1. Barbara J Turner MD, MSED, MA
Director, Center for Research to Advance Community
Health
James D and Ona I Dye Professor of Medicine
2.
3. What is chronic pain?
Pain lasting at least 3 months or past the
normal time for tissue healing*
Pain disrupts everyday activities and often
affects sleep
Does not have to be constant to be a
significant problem
*Chou et al. Ann Intern Med. 2015:162:276-86
6. Huge impact on health
1 in every 3 Americans will have chronic
pain at some point in their lives
When it starts, it usually lasts
60% of older adults reporting pain still have pain
after one year.
Institute of Medicine. Relieving Pain in America: A Blueprint for
Transforming Prevention, Care, Education, and Research, 2011
7. How common is it?
Condition # people in U.S. Source
Chronic Pain Over 25 million with
moderate to severe pain
Institute of
Medicine, NIH
Diabetes 26 million (including
not yet diagnosed)
American Diabetes
Association
Heart disease
Stroke
16.3 million
7.0 million
American Heart
Association
Cancer 11.9 million American Cancer
Society
8. Chronic pain has many effects
Report fair or poor health: 25–33%
Unable to work: 15–22%
Sleeping <6 hours: 12–17%
Daily mental distress/strain: 6–13%
9. What is the most
common reason
people see a
doctor in the USA?
Pain!
10.
11. Huge demand for health care
Adults with joint pain
11,000,000 physician office visits,
>1,100,000 outpatient hospital visits,
1,500,000 emergency department visits
177,ooo inpatient hospitalizations
Adults with back pain
700,000 physician office visits,
762,000 outpatient hospital visits,
>1,500,000emergency department visits
227,ooo inpatient hospitalizations
Source: NIH
12. Economic burden
Pain costs an
estimated $100 billion
annually in lost
workdays, medical
expenses, and other
benefit costs.
NIH Evidence Review,
2015
23. NIH America’s Addiction to Opioids: Heroin and Prescription Drug Abuse
Opioid prescriptions from retail pharmacies—
US, 1991–2013
24.
25. • Use of oral opioids for at least 4 weeks versus placebo or other pain
medication
• Fifteen trials (5540 participants)
• Generally lower quality studies
• Small to moderate efficacy for short-term treatment (< 15 weeks)
• The effectiveness and safety of long-term opioid therapy unproven
• Remember these studies only involve pills for back pain
28. Drug overdose deaths by major drug type
U.S. 1999–2010
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
NumberofDeaths
Year
Opioids Heroin Cocaine Benzodiazepines
CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.
31. 206,869 privately insured patients aged 18 to 64 with non-cancer
pain and at least 2 filled prescriptions for Schedule II or III opioids
from 1/2009 to 7/2012. Opioid therapy examined in 6-month
intervals including 6 months before a drug overdose
32. Daily opioid dose and overdose
Drug overdose in 1,385 (.67%) subjects
36. Hypothesis: Opioids and other drugs used to treat
chronic pain are associated with an even greater
risk for overdose in all patients but especially
those with mental health disorders
J Gen Intern Med, in press
37. Risks of combining opioids with
other drugs
In a patient with depression, treatment with a
moderately high opioid dose (e.g. 60 mg/d) plus
benzodiazepines (e.g. Xanax) for >1 month
increased the likelihood of drug overdose by 12
times (vs none of these drugs and not depressed)
Co-treatment with zolpidem (e.g., Ambien) increased
the likelihood of overdose by 14 times
38. High dose opioids even more risky for men than women
Men also have greater risks from long-term
benzodiazepines
But women have greater risks from zolpidem (Ambien)
39.
40. Blue Cross Blue Shield of Texas enrollees with diabetes
Significantly less likely to be checked for diabetes control
with higher dose or longer term opioids
Higher dose and duration of opioids associated with 6 to 8
times higher odds of being hospitalized and over 3
times greater odds of going to the emergency room
45. CDC guidelines 2016
Nonpharmacologic therapy preferred
Do not use only opioids, use with nonpharmacologic
therapy and/or non-opioid therapy
Establish realistic goals for pain and function in an
agreement
Discuss risk/benefits and physician/patient
responsibilities
Initiate with short-acting not long-acting opioids
Prescribe lowest effective dosage, avoid >50 MME/d
46. CDC guidelines 2016, cont.
For acute pain, <=3 days of short-acting opioids, rarely >7
days – at lowest effective dose
Review benefits/harms 1-3 weeks after start, then every 3
mos. if benefits < harms, focus on alternatives and tapering
Consider naltrexone if increased risk of overdose
Avoid opioids with benzodiazepines
Urine drug testing before starting and at least annually
Buprenorphine or methadone with behavioral therapies for
patients with opioid use disorder
47. Where are we heading with
chronic pain management?
48. Chronic pain and the brain
Chronic pain engages brain
regions critical for
cognitive/emotional
assessments
Neuroimaging studies also
highlight impact of environment
and genetics in chronic pain
These features of chronic pain
may be a distinctive vs acute
pain
Chronic pain appears to be less
related to ongoing tissue
damage
J Clin Invest. 2010;120:3788-97
49. Evidence-based non-drug treatment
of chronic low back pain
Exercise
Physical therapy
Spinal manipulation
Massage
Yoga
Acupuncture
Cognitive behavioral therapy
Progressive relaxation
Chou et al. Ann Intern Med, 2007
53. Walking for low back pain
ITT analysis found significant improvements at 12 mos. in the Oswestry Disability Index
(Primary Outcome), Numerical Rating Scale, Fear Avoidance-PA scale, and EuroQol
Weighted Health Index (P<0.05), but no significant between-group differences
56. Trial of multi-modality non-drug
treatment for chronic pain
Setting lifestyle goals to live better beyond pain
Walking
Safe exercises
Stretching
Self- or partnered-massage
Mind-body skills
Improve sleep habits
Eat healthier and smarter
Dealing with set backs
57. Not the kind of water exercise we
are looking for!
Editor's Notes
3. Chronic pain facts
What is chronic pain?
Big picture – National figures
Could include additional slides for the following (if not too long):
Texas figures
Bexar County
Card study results (include a few simple pie/bar chart graphics)
Clip from PCORI – someone audience may identify with
The key prevention policies we believe will have the greatest impact in the shortest amount of time are:
Prescription drug monitoring programs
Patient review and restriction programs
State laws, regulations, and policies aimed at reducing diversion, abuse, and overdose
Insurer and pharmacy benefit manager mechanisms
The use of clinical guidelines to improve clinical practice
This is not an exhaustive list, and we must continue to press forward on education initiatives, increasing access to substance abuse treatment, and engaging communities with drug-take back programs and prevention efforts.
General Notes:
Design:
Colorful template with lots of images, a few graphs and animation
Potential Jeopardy-style questions periodically included to increase engagement and audience participation
Minimal words + lots of pictures (ex pic of proper vs. poor lifting technique)
Length:
20 minutes or less
Aims:
What do we want the audience to do with this information?
To talk more about chronic pain
Increase discussion within social network
To share their new awareness of:
The prevalence of chronic pain
The short-comings of current management
Non-pharmacologic alternatives
Resources for active management in the community
To provide feedback on the presentation
Greater community input and quality improvement
To think about community programs that could be beneficial
Informing the Alliance’s primary question:
“What infrastructure elements need to be in place in order to create a sustainable program to support primary care providers who care for patients suffering from chronic non-cancer pain in Bexar County?”
Dissemination:
What is the Alliance’s dissemination plan for this?
What target audiences would be selected and who would deliver it?
Goal is to create an easily modifiable format to fit different target audiences