Safe and effective pain care

1. Safe and effective pain care Bob Twillman, Ph.D., FACLP Clinical Associate Professor of Psychiatry (Volunteer Faculty) University of Kansas School of Medicine Pain Management Psychologist Saint Luke’s Health System Kansas City, MO

2. DISCLOSURE • Consultant for Millennium Health • Speaker for Collegium Pharmaceutical

3. Walking the Tightrope of Pain Management Adverse Events Pain Management Misuse Death Diversion Addiction Abuse

4. Waiting at the End of the Wire: Cerberus Opioid Use Disorder Chronic Pain Mental Health

5. Three Major Public Health Problems

6. Regarding the “Opioid Epidemic”… We don’t really have an “opioid epidemic” in this country What we really have is an “opioid syndemic”

7. There’s a New Word to Describe This Syndemic: A set of linked health problems involving two or more afflictions, interacting synergistically, and contributing to excess burden of disease in a population.

8. Social Determinants Play a Role, Too • Desire for an easy solution • Low educational achievement • Low economic opportunity • Generational poverty • Few supports in community • Low degree of social connectedness Miasma of Misery Pain OUD Mental Health

9. More Commonalities than Differences • Prescription drug abuse, chronic pain, and mental disorders are more alike than different: • All are highly prevalent • All are very costly, in economic and human terms • All highly stigmatized--patients can be blamed • All are poorly understood by the medical profession • All are under-resourced vis-à-vis treatment • All are complex problems, with many moving parts • All best addressed with a biopsychosocial approach • Most importantly: All involve tremendous suffering

10. A Thought “For every complex problem, there is a solution that is neat, simple, and wrong”—H.L. Mencken I believe that implementing overly simplistic policy solutions for these three very complex problems leads to the zero-sum game that we so often perceive Perhaps the solutions we should be seeking are as complex as the problems we are trying to solve

11. Overdose Deaths Involving Prescription Opioids • Most are poly-substance overdoses: • CDC research: 75-80% used multiple drugs, not including alcohol • Florida, first half of 2013: state medical examiners’ network reported that 93.5% of drug OD decedents used multiple drugs • Most decedents don’t have active prescriptions: • Two studies (one from CDC): as many as 55-60% did not have an active prescription for the drugs involved • Massachusetts: only 8% of decedents had active prescriptions • We need much better understanding of what these numbers mean, so we can craft better solutions

12. How Does Mental Health Fit In? • Several mental disorders are more common in people with chronic pain, and complicate its treatment • Both adolescents and adults with pre-existing mental health diagnoses are more likely to develop: • Chronic pain after an acute pain episode • An OUD after opioid treatment for acute pain • At the VA, system-wide involuntarily tapering of opioids was associated with an increase in suicides • Could be due to increased pain, re-emergent mental health issues, or both

13. The Graph That Started Efforts to Reduce Opioid Prescribing CDC graph of opioid sales, overdose deaths, and treatment admissions

14. Prescribing and OD Deaths No Longer Correlated https://reason.com/blog/2018/04/19/as-opioid-prescriptions-fall-opioid-deat/print

15. However, Decreased Prescribing Has Created “Opioid Refugees” • Increasingly, prescribers (especially primary care providers) have begun sharply limiting opioid prescriptions • Some have eliminated opioid prescribing in their practices—even for patients doing well on opioid therapy • Patients who have opioid doses tapered or stopped often go from provider to provider, trying to find someone to prescribe for them—often without success • These “opioid refugees” are at risk of seeking illicit drugs or attempting suicide

16. Asking the Right Questions To get the right answers, we have to ask the right questions

17. The Right Question about Opioids for Chronic Pain The wrong question is, “Should we use opioids to treat chronic pain?” The right question is, “In which patients should we use opioids, at what doses, for how long, with which adjunctive treatments, and with what precautions?”

18. Pathways to Prevention Findings • In September 2014, NIH sponsored a two-day “Pathways to Prevention” workshop on The Role of Opioids in the Treatment of Chronic Pain • Extensive evidence review was carried out prior to the meeting • After the meeting, an unbiased panel developed a report regarding the risks and benefits of using opioids to treat chronic pain • The key conclusion: • There is “insufficient evidence for every clinical decision that a provider needs to make regarding use of opioids for chronic pain.” • Question: If that’s the case, then how do we find our way out of the mess we’re in?

19. The Biopsychosocial Model of Chronic Pain • The biomedical model works well for acute pain, but fails miserably when it tries to explain chronic pain • This model considers disorders to be caused by presence of a pathogen or injury, or absence of a vital substance • For chronic pain, neither applies in many (most?) cases • Chronic pain etiology is complex; it can result from myriad chronic medical conditions • A model considering the biological, psychological, social, and spiritual aspects of the individual’s experience is needed to understand chronic pain and guide treatment

20. Comprehensive Integrative Pain Care Comprehensive Integrative Pain Management includes biomedical, psychosocial, complementary health, and spiritual care. It is person-centered and focuses on maximizing function and wellness. Care plans are developed through a shared decision-making model that reflects the available evidence regarding optimal clinical practice and the person’s goals and values. Consensus definition: Inaugural Integrative Pain Care Policy Congress, 2017

21. What Evidence is Required? • One common objection to covering non-pharmacological treatments is lack of high-quality and long-term evidence • This seems perhaps hypocritical: • Long-term opioid therapy is covered despite evidence that is no better • Legislators, regulators, and payers all are instituting laws/regulations/guidelines/policies based on the CDC opioid guideline, which contains only Level 3 and Level 4 evidence (out of 4 levels, where a higher number is lower-quality)

22. Accessing the Pain Care Toolbox “If all you have is a hammer, every problem looks like a nail.” Abraham Maslow • The biopsychosocial model recognizes the need to use multiple tools to fix the broken system causing chronic pain • Unfortunately, the system that provides those tools also is broken. We need more tools. This requires: • More basic medical education content for “traditional” students • Extensive continuing education for licensed providers • Available providers of non-medication treatments • Access to referral networks for those providers • Adequate reimbursement for those providers

23. Pain Management Best Practices • Pursue a balanced, multi-disciplinary approach to providing pain care • Individualize treatment plans for each person with pain—there is no cookbook, and one size doesn’t even fit most • Decrease opioid prescribing by incorporating multimodal analgesia • Emphasize proper use, storage, and disposal; educate people with pain, family members, other loved ones and caregivers

24. Thank you