEN NEWS MEDIA REPORT VOLUME AND

OPIOID-RELATED MORTALITYDASGUPTA N ET AL PLOS ONE 2009 NOV 184(11)E7758

3212018

5

So Why do we use opioids at all

The Art of Negative Capability

AMERICAN OPIOID HISTORY

bull Widespread use of Morphine during and after US Civil War

bull Harrison Act 1914-dramatic curtailing of opioid availability

bull Gradual return of opioid availability during 20th Century

bull Explosive rise in opioid use in the past 20 years--94 billion dosage units prescribed per year Katz Clin J Pain 2007

RISK OF ADDICTION

bull No one really knows

bull DSMIV criteria donrsquot apply to prescription opioids

bull There is not an accepted definition of addiction for patients with chronic

pain

AuthorJournal Year Addiction Rate article type

Ives et al BMC Health Serv Res 2006

32 prospective survey

Adams et al J Pain Symp Manag 2006

49 prospective registry

Fishbain et al

Clin J Pain 1992

189 systematic review

Portenoy and Foley Pain 1986

5 case series

MINIMAL DATA ON LONG TERM OUTCOMES

bull Epidemiologic study from Denmarkbull Liberal opioid prescription policy

bull Overall worse pain higher healthcare utilization and lower

activity levels in opioid treated patients versus a matched cohort

not using opioids Eriksen Pain

2006

PORTENOY ET AL PROSPECTIVE 3 YEAR REGISTRY STUDY

bull 233 patients open label oxycodone CR

bull 133 discontinued study prematurely

bull Of the 100 remaining in the study 90 had at least a 1 point pain increase and 65 had at least a 2 point pain increase

bull At 1 year 41 (58140) developed tolerance(either dose escalation or worse pain)

bull At 1 year 46(65140) had no evidence of tolerance

bull Conservatively if all drop-outs are considered failures 279 (65233) were on stable doses at 1 year

bull At 3 years 31 (1239) did not show tolerance--5(12233) conservatively

bull At 3 years 21 (839) had increased pain with dose increases

SHORT-TERM EFFICACYBALLANTYNE PAIN PHYSICIAN 2007

KALSO PAIN 2004

bull 18 Randomized controlled trialsbull All studies performed since 1990

bull 1418 with fu less than 12 weeks

bull Longest fu 32 weeks

bull Summary-opioids are effective for all types of pain in the short-term

bull Opioids are effective treatment for neuropathic pain if higher doses are used

bull Opioids are the most effective short term pain medication available

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THE PRESENT REALITY OPIOID DEATHS CONTINUE TO INCREASE

bull Nearly 24 million people in the United States have a substance use

disorder (SUD) related to prescription opioids

bull Approximately a half million people have an SUD related to heroin

bull There has been a significant increase in hospitalizations for opioid

misuse

wwwdhpvirginiagov

Dasgupta N Creppage K Austin A Ringwalt C Sanford C Proescholdbell SK2014 Observed transition from opioid analgesic deaths toward heroin DrugAlcohol Depend 145

238ndash241

Heroin in North Carolina

Date of download 982015Copyright copy 2015 American Medical Association

All rights reserved

From The Changing Face of Heroin Use in the United States A

Retrospective Analysis of the Past 50 YearsJAMA Psychiatry 201471(7)821-826 doi101001jamapsychiatry2014366

WHAT ABOUT ILLICIT OPIOIDSOPIATES

bull No signs of slowing in the heroin initiation group

bull Cicero et al Addict Behav 2017 Nov

Heroin initiation OxyHydrocodone

2005 87 424423

2015 335 241278

Date of download 742017Copyright 2017 American Medical Association

All Rights Reserved

From New Persistent Opioid Use After Minor and Major Surgical Procedures in US AdultsJAMA Surg 2017152(6)e170504 doi101001jamasurg20170504

bull Risk of new ongoing persistent opioid use reaches ~6

bull Most likely peri-surgical complication

3212018

7

Date of download 742017Copyright 2017 American Medical Association

All Rights Reserved

From New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults

Brummett Cet al JAMA Surg 2017152(6)e170504

Incidence of New Persistent Opioid Use by Surgical Condition The incidence of new persistent opioid use was similar between the

2 groups (minor surgery 59 vs major surgery 65 odds ratio 112 SE 006 95 CI 101-124) By comparison the incidence

in the nonoperative control group was only 04

bull No difference in minor or

major procedures in terms of

risk of ongoing opioid use

bull What are implications for pre

and perioperative use of

opioids

bull Rx writing management for

convenience

bull Persistent opioid refills are at least in part due to

Anesthesiologists Acute Pain Services and Surgeons

bull With more than 50 million ambulatory procedures

yearly more than 2 million persons may become

persistent opioid users each year

bull Ongoing use may be unrelated to ongoing pain

suggesting need to evaluate other reasons for use

Conclusion Persistent Opioid Study

Strong recommendations for use

Gapabentin 1200ndash3600 mg in three divided doses First line

Gabapentin extended release or enacarbil 1200ndash3600 mg in two divided doses First line

Pregabalin 300ndash600 mg in two divided doses First line

Serotonin-noradrenaline reuptake inhibitors duloxetine or venlafaxine First line

Tricyclic antidepressants 25ndash150 mg once a day or in two divided doses

First linedagger

Weak recommendations for use

Capsaicin 8 patches 1-4 patches to the painful area for 30-60 min every 3 months Second line

Lidocaine patches 1-3 patches to the region of pain once a day for up to 12 h Second line

Tramadol 200ndash400 mg in two (tramadol extended release) or three divided doses Second line

Botulinum toxin A sq ) 50ndash200 units to the painful area every 3 months Third line

Strong opioids Individual titration

Third line

Neuropathic Pain Guidelines

Finnerup NB Attal N Haroutounian S et al Pharmacotherapy for neuropathic pain in adults a systematic review and meta-analysis The Lancet Neurology 201514(2) 162 - 173

Efficacy and Safety of Opioids in Older Patients

Systematic review RCTrsquos with ages gt60 years compared with

placebo for MSK pain

bull 23 RCTrsquos included for meta-analysis with mean differences

odds ratios and confidence intervals

bull Opioids had very small effect on pain intensity SMD -027 95

CI (-033-022) and improved function -027 95 CI (-036mdash

018)

bull Odds for an adverse event were 3 fold higher

Megale RZ Deveza LA Blyth FM et al Efficacy and

safety of oral and transdermal opioid analgesics for

musculoskeletal pain in older adults a systematic

review of randomized placebo-controlled trials J Pain

2017

Efficacy of opioids for older adults

bull Based on results of multiple RCTrsquos in MSK painolder adults doses of

opioids ranging from 10-300 mg oral morphine equivalents had a

small benefit from opioids equalling approximately 68 mm on

100 mm scale and this coincides with other studies from younger

adults

bull On function opioids produced about a 056 units change on a 10

point WOMAC scale

bull Overall these small benefits may be outweighed by risks of adverse

events

Megale RZ Deveza LA Blyth FM et al Efficacy and safety of oral and transdermal opioid

analgesics for musculoskeletal pain in older adults a systematic review of randomized

placebo-controlled trials J Pain

Effect of Opioid vs Nonopioid Medications on Pain-

Related Function in Patients With Chronic Back Pain

or Hip or Knee Osteoarthritis Pain The SPACE

Randomized Clinical TrialKrebs EE12 Gravely A1 Nugent S1 Jensen AC1 DeRonne B1 Goldsmith ES13 Kroenke K456 Bair

MJ456 Noorbaloochi S12 JAMA 2018 Mar 6319(9)872-882

3212018

6

THE PRESENT REALITY OPIOID DEATHS CONTINUE TO INCREASE

bull Nearly 24 million people in the United States have a substance use

disorder (SUD) related to prescription opioids

bull Approximately a half million people have an SUD related to heroin

bull There has been a significant increase in hospitalizations for opioid

misuse

wwwdhpvirginiagov

Dasgupta N Creppage K Austin A Ringwalt C Sanford C Proescholdbell SK2014 Observed transition from opioid analgesic deaths toward heroin DrugAlcohol Depend 145

238ndash241

Heroin in North Carolina

Date of download 982015Copyright copy 2015 American Medical Association

All rights reserved

From The Changing Face of Heroin Use in the United States A

Retrospective Analysis of the Past 50 YearsJAMA Psychiatry 201471(7)821-826 doi101001jamapsychiatry2014366

WHAT ABOUT ILLICIT OPIOIDSOPIATES

bull No signs of slowing in the heroin initiation group

bull Cicero et al Addict Behav 2017 Nov

Heroin initiation OxyHydrocodone

2005 87 424423

2015 335 241278

Date of download 742017Copyright 2017 American Medical Association

All Rights Reserved

From New Persistent Opioid Use After Minor and Major Surgical Procedures in US AdultsJAMA Surg 2017152(6)e170504 doi101001jamasurg20170504

bull Risk of new ongoing persistent opioid use reaches ~6

bull Most likely peri-surgical complication

3212018

7

Date of download 742017Copyright 2017 American Medical Association

All Rights Reserved

From New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults

Brummett Cet al JAMA Surg 2017152(6)e170504

Incidence of New Persistent Opioid Use by Surgical Condition The incidence of new persistent opioid use was similar between the

2 groups (minor surgery 59 vs major surgery 65 odds ratio 112 SE 006 95 CI 101-124) By comparison the incidence

in the nonoperative control group was only 04

bull No difference in minor or

major procedures in terms of

risk of ongoing opioid use

bull What are implications for pre

and perioperative use of

opioids

bull Rx writing management for

convenience

bull Persistent opioid refills are at least in part due to

Anesthesiologists Acute Pain Services and Surgeons

bull With more than 50 million ambulatory procedures

yearly more than 2 million persons may become

persistent opioid users each year

bull Ongoing use may be unrelated to ongoing pain

suggesting need to evaluate other reasons for use

Conclusion Persistent Opioid Study

Strong recommendations for use

Gapabentin 1200ndash3600 mg in three divided doses First line

Gabapentin extended release or enacarbil 1200ndash3600 mg in two divided doses First line

Pregabalin 300ndash600 mg in two divided doses First line

Serotonin-noradrenaline reuptake inhibitors duloxetine or venlafaxine First line

Tricyclic antidepressants 25ndash150 mg once a day or in two divided doses

First linedagger

Weak recommendations for use

Capsaicin 8 patches 1-4 patches to the painful area for 30-60 min every 3 months Second line

Lidocaine patches 1-3 patches to the region of pain once a day for up to 12 h Second line

Tramadol 200ndash400 mg in two (tramadol extended release) or three divided doses Second line

Botulinum toxin A sq ) 50ndash200 units to the painful area every 3 months Third line

Strong opioids Individual titration

Third line

Neuropathic Pain Guidelines

Finnerup NB Attal N Haroutounian S et al Pharmacotherapy for neuropathic pain in adults a systematic review and meta-analysis The Lancet Neurology 201514(2) 162 - 173

Efficacy and Safety of Opioids in Older Patients

Systematic review RCTrsquos with ages gt60 years compared with

placebo for MSK pain

bull 23 RCTrsquos included for meta-analysis with mean differences

odds ratios and confidence intervals

bull Opioids had very small effect on pain intensity SMD -027 95

CI (-033-022) and improved function -027 95 CI (-036mdash

018)

bull Odds for an adverse event were 3 fold higher

Megale RZ Deveza LA Blyth FM et al Efficacy and

safety of oral and transdermal opioid analgesics for

musculoskeletal pain in older adults a systematic

review of randomized placebo-controlled trials J Pain

2017

Efficacy of opioids for older adults

bull Based on results of multiple RCTrsquos in MSK painolder adults doses of

opioids ranging from 10-300 mg oral morphine equivalents had a

small benefit from opioids equalling approximately 68 mm on

100 mm scale and this coincides with other studies from younger

adults

bull On function opioids produced about a 056 units change on a 10

point WOMAC scale

bull Overall these small benefits may be outweighed by risks of adverse

events

Megale RZ Deveza LA Blyth FM et al Efficacy and safety of oral and transdermal opioid

analgesics for musculoskeletal pain in older adults a systematic review of randomized

placebo-controlled trials J Pain

Effect of Opioid vs Nonopioid Medications on Pain-

Related Function in Patients With Chronic Back Pain

or Hip or Knee Osteoarthritis Pain The SPACE

Randomized Clinical TrialKrebs EE12 Gravely A1 Nugent S1 Jensen AC1 DeRonne B1 Goldsmith ES13 Kroenke K456 Bair

MJ456 Noorbaloochi S12 JAMA 2018 Mar 6319(9)872-882

3212018

7

Date of download 742017Copyright 2017 American Medical Association

All Rights Reserved

From New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults

Brummett Cet al JAMA Surg 2017152(6)e170504

Incidence of New Persistent Opioid Use by Surgical Condition The incidence of new persistent opioid use was similar between the

2 groups (minor surgery 59 vs major surgery 65 odds ratio 112 SE 006 95 CI 101-124) By comparison the incidence

in the nonoperative control group was only 04

bull No difference in minor or

major procedures in terms of

risk of ongoing opioid use

bull What are implications for pre

and perioperative use of

opioids

bull Rx writing management for

convenience

bull Persistent opioid refills are at least in part due to

Anesthesiologists Acute Pain Services and Surgeons

bull With more than 50 million ambulatory procedures

yearly more than 2 million persons may become

persistent opioid users each year

bull Ongoing use may be unrelated to ongoing pain

suggesting need to evaluate other reasons for use

Conclusion Persistent Opioid Study

Strong recommendations for use

Gapabentin 1200ndash3600 mg in three divided doses First line

Gabapentin extended release or enacarbil 1200ndash3600 mg in two divided doses First line

Pregabalin 300ndash600 mg in two divided doses First line

Serotonin-noradrenaline reuptake inhibitors duloxetine or venlafaxine First line

Tricyclic antidepressants 25ndash150 mg once a day or in two divided doses

First linedagger

Weak recommendations for use

Capsaicin 8 patches 1-4 patches to the painful area for 30-60 min every 3 months Second line

Lidocaine patches 1-3 patches to the region of pain once a day for up to 12 h Second line

Tramadol 200ndash400 mg in two (tramadol extended release) or three divided doses Second line

Botulinum toxin A sq ) 50ndash200 units to the painful area every 3 months Third line

Strong opioids Individual titration

Third line

Neuropathic Pain Guidelines

Finnerup NB Attal N Haroutounian S et al Pharmacotherapy for neuropathic pain in adults a systematic review and meta-analysis The Lancet Neurology 201514(2) 162 - 173

Efficacy and Safety of Opioids in Older Patients

Systematic review RCTrsquos with ages gt60 years compared with

placebo for MSK pain

bull 23 RCTrsquos included for meta-analysis with mean differences

odds ratios and confidence intervals

bull Opioids had very small effect on pain intensity SMD -027 95

CI (-033-022) and improved function -027 95 CI (-036mdash

018)

bull Odds for an adverse event were 3 fold higher

Megale RZ Deveza LA Blyth FM et al Efficacy and

safety of oral and transdermal opioid analgesics for

musculoskeletal pain in older adults a systematic

review of randomized placebo-controlled trials J Pain

2017

Efficacy of opioids for older adults

bull Based on results of multiple RCTrsquos in MSK painolder adults doses of

opioids ranging from 10-300 mg oral morphine equivalents had a

small benefit from opioids equalling approximately 68 mm on

100 mm scale and this coincides with other studies from younger

adults

bull On function opioids produced about a 056 units change on a 10

point WOMAC scale

bull Overall these small benefits may be outweighed by risks of adverse

events

Megale RZ Deveza LA Blyth FM et al Efficacy and safety of oral and transdermal opioid

analgesics for musculoskeletal pain in older adults a systematic review of randomized

placebo-controlled trials J Pain

Effect of Opioid vs Nonopioid Medications on Pain-

Related Function in Patients With Chronic Back Pain

or Hip or Knee Osteoarthritis Pain The SPACE

Randomized Clinical TrialKrebs EE12 Gravely A1 Nugent S1 Jensen AC1 DeRonne B1 Goldsmith ES13 Kroenke K456 Bair

MJ456 Noorbaloochi S12 JAMA 2018 Mar 6319(9)872-882

3212018

8

SO WHAT DID WE DO THE ART OF HEALING

CASE SFC JUSTIN MINYARD EFFICACY OF TREATMENTS

PSYCHOLOGICALLY AT RISK PATIENT DONrsquoT HAVE TOLERANCE FOR FAILURE

0

10

20

30

40

50

60

70

80

90

gt 3 months after

diagnosis

lt3 months from

diagnosis

Success rate after

discectomy

Normal At Risk Distressed

MANY OPINIONShellipLITTLE FACTS

GUIDELINE SOUP

PLACEBO EFFECT DOES ANYTHING WORK

DOES EVERYTHING WORK

Cochrane review of placebo interventions for all clinical conditionsHrobjartsson A Gotzsche PC Cochrane Library 2004

118 placebo controlled clinical trials were evaluated (7453 patients)

A beneficial effect was present for pain (SMD) -025 (95 CI -035 to -016)

PLACEBO TREATMENTS ARE PAIN TREATMENTS

HOW DOES PLACEBO WORK

bull Mediated by the endogenous opioid system Levine et al Lancet 1978

bull Reversed by naloxone Levine et al Nature 1978

bull Non-opioid mechanisms also involved Amanzio and Benedetti J Neurosci 1999

bull HIGH DEGREE OF VARIABILITY CORRELATED TO THE INTERNAL AFFECTIVE STATE OF THE PATIENT

bull Zubieta Brain Behavior and Immunity 2006

3212018

9

COVARIATION OF CORTEX AND BRAINSTEM ACTIVITY PETROVIC ET AL SCIENCE 2002 HIGH INDIVIDUAL VARIABILITY

PETROVIC ET AL SCIENCE 2002

Pooled mean difference Immediate pain in trials NSAID v placebo

Pinto R Z et al BMJ 2012344bmje497

copy2012 by British Medical Journal Publishing Group

CONCLUSIONS FROM PINTO ET AL

Overall evidence quality low for efficacy of NSAIDs

corticosteroids and anticonvulsants for sciatica

The favorable effects of NSAIDs corticosteroids

antidepressants muscle relaxants opioids lacking for

immediate term

Some evidence for gabapentin oral steroids in short

term

Figure 4 Results of the Meta-analysis of Intermediate-term Trial Efficacy Data are presented as mean

(95 confidence interval [CI]) differences in posttreatment pain intensity (on a visual analog scale

from 0-100) between active treatment and placebo (fixed-effects model)

Copyright restrictions may apply

Efficacy and Safety of Opioid Agonists in the Treatment of

Neuropathic Pain of Nonmalignant Origin Systematic Review and

Meta-analysis of Randomized Controlled TrialsEisenberg E et al JAMA 20052933043-3052

Arthroscopic partial meniscectomy versus sham

surgery for a degenerative meniscal tearSihvonen R1 Paavola M Malmivaara A Itaumllauml A Joukainen A Nurmi H Kalske J Jaumlrvinen TL

Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group

Multicenter randomized double-blind sham-controlled trial in 146 patients 35 to 65 years of age who

had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis 12 Month

StudyPatients were randomly assigned to arthroscopic partial meniscectomy or sham surgery

RESULTS

In the intention-to-treat analysis there were no significant between-group differences in the change from baseline

to 12 months in any primary outcome The mean changes (improvements) in the primary outcome measures were as

follows Lysholm score 217 points in the partial-meniscectomy group as compared with 233 points in the sham-

surgery group

CONCLUSIONS

In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus

tear the outcomes after arthroscopic partial

meniscectomy were no better than those after a

sham surgical procedure

3212018

10

ALL TREATMENTS HAVE A SIGNIFICANT FAILURE RATE

bull Surgery fails in 30-50

bull Comprehensive rehabilitation fails in 25-50 (30 have

surgery by 2 years)

bull Acupuncture fails in 55+

bull ESIs fail in 45

bull Facet radiofrequency ablation fails in 30

Original Article

A Randomized Trial of Epidural GlucocorticoidInjections for Spinal Stenosis

Janna L Friedly MD Bryan A Comstock MS Judith A Turner PhD Patrick J Heagerty PhD Richard A Deyo MD MPH Sean D Sullivan PhD Zoya

Bauer MD PhD Brian W Bresnahan PhD Andrew L Avins MD MPH Srdjan S Nedeljkovic MD David R Nerenz PhD Christopher Standaert MD Larry Kessler PhD Venu Akuthota MD Thiru Annaswamy MD Allen Chen MD

MPH Felix Diehn MD William Firtch MD Frederic J Gerges MD Christopher Gilligan MD Harley Goldberg MD David J Kennedy MD Shlomo Mandel MD

Mark Tyburski MD William Sanders MD David Sibell MD Matthew Smuck MD Ajay Wasan MD Lawrence Won MD and Jeffrey G Jarvik MD

MPH

N Engl J Med Volume 371(1)11-21 July 3 2014

ESI AND SPINAL STENOSIS

bull Two outcomes RMDQ and NRS analgesia

bull Intention to treat with crossover allowed at 6 weeks

bull No differences in primary outcomes at 6 weeks small clinically

insignificant improvement in steroid groups at 3 weeks

bull Interlaminar injections of steroid had significant advantages for

function and pain at 3 weeks but effect lost at 6 weeks

Friedly JL Comstock BA Turner JA et al NEJM

2014 111-21

GENICULAR RF CHRONIC KNEE PAIN

bull Randomized double blind study 38 elderly knee OA patients

resistant to other therapies

bull Primary outcomes mean changes from baseline knee pain

as measured by VAS at 1 4 and 12 weeks and achieving at

least 50 knee pain relief at 12 weeks

bull Secondary outcomes functional changes patient

satisfaction and adverse effects

copy 2011 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Choi W-J Hwang S-J Song J-G et al Radiofrequency treatment relieves chronic knee osteoarthritis pain A double-blind randomized controlled trialPain 2011 152(3)481-487

2

Choi W-J Hwang S-J Song J-G et al Radiofrequency treatment relieves chronic knee osteoarthritis pain A double-blind randomized controlled trialPain 2011 152(3)481-487

3212018

11

2

Fig 2

Choi W-J Hwang S-J Song J-G et al Radiofrequency treatment relieves chronic knee osteoarthritis pain A double-blind randomized controlled trialPain2011 152(3)481-487

FUNCTIONAL IMAGING AND CBT

bull Different psychological and non-pharma techniques have effects on

somatosensory processing

bull Distraction CBT guided imagery biofeedback exercise etc may

change pain expression through modulatory activations in eg

dorsolateral prefrontal cortex

bull This may be demonstrated with fMRI

Jensen KB Berna C Loggia M Wasan AD Edwards RR Gollub RL

Neuroscience Letters 2012 520156 - 164

Jensen KB Berna C Loggia M Wasan AD Edwards RR Gollub RL

Neuroscience Letters 2012 520156 - 164

THE USE OF FUNCTIONAL NEUROIMAGING TO EVALUATE CBT AND OTHER NON-PHARMACOLOGICAL TREATMENTS FOR CLINICAL PAIN FMRI AFTER CBT IN FIBROMYALGIA

bull 152 patients with causalgia or CRPS 1complex regional pain

syndrome

bull Percentage of patients with ge50 pain relief greater in the DRG

treated (812) than in the SCS arm (557 P lt 0001) at 3 months

bull No difference in serious adverse events between groups

bull Deer TR Levy RM Kramer J et al Dorsal root ganglion stimulation yielded higher

treatment success rate for complex regional pain syndrome and causalgia at 3 and 12

months a randomized comparative trial Pain 2017158669-81

Accurate Study

3212018

12

GERMAN ACUPUNCTURE TRIALS (GERAC) FOR CHRONIC LOW BACK PAIN RANDOMIZED

MULTICENTER BLINDED PARALLEL-GROUP TRIAL WITH 3 GROUPS

HAAKE M ET ALARCH INTERN MED 2007 SEP 24167(17)1892-8

Acupuncture Sham Conservative

therapy

Success Rate 476 442 274

Success defined as 33 improvement in pain scores

12 improvement in disability

Randomized double blind trial 1162 patients 10 thirty

minute sessions 2 per week partial responders

received 5 extra sessions

PATIENT SATISFACTION WITH CHRONIC OPIOID TREATMENT FOLLOWING CURRENT

GUIDELINESTHE ART OF HEALING

bull 96 overall provider satisfaction rate

bull Predictors of satisfaction with multivariate analysis

bull ldquoListened to you carefullyrdquo

bull ldquoTreated you with courtesy and respectrdquo

bull ldquoHelped you with your problemrdquohelliphellipThis did not correlate with actual improvement only

the perception of help

Dragovich et al Pain Practice 2017

DETERMINANTS OF PATIENT SATISFACTION IN A PRIVATE PRACTICE PAIN MANAGEMENT CLINIC

DRAGOVICH ET AL PAIN PRACTICE MARCH 2017

Table 4 Patient Progress Assessment

n

Greatly

Improved Improved

Has not

Changed Worsened

General energy level 97 9 40 47 3

Ability to perform activities

of daily living97 12 41 41 5

Ability to perform activities

such as sports and leisure98 9 27 57 7

Mood 85 49 39 12

Level of stress 97 9 33 43 14

Sleep 98 10 32 42 16

HOW CAN PHARMACISTS HELP

CLINICAL BENEFITS OF AN EMBEDDED PHARMACIST

Chart Reviews for

bull Adherence to protocols

bull Ensure recommended lab tests are obtained

bull Flag high risk drug combinations

bull Monitor for side effects eg data mining for weight gain

bull Patient counseling

bull Naloxone use

bull Medication safety

bull Medication interactions Drugdrug DrugFood Drugsupplement

ABERRANT BEHAVIORS ARE COMMONPASSIK SD ET AL J OPIOID MANAGE 20051257-266

554

253

8567

41

0

10

20

30

40

50

60

0 1 to 2 3 to 4 5 to 7 8+

Number of Behaviors Reported

Patients

Exh

ibitin

g B

ehavio

rs (

)

3212018

11

2

Fig 2

Choi W-J Hwang S-J Song J-G et al Radiofrequency treatment relieves chronic knee osteoarthritis pain A double-blind randomized controlled trialPain2011 152(3)481-487

FUNCTIONAL IMAGING AND CBT

bull Different psychological and non-pharma techniques have effects on

somatosensory processing

bull Distraction CBT guided imagery biofeedback exercise etc may

change pain expression through modulatory activations in eg

dorsolateral prefrontal cortex

bull This may be demonstrated with fMRI

Jensen KB Berna C Loggia M Wasan AD Edwards RR Gollub RL

Neuroscience Letters 2012 520156 - 164

Jensen KB Berna C Loggia M Wasan AD Edwards RR Gollub RL

Neuroscience Letters 2012 520156 - 164

THE USE OF FUNCTIONAL NEUROIMAGING TO EVALUATE CBT AND OTHER NON-PHARMACOLOGICAL TREATMENTS FOR CLINICAL PAIN FMRI AFTER CBT IN FIBROMYALGIA

bull 152 patients with causalgia or CRPS 1complex regional pain

syndrome

bull Percentage of patients with ge50 pain relief greater in the DRG

treated (812) than in the SCS arm (557 P lt 0001) at 3 months

bull No difference in serious adverse events between groups

bull Deer TR Levy RM Kramer J et al Dorsal root ganglion stimulation yielded higher

treatment success rate for complex regional pain syndrome and causalgia at 3 and 12

months a randomized comparative trial Pain 2017158669-81

Accurate Study

3212018

12

GERMAN ACUPUNCTURE TRIALS (GERAC) FOR CHRONIC LOW BACK PAIN RANDOMIZED

MULTICENTER BLINDED PARALLEL-GROUP TRIAL WITH 3 GROUPS

HAAKE M ET ALARCH INTERN MED 2007 SEP 24167(17)1892-8

Acupuncture Sham Conservative

therapy

Success Rate 476 442 274

Success defined as 33 improvement in pain scores

12 improvement in disability

Randomized double blind trial 1162 patients 10 thirty

minute sessions 2 per week partial responders

received 5 extra sessions

PATIENT SATISFACTION WITH CHRONIC OPIOID TREATMENT FOLLOWING CURRENT

GUIDELINESTHE ART OF HEALING

bull 96 overall provider satisfaction rate

bull Predictors of satisfaction with multivariate analysis

bull ldquoListened to you carefullyrdquo

bull ldquoTreated you with courtesy and respectrdquo

bull ldquoHelped you with your problemrdquohelliphellipThis did not correlate with actual improvement only

the perception of help

Dragovich et al Pain Practice 2017

DETERMINANTS OF PATIENT SATISFACTION IN A PRIVATE PRACTICE PAIN MANAGEMENT CLINIC

DRAGOVICH ET AL PAIN PRACTICE MARCH 2017

Table 4 Patient Progress Assessment

n

Greatly

Improved Improved

Has not

Changed Worsened

General energy level 97 9 40 47 3

Ability to perform activities

of daily living97 12 41 41 5

Ability to perform activities

such as sports and leisure98 9 27 57 7

Mood 85 49 39 12

Level of stress 97 9 33 43 14

Sleep 98 10 32 42 16

HOW CAN PHARMACISTS HELP

CLINICAL BENEFITS OF AN EMBEDDED PHARMACIST

Chart Reviews for

bull Adherence to protocols

bull Ensure recommended lab tests are obtained

bull Flag high risk drug combinations

bull Monitor for side effects eg data mining for weight gain

bull Patient counseling

bull Naloxone use

bull Medication safety

bull Medication interactions Drugdrug DrugFood Drugsupplement

ABERRANT BEHAVIORS ARE COMMONPASSIK SD ET AL J OPIOID MANAGE 20051257-266

554

253

8567

41

0

10

20

30

40

50

60

0 1 to 2 3 to 4 5 to 7 8+

Number of Behaviors Reported

Patients

Exh

ibitin

g B

ehavio

rs (

)

3212018

12

GERMAN ACUPUNCTURE TRIALS (GERAC) FOR CHRONIC LOW BACK PAIN RANDOMIZED

MULTICENTER BLINDED PARALLEL-GROUP TRIAL WITH 3 GROUPS

HAAKE M ET ALARCH INTERN MED 2007 SEP 24167(17)1892-8

Acupuncture Sham Conservative

therapy

Success Rate 476 442 274

Success defined as 33 improvement in pain scores

12 improvement in disability

Randomized double blind trial 1162 patients 10 thirty

minute sessions 2 per week partial responders

received 5 extra sessions

PATIENT SATISFACTION WITH CHRONIC OPIOID TREATMENT FOLLOWING CURRENT

GUIDELINESTHE ART OF HEALING

bull 96 overall provider satisfaction rate

bull Predictors of satisfaction with multivariate analysis

bull ldquoListened to you carefullyrdquo

bull ldquoTreated you with courtesy and respectrdquo

bull ldquoHelped you with your problemrdquohelliphellipThis did not correlate with actual improvement only

the perception of help

Dragovich et al Pain Practice 2017

DETERMINANTS OF PATIENT SATISFACTION IN A PRIVATE PRACTICE PAIN MANAGEMENT CLINIC

DRAGOVICH ET AL PAIN PRACTICE MARCH 2017

Table 4 Patient Progress Assessment

n

Greatly

Improved Improved

Has not

Changed Worsened

General energy level 97 9 40 47 3

Ability to perform activities

of daily living97 12 41 41 5

Ability to perform activities

such as sports and leisure98 9 27 57 7

Mood 85 49 39 12

Level of stress 97 9 33 43 14

Sleep 98 10 32 42 16

HOW CAN PHARMACISTS HELP

CLINICAL BENEFITS OF AN EMBEDDED PHARMACIST

Chart Reviews for

bull Adherence to protocols

bull Ensure recommended lab tests are obtained

bull Flag high risk drug combinations

bull Monitor for side effects eg data mining for weight gain

bull Patient counseling

bull Naloxone use

bull Medication safety

bull Medication interactions Drugdrug DrugFood Drugsupplement

ABERRANT BEHAVIORS ARE COMMONPASSIK SD ET AL J OPIOID MANAGE 20051257-266

554

253

8567

41

0

10

20

30

40

50

60

0 1 to 2 3 to 4 5 to 7 8+

Number of Behaviors Reported

Patients

Exh

ibitin

g B

ehavio

rs (

)

3212018

13

ABNORMAL URINE DRUG SCREEN

Gupta A et al Retrospective review of physician opioid prescribing

practices in patients with aberrant behaviors Pain Physician 2011 14383-

389

RESULTS OF INTEGRATION OF A PHARMACIST INTO A CLINIC

bull Used suboxone to successfully detoxify 46 soldiers out of 64 treated

bull Excellent patient satisfaction 100 patient satisfaction rating on the APLSS survey

bull Decreased overall opioid prescription by 50 2010 versus 2009

bull Organized the first joint DODVA conference 100 rated at good or excellent 89

stated it fit their scope practice and 83 stated it would change their practice

bull Decreased the WTU non-fatal opioid overdose rate

from 131000 to 141000 over a 12 fold decrease

WHO OVERDOSES

20-49 MEQ 50-99 MEQ gt 100 MEQ

144x 373x 887x

Dowell D et al CDC Guideline for prescribing opioids for chronic pain ndash United States 2016 MMWR 2016 65 1-45

20-49 MEQ 50-99 MEQ 100-200 MEQ gt 200 MEQ

132x 192x 204x 288x

Overdose Events

Overdose Death

50-99 MEQ gt100 MEQ

31x 112x

Serious Overdose

Events

Dunn KM et al Opioid prescriptions for chronic pain and overdose a cohort study Annals of Internal Medicine 2010 152 85-92

PHARMACISTS CAN GREATLY AID IN THE RECOGNITION OF ADDICTIONhellipWHO

OVERDOSES ON LOW DOSEShellipADDICTS

BUPRENORPHINENALOXONE

bull WARM HANDOFFS

bull ASK if the patient is obtaining counselinghellipit makes a

difference and it is required

bull Addiction treatment could be an excellent niche for

pharmacists

Dowell D et al CDC Guideline for prescribing opioids for chronic

pain ndash United States 2016 MMWR 2016 65 1-45

OPIOID WEANING REGIMENSTREAT THE SYMPTOMS

bull Insominia--ambien 10mg qhs

bull Gastritis--Prilosec 20mg qd

bull Sympathetic hyperactivity --clonidine 01mg patch x 1 week

bull Nausea--zofran 4mg q 6 hours x 5 days phenergan 25mg q 6 hours prn refractory nausea

bull Anxiety--Ativan 05mg bid prn

bull Myalgias--NSAIDS Tylenol

3212018

14

Right Patient

Right Treatment

Right Time

YOUR PATIENTS NEED YOU IN THE COMMUNITY

Not just the Pharmacy

Of every one-hundred men ten shouldnt even be there eighty are nothing but targets nine are real fightersWe are lucky to have them they make the battleAH but ONE one of them is a Warriorhe will bring the others back

Heraclitus c 500 BC

QUESTIONREFERENCES

QoL quality of lifePassik SD Kirsh KL J Support Oncol 2005383-86

Passik SD et al J Opioid Manage 20051257-266

Katz NP et al Clin J Pain 200723648-660

Webster LR Fine PG J Pain 201011602-611

Efficacy and Safety of Opioid Agonists in the Treatment of Neuropathic Pain of

Nonmalignant Origin Systematic Review and Meta-analysis of Randomized Controlled

Trials Eisenberg E et al JAMA 20052933043-3052

Washington State Agency Medical Directorsrsquo Group Interagency guidelines on opiod

dosing for chronic non-cancer pain an educational aid to improve care and safety with

opioid treatment Olympia (WA) Washington State Department of Labor and Industries

2010 55 p

3212018

14

Right Patient

Right Treatment

Right Time

YOUR PATIENTS NEED YOU IN THE COMMUNITY

Not just the Pharmacy

Of every one-hundred men ten shouldnt even be there eighty are nothing but targets nine are real fightersWe are lucky to have them they make the battleAH but ONE one of them is a Warriorhe will bring the others back

Heraclitus c 500 BC

QUESTIONREFERENCES

QoL quality of lifePassik SD Kirsh KL J Support Oncol 2005383-86

Passik SD et al J Opioid Manage 20051257-266

Katz NP et al Clin J Pain 200723648-660

Webster LR Fine PG J Pain 201011602-611

Efficacy and Safety of Opioid Agonists in the Treatment of Neuropathic Pain of

Nonmalignant Origin Systematic Review and Meta-analysis of Randomized Controlled

Trials Eisenberg E et al JAMA 20052933043-3052

Washington State Agency Medical Directorsrsquo Group Interagency guidelines on opiod

dosing for chronic non-cancer pain an educational aid to improve care and safety with

opioid treatment Olympia (WA) Washington State Department of Labor and Industries

2010 55 p