1. PAIN & ADDICTION Presented by: Stacy Seikel, MD Board Certified Addiction Medicine Board Certified Anesthesiology

6. Analgesia and the Pain Pathway Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84. Descending modulation Dorsal horn Ascending signals input Spinothalamic tract Dorsal root ganglion Peripheral nerve Peripheral nociceptors Pain Trauma Local anesthetics Opioids  2 agonists Opioids  2 agonists Centrally acting analgesics COX-2–specific inhibitors Traditional NSAIDs Local anesthetics AEDs Local anesthetics Corticosteroids Traditional NSAIDs Cox-2–specific inhibitors Substance P inhibitors Opioids Baclofen Clonidine Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84. Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84. Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84. Adapted from Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84.

15. Spectrum of Risk of Addiction or Aberrant Behavior <1 % ~ 45% LOW Short-term Exposure to Opioids in Non-addicts Porter and Jick HIGH Long-term Exposure to Opioids in Addicts, Dunbar and Kafz Where is your patient ?

25. Prescription Opioid Abuse Is a Significant and Costly Public Health Problem Birnbaum HG et al. Clin J Pain . 2006;22:667-676. Total cost of prescription opioid abuse in the United States was $8.6 billion in 2001 and continues to grow. Health Care 30% Workplace 53% Criminal Justice 17% $4.6 billion $1.4 billion $2.6 billion

26. Annual Numbers of New Nonmedical Users of Pain Relievers, by Age at Initiation: 1965-2003, SAMHSA

27. Drug Mortality Rate, Source, and Misuse of Prescription Drugs: Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health, SAMHSA

28. Increase in New Starts of Prescription Opioid Abuse Among Teenagers Adapted from Manchikanti L. Pain Physician . 2006;9:287-321. 700 600 500 400 300 200 100 0 Percent Increase 1992 2003 542% —Incidence of new starts of prescription opioid abuse among teenagers 150% —Prescriptions written for controlled substances 14% —US population 212% ----Number of 12-17 year olds abusing CS 81% ---Adults abusing controlled substances

29. Past Year Users of Selected Drugs (Prevalence), Including Nonmedical Users of Prescription Psychotherapeutic Drugs: Annual Averages Based on 2002-2004 SAMHSA

30. Past Year Initiates (Incidence) of Illicit Drug Use, by Drug: Annual Averages Based on 2002-2004 (12 or older, 2002-2004) SAMHSA

31. Annual number of new non-medical users of Oxycontin

33. DAWN Comparison 2004 V. 2005 Adapted from the Drug Abuse Warning Network. DHHS Publication No. 07-4256, 2007.

36. OPIOID THERAPY FOR CHRONIC PAIN ?

37. Guidelines and Prescribing Principles for Opioid Therapy

44. PAIN MANAGEMENT = RATIONAL POLYPHARMACY Ongoing PT, Psych, interventional mgt.

45. Buprenorphine and Methadone use in pain and addiction medicine.

51. The rationale for opioid therapy

56. Federal laws governing addiction treatment

63. Buprenorphine and Pain

69. -10 -9 -8 -7 -6 -5 -4 0 10 20 30 40 50 60 70 80 90 100 Intrinsic Activity Log Dose of Opioid Full Agonist (Morphine) Partial Agonist (Buprenorphine) Antagonist (Naloxone) Intrinsic Activity: Full Agonist (Morphine), Partial Agonist (Buprenorphine), Antagonist (Naloxone)

79. Thank You.