Rethink Chronic Pain - Pfizer Medical Information - US · 2019-01-23 · How Do Chronic Pain States Develop? - Uncoupling of pain from peripheral stimuli - Membrane excitability,

Rethink Chronic Pain

A Structured Approach to the Management of Patients with Chronic Pain

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Why Rethink Chronic Pain?1

2FM-PNP-0006 - 2-0

Approved For your personal use. Not for further distribution

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The Public Health Challenges of Chronic Pain

1. IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.2. IOM. Pain Management and Prescription Opioid-Related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press, 2016.3. FDA. Guidance for Industry: Abuse-Deterrent Opioids—Evaluation and Labeling. Rockville, MD: FDA; April, 2015.4. Volkow ND, McLellan TA. JAMA. 2011;305(13):1346-1347.5. Becker WC, Fiellin DA.. Abuse-Deterrent Opioid Formulations - Putting the Potential Benefits into Perspective. N Engl J Med. 2017 Jun 1;376(22):2103-2105. doi: 10.1056/NEJMp1701553

• Chronic pain is a serious public health issue1, 2

• Patients with chronic pain, clinicians, payers, employers, and the government, are confronted by two dual interrelated issues1:

• Poor understanding and often inappropriate treatment of pain, including prescription therapy

• Misuse, abuse, and diversion of medications intended to treat pain, namely opioids

• These challenges must be addressed in parallel to ensure that concerns about abuse and misuse of opioids do not preclude clinically appropriate opioid therapy for patients who need it3,4

• There needs to be R&D investment in new non-opioid chronic pain treatments and models of care, which could potentially help to address these challenges5


4

Chronic Pain Is a Serious Public Health Burden

$560–635billion

• Exceeds costs of cardiovascular disease ($444B), diabetes ($174B), and cancer ($125B)

• High health care costs globally, although estimates vary

~100million

• 23 million report ‘being in substantial’

pain

• Exceeds prevalence of cardiovascular disease (~27M), diabetes (~26M), and cancer (~12M) in US population

• Similar prevalence estimates globally1. IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 20112. SEER Cancer Statistics Review, 1975-2012. Howlader N, Noone AM, Krapcho M, et al. Available at http://seer.cancer.gov/csr/1975_2012 [Last accessed 23 November 2015]3. Schiller JS, Lucas JW, Ward BW, et al. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. Vital and health statistics Series 10, Data from the National Health Survey 2012:1-2074. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. National Center for Health Statistics, 2012. Available at http://www.cdc.gov/nchs/data/hus/hus11.pdf [Last accessed 23 Nov 2015]5. Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain. 2015;16:769–780

HIGH COST:HIGH PREVALENCE:

is the estimated annual cost of chronic pain in the US1-4

American adults are affected by chronic pain1-5


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Opioid Prescriptions and Rates of Serious Health Consequences of Opioid Misuse and Abuse

0

100,000

200,000

300,000

400,000

500,000

0

3,000

6,000

9,000

12,000

15,000

18,000

21,000

24,000

1999 2001 2003 2005 2007 2009 2011 2013 2015

# of Opioid-R

elated ED Visits#

of P

resc

riptio

n O

pioi

d-R

elat

ed

Dea

ths

76 8091 100

120139

151169

192202

219204

181

0

50

100

150

200

250

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

# of

Pre

scrip

tions

(in

milli

ons)

2015:22,598

1999: 4,030

2004:172,738

2011: 488,004

Opioid Prescriptions Dispensed by Retail Pharmacies1

(US, 1991-2015)

Prescription Opioid Overdose Deaths2

and Emergency Department Visits3

(US, 1999-2015)

ED

Visits

Overdose

Deaths

Opioid

Prescriptions

1. Adapted from CDC. Primary Care and Public Health Initiative. Prescription Drug Abuse and Overdose: Public Health Perspective. October 24, 2012. Data from Source™ Prescription Audit (SPA) & IMS Health Vector One®: National (VONA).

2. CDC. Overdose Death Rates. Accessed from: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates3. SAMHSA. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD: SAMHSA; 2013. HHS Publication No. (SMA) 13-4760, DAWN Series D-39.4. IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.

50% to 80% of people who die from prescription opioid

overdoses have a history of chronic pain.4


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UnderstandingChronic Pain2


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Chronic Pain Is Different From Acute Pain

Usually obvious tissue damage

Pain resolves upon healing

Serves a protective function

< 3 Months

Pain for 3 months or more

Pain beyond expected period of healing

Usually has no protective function

≥ 3-6 Months

ACUTE PAIN CHRONIC PAIN

TIME

Mirchandani A et al. Acute and chronic mechanisms of pain. In: Vadivelu N et al, eds. Essentials of Pain Management. New York, NY: Springer Science; 2011:45-48.


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CNS and Peripheral Pain Signaling Pathways

Descending tracts

play a role in pain modulation via the midbrain periaqueductal gray

matter and nucleus raphe

Ascending tracts

(e.g., spinothalamic) convey pain signals to the brain, where they are

processed by the thalamus

DORSAL ROOT

DORSAL ROOTGANGLION

AFFERENTNEURON

VENTRAL ROOT

MEDULLA

THALAMUS

Spinal Cord

Cross-Section

Skin

PERIPHERALNOCICEPTORS


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How Do Chronic Pain States Develop?

- Uncoupling of pain from peripheral stimuli - Membrane excitability, synaptic recruitment and decreased inhibition

Central

Sensitization

- Nociceptor sensitization and direct pain messenger effects on nerve endings- Reduction in pain threshold due to primary and secondary pain messenger activity

Peripheral

Sensitization

DESCENDINGMODULATION

ASCENDINGINPUT

PAIN

TRAUMA

Spinal Cord

Cross-Section

Skin

PERIPHERALNOCICEPTORS


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Chronic Pain Categories and Multimodal Pain Management

3


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Chronic Pain Is a Biological, Psychological,and Social Phenomenon1

• For many patients with chronic pain, effective assessment and treatmentis multimodal and multidisciplinary, taking into account:• Biological factors (mix of symptoms,

type of pain, etc.)• Psychological, emotional and cognitive

factors (anxiety, depression, anger, fear of movement, catastrophizing)

• Social factors (social and financial circumstances)

1. IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011. Turk DC, Melzack R. Handbook of Pain Assessment. New York: The Guilford Press: 2011.

Chronic Pain

Social

Psychological

Biological


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Multimodal Chronic Pain Management1

• For many patients with chronic pain, effective assessment and treatmentis multimodal and multidisciplinary

• Nonpharmacologic intervention that can be chosen based on the patient’s profile and treatment availability• Psychological therapies, such as cognitive-behavioral therapy, relaxation, biofeedback• Rehabilitative/physical therapies, such as stretching, exercise, massage• Other complementary alternative medicine, such as yoga, acupuncture• Patient self-management, such as pacing of activity, brief planned rests

• Pharmacological interventions

• Interventional Techniques (i.e., for chronic spinal pain)• Spinal interventional techniques (Diagnostic & therapeutic interventional techniques)• Cervical, thoracic, and lumbar interventional techniques (i.e., facet joint, epidurals,

decompression, neurotomy)• Implantables (i.e., Spinal Cord Stimulators, Implantable Intrathecal Drug Administration)

1. IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011. Turk DC, Melzack R. Handbook of Pain Assessment. New York: The Guilford Press: 2011.

2. Manchikanti, L., et al. "An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part I: introduction and general considerations." Pain Physician 16.2 Suppl (2013): S1-48.

3. Manchikanti, L., et al. "An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations." Pain Physician 16.2 Suppl (2013): 1:S49-S283.

Most patients with chronic pain will need pharmacotherapy as well


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Chronic Pain Conditions Can Be Classified Based on Type of Pain Pathophysiology

Three Main Types of Pain Pathophysiology:

Phillips K, Clauw DF. Best Pract Res Clin Rheumatol. 2011;25(2):141-154.Adapted from Stanos et al. Postgrad Med. 2016 Jun;128(5):502-15.

Nociceptive

Pain

Neuropathic

Pain

Sensory

Hypersensitivity

Pain related to damage of somatic or

visceral tissue, due to trauma or inflammation

EXAMPLES:

rheumatoid arthritis, osteoarthritis, gout

Pain related todamage of peripheral

or central nerves

EXAMPLES:

painful diabetic peripheral neuropathy (pDPN),

postherpetic neuralgia

Pain without identifiable

nerve or tissue damage; thought to result from persistent

neuronal dysregulation

EXAMPLES:

fibromyalgia


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Sensory

Hypersensitivity

• Fibromyalgia• Irritable bowel syndrome• Functional dyspepsia• Interstitial cystitis

• Neck and back pain without structural pathology

• Myofascial pain / Temporo-mandibular joint (TMJ) disorder

• Pelvic pain syndrome• Restless legs syndrome• Headaches• Chronic fatigue syndrome

• Gout• Osteoarthritis • Rheumatoid arthritis• Tendonitis, bursitis• Ankylosing spondylitis • Tumor-related

nociceptive pain• Neck and back pain with

structural pathology• Sickle-cell disease• Inflammatory bowel disease

Nociceptive

Pain

• Postherpetic neuralgia• Painful diabetic peripheral

neuropathy• Sciatica/stenosis• Spinal cord injury pain• Tumor-related neuropathy• Chemotherapy-induced

neuropathy• Small-fiber neuropathy• Post-stroke pain• Multiple sclerosis pain• Persistent postoperative pain

Neuropathic

Pain

The Three Types of Pain, Separately or Together, Give Rise to Various Chronic Pain Conditions

Chronic low back pain

has been acknowledged to have multiple potential mechanisms and is often viewed as a prototypical “mixed-pain state”

Adapted from Stanos et al. Postgrad Med. 2016 Jun;128(5):502-15FM-PNP-0006 - 2-0


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Assessing and ManagingChronic Pain4


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Comprehensive Pain Assessment Involves the Evaluation of Three Elements

Identify and document potential underlying

cause of pain1

• Evaluate health status, medical history, comorbid illnesses, prior and current medications, family history, etc

• Assess duration, location, and the likely source of pain

• Use advanced diagnostic techniques for certain patients

Record pain severity,

impact on function,

mood, and sleep1

• Assess and record pain severity, eg, using VAS

• Evaluate impact on function, sleep, mood

At present, rarely done in primary care setting, and rarely (if ever) included in available EMR modules

Identify and documenttype(s) of pain

pathophysiology1-5

• Evaluate pain descriptors, presence of allodynia, hyperalgesia1

• Use tools to help determine the type of pain pathophysiology:

ID Pain® screening tool (6-item scale to identify non-nociceptive pain)2

PainDETECT (detects neuropathic pain in low back pain patients)3

Wolfe FM Questionnaire4

or FM Survey Questionnaire5

1. Gulati A, Loh J. Assessment of pain: complete patient evaluation.In: Vadivelu N et al, eds. Essentials of Pain Management. New York, NY: Springer Science; 2011:57-74.

2. Portenoy R. Curr Med Res Opin. 2006;22(8):1555-1565

3. Freynhagen R et al. Curr Med Res Opin. 2006;22(10):1911-1920.4. Wolfe F et al. J Rheumatol. 2011;38(6):1113-1122.5. Wolfe F et al. Pain. 2011;152(2):291-299.

BPI: Brief Pain Inventory; EMR: electronic medical record; VAS: visual analog scale; FM: fibromyalgia


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ID Pain® screening tool (6-item scale to identify non-nociceptive pain)

• Score of ≥ 3 was shown to indicate the presence of a neuropathic component of pain

• ID-Pain consists of 5 sensory descriptor items and 1 item relating to whether pain is located in the joints (used to identify nociceptive pain)

• Developed in 586 patients with chronic pain of nociceptive, mixed or neuropathic etiology, and validated in 308 patients with similar classifications as determined by pain specialist diagnoses

• In the validation study, 22% of the nociceptive group, 39% of the mixed group, and 58% of the neuropathic group scored above the cutpoint score of 3

ID PAIN® Screener1

*Portenoy R. Curr Med Res Opin. 2006;22(8):1555-1565.

Question Score

Yes No1. Did the pain feel like pins and needles?

1 0

2. Did the pain feel hot/burning? 1 0

3. Did the pain feel numb? 1 0

4. Did the pain feel like electrical shocks?

1 0

5. Is the pain made worse with the touch of clothing or bed sheets?

1 0

6. Is the pain limited to your joints? -1 0


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Step 1 Identify Pain Type

Step 2Use Guideline Driven

First Line Treatment

NSAIDs, acetaminophen

Treatment of underlying inflammatory

condition may include corticosteroids, biologics and

disease-modifying agents

Selected AEDs, SNRIs, and TCAs

Step 3Optimize First Line

Treatment

Titrate, when appropriate, to FDA approved therapeutic doses based on tolerability prior to treatment being deemed inadequate and necessitating change

Step 4Switch to Alternative

Non-Opioid Treatment

When first line therapy is deemed inadequate, consider switching to another drug in the class or alternative non-opioid drug class

Treatment of Chronic Pain Includes Opioid Pain Medications Only When Appropriate

Nociceptive

PainNeuropathic

Pain

Sensory

Hypersensitivity

1. Phillips K, Clauw DJ. Best Pract Res Clin Rheumatol. 2011;25(2):141-154.2. ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46(2):328-346.3. Hochberg M et al. Arthritis Care Res (Hoboken). 2012;64(4):465-474. 4. Khanna D et al. Arthritis Care Res. 2012;64(10):1447-1461.5. Passik SD. Mayo Clin Proc. 2009;84(7):593-601.6. Dworkin RH et al. Pain. 2007;132(3):237-251.7. Attal N et al. Eur J Neurol. 2010;17(9):1113-1123.8. Carville SF et al. Ann Rheum Dis. 2008;67(4):536-541.9. Dowell D, et al.. CDC Guideline for Prescribing Opioids for Chronic Pain —

United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49

10. Chou R et al. J Pain. 2009;10(2):113-130. 11. VA/DoD. https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPGProviderSummary022817.pdf. Accessed November 17, 201712. Manchikanti L et al. Pain Physician. 2012;15(3 suppl):S67-S116.13. US FDA. http://www.fda.gov/downloads/Drugs/DrugSafetyInformationbyDrugClass/UCM367697.pdf. Accessed November 16, 2017.14. Painter JT, Crofford LJ. J Clin Rheumatol. 2013;19(2):72-77. 15. Franklin G. Neurology 2014;83;1277-1284.16. Peng X, Robinson RL, Mease P, et al.. Clin J Pain 2015: 31:7-1317. Hooten M, et al. Institute for Clinical Systems Improvement. Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management.

Updated September 2016.18. Stanos S et al. Postgrad Med. 2016 Jun;128(5):502-15


https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPGProviderSummary022817.pdf./

http://www.fda.gov/downloads/Drugs/DrugSafetyInformationbyDrugClass/UCM367697.pdf. Accessed November 16

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Treatment of Chronic Pain Includes Opioid Pain Medications Only When Appropriate

Adapted from Stanos et al. Postgrad Med. 2016 Jun;128(5):502-15

Step 1 Identify Pain Type

Step 2Use Guideline Driven

First Line Treatment

NSAIDs, acetaminophen

Treatment of underlying inflammatory

condition may include corticosteroids, biologics and

disease-modifying agents

Selected AEDs, SNRIs, and TCAs

Step 3Optimize First Line

Treatment

Titrate, when appropriate, to FDA approved therapeutic doses based on tolerability prior to treatment being deemed inadequate and necessitating change

Step 4Switch to Alternative

Non-Opioid Treatment

When first line therapy is deemed inadequate, consider switching to another drug in the class or alternative non-opioid drug class

Nociceptive

PainNeuropathic

Pain

Sensory

Hypersensitivity

Step 5

Consider Opioids for

When Non-Opioid

Treatments are

Inadequate

Reserve ER/LA Opioids for the management of pain severe enough to require daily, around-the-clock, long-term treatment

in patients with nociceptive or neuropathic pain.

Opioids should be avoided in patients with sensory hypersensitivity

Step 6 Mitigate Risk

When prescribing an opioid, employ risk mitigation strategies, such as: assess patient risk, use abuse-deterrent opioids, prescribe lowest effective dose, and monitor for abuse, misuse

and diversion (e.g. PDMP, UDT)FM-PNP-0006 - 2-0Approved For your personal use. Not for further distribution

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Special Populations Risks

Older Adults • Smaller therapeutic window• Greater risk of respiratory depression and overdose• Increased risk of falls and fractures

Renal/Hepatic insufficiency

• Smaller therapeutic window• Greater risk of respiratory depression and overdose

Pregnant Women • Risk to mother and fetus• Some evidence of birth defects: neural tube

defects, congenital heart defects, preterm delivery, stillbirth

• Neonatal opioid withdrawal

Depression • Higher risk for opioid use disorder

Alcohol or other substance abuse

• Higher risk for opioid use disorder

Sleep Apnea • Opioid therapy can worsen central sleep apnea; further desaturation

Risks Associated with Opioid Use in Special Populations

CDC guideline for prescribing opioids for chronic pain-United States, 2016


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Guidelines Vary, But They Do Align on Certain Aspects of Assessment and Treatment

Guideline Year TopicMultimodal

Management

Multidisciplinary

Approach

Assess Pain

Mechanism

Use of

Opioids

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 2016 Opioid use ✔ ✔ ✔ 2nd lineASIPP: Responsible, Safe and Effective Prescription of Opioids for Chronic Non-cancer pain 2017 Opioid use ✔ ✔ ✔ 2nd line

VA-DOD: Guideline for Opioid Therapy for Chronic Pain 2017 Opioid use ✔ ✔ ✔ 2nd line

Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain 2010 Opioid use ✔ ✔ No mention 2nd line

Washington State Interagency Guideline on Prescribing Opioids for Pain 2015 Opioid Use ✔ ✔ ✔ 2nd or 3rd line

APS-AAPM: Use of Chronic Opioid Therapy in Chronic Noncancer Pain 2009 Opioid use ✔ ✔ ✔ 2nd line

Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain 2009 Opioid use ✔ ✔ ✔ 2nd line

ICSI Pain: Assessment, non-opioid treatment Approaches and Opioid Management 2016 Opioid Use ✔ ✔ ✔ 2nd or 3rd line

ICSI Health Care Guideline: Assessment and Management of Chronic Pain (2013 update) 2013 Chronic noncancer pain ✔ ✔ ✔ 2nd line

ACR: Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, & Knee 2012 OA ✔ ✔ No mention 2nd line

ACR: Guidelines for the Management of Rheumatoid Arthritis (2015 update) 2015 RA ✔ ✔ No mention Not mentioned

AAN/AANEM/AAMP&R: Evidence-based Guideline: Treatment of Painful Diabetic Neuropathy 2011 pDPN ✔ No mention No mention Level B

evidence

Diabetic Neuropathy: a position statement by the American Diabetes Association 2016 pDPN ✔ ✔ ✔ Discouraged

IASP/NeuPSIG: Pharmacologic Management of Neuropathic Pain: Evidence-based Recommendations (updated review) 2015 Neuropathic ✔ ✔ ✔ 3rd line

EFNS Guidelines on the Pharmacological Treatment of Neuropathic Pain (2010 Revision) 2010 Neuropathic No mention No mention ✔2nd or3rd line

Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome 2012 FM ✔ ✔ ✔ Discouraged

EULAR: Evidence Based Recommendations for the Management of Fibromyalgia Syndrome (2016 update) 2016 FM ✔ ✔ ✔

Notrecommended

Dowell D, et al.. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1; Adapted from Stanos et al. Postgrad Med. 2016 Jun;128(5):502-15

FM-PNP-0006 - 2-0Approved

For your personal use. Not for further distribution

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Addressingthe Opioid Problem5


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While Clinical Guidelines Do Not Recommend Opioids as 1st Line, Up to 50% of Patients Receive Them 1st Line (Alone or in Combination)

In the US, opioid medication utilization as first treatment post-diagnosis for chronic pain conditions* (prescribed alone or in combination with other pain therapy) does not appear to follow

opioid treatment guidelines

52%42% 43%

0

20

40

60

80

100

OA DPN FM

Perc

en

t o

f P

ati

en

ts

Opioids Prescribed as First-line Pharmacologic Treatment by Condition

*Based on national claims data analysis between March 2008 and February 2012.

IMS. PLD Findings for the Pain Franchise. Data on file. Pfizer Inc, New York, NY; 2012.


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Why Are Opioids Overprescribed?

• Opioids may be perceived as an easy choice since they can provide relief for various types of pain

• The prescriber may not consider etiologies/pathophysiology of pain or differential diagnosis

• Payers may provide greater access to generic opioids vs branded non-opioid medicines for pain or branded abuse-deterrent opioids

• Clinicians often underestimate patient risk for prescription opioid abuse1

• Even when a patient is identified as being high risk, there is limited use of opioid risk reduction strategies2

Assessing risk for misuse and abuse, and detecting such behaviors in

patients already receiving opioids is difficult.3 Therefore, risk reduction

strategies should be applied universally with every patient.

1. Turk DC et al. Clin J Pain. 2008;24(6):497-508.2. Starrels JL et al. J Gen Intern Med. 2011;26(9):958-964.3. Brown J et al. J Opioid Manag. 2011;7(6):467-483.


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Routes of Administration of Extended-Release (ER) Oxycodone at Initiation of Useand at Addiction-treatment Admission (October 2000 to March 2002; N=187)

Patients admitted to substance abuse treatment centers reported progression fromprimarily oral ingestion to snorting/injection of ER oxycodone in <2 years (average time)

83

14

16

62

1

26

0

20

40

60

80

100

Initial Route of Administration(n=112/187)

Route of Administration at Admission(n=133/187)

Pe

rce

nta

ge

Oral Snorting Injection

Mean19.2 Months*

Abuse of Prescription Opioids May Progress fromOral Ingestion to Snorting and Injection

*Average time between first use/misuse and addiction-treatment admission.Note: Percentages at admission do not add up to 100% because respondents could report multiple routes of administration. Adapted from Hays LR. J Addict Dis. 2004;23(4):1-9.


26

Extended-Release (ER) Opioids Are Tampered With for Purposes of Misuse and Abuse

55

3847

5362

25

60.2 1.0

36

9

46

0

20

40

60

80

ER Oxycodone ER Oxymorphone ER Morphine

Pe

rce

nt

of

Pe

rso

ns A

bu

sin

g

Oral Snorting Smoking Injecting

Abuse of ER Formulations of Prescription

Opioid Medications by Route of Administration

June 1, 2009 to August 8, 2010*140,496 individuals assessed for substance use problems from 357 US

centers participating in the National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO) surveillance system

Adapted from Butler S et al. J Pain. 2013;14(4):351-358. Used with permission.

* Prior to introduction of reformulated ER oxycodone and ER oxymorphone.Note: Percentages for each drug do not add up to 100% because respondents could report multiple routes of administration.


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Knowing When to Use Opioid Medications Is as Important as Knowing How to Use Them

Prescribe ER/LA opioids only for patients with pain severe enough to

require daily, around-the-clock, long-term treatment and for whom

alternative treatment options are inadequate

WHEN to use opioids?Clinically Appropriate

Treatment Selection

for Chronic Pain

Universal Precautionsfor Opioid Prescribing

MonitorTreatment

4

DialogueWith

Patient

3

SelectOpioid

2

AssessRisk

1

A set of uniform prescribing practices should be applied to all patients to help address misuse, abuse, and diversion*

HOW to use opioids appropriately?

Adapted from Stanos et al. Postgrad Med. 2016 Jun;128(5):502-15FM-PNP-0006 - 2-0


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Know When to Refer the Patient With Pain• Certain findings (or the need for the more extensive assessments)

are likely to trigger a referral to a pain specialist, neurologist, rheumatologist, or oncologist1,2

• Unexplained weight loss and/or history of cancer with new onset of pain• Fever and/or inflammation• Neurological deficits or progressive motor weakness• Urinary retention, fecal incontinence, etc.

• The need for treatment modalities such as regional anesthetic interventions and surgery may require referral to a pain specialist3

• Referral should also be considered in the following situations4,5:• The patient has not responded to conservative/conventional treatments for pain • The pain continues to have a negative impact on patient’s quality of life, family/work life

• The health care provider feels uncomfortable with dosage, number, or type of medications needed • Complicated and/or rare pain conditions such as chronic regional pain syndromes (reflex

sympathetic dystrophy and causalgia) are suspected

1. Washington State AMDG. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain:

An Educational Aid to Improve Care and Safety With Opioid Therapy. 2010 Update. Olympia, WA: Washington State Agency Medical Directors Group; 2010.

2. ACR Web site. American College of Rheumatology Referral Guidelines. http://www.rheumatology.org/practice/clinical/position/index.asp. August 2010. Accessed August 27, 2014.

3. Chou R et al. Ann Intern Med. 2007;147(7):505-514.4. VA/DoD. Clinical Practice Guideline for Management of Opioid Therapy for Chronic

Pain, 2010. Version 2.0. Washington, DC: VA/DoD; 2010.5. Hooten WM et al. Assessment and Management of Chronic Pain. Bloomington, MN:

Institute for Clinical Systems Improvement (ICSI); Updated 2013.


http://www.rheumatology.org/practice/clinical/position/index.asp

29

Taking Actionon Chronic Pain6


30

Adopting These Principles May Help Clinicians Achieve Better Outcomes in Chronic Pain• There are significant public health problems that must be addressed in

parallel• Poor understanding and often inappropriate treatment of pain• Misuse, abuse, and diversion of opioid medications• Development of new non-opioid chronic pain treatments and new models of care

• Clinical considerations• Consider psychological and social risk factors• Establish the pathophysiologic pain type(s) using available screening tools • Document pain assessments to enable effective management and monitoring • Use the pathophysiologic pain type(s) to help guide 1st line treatment selection• Consider opioid medications second line, unless contraindicated• Employ universal precautions to opioid prescribing• Set treatment goals with follow-up reevaluation of pain type and severity, impact,

medication management and referrals to specialists, when appropriate


Documents

Rethink Chronic Pain - Pfizer Medical Information - US · 2019-01-23 · How Do Chronic Pain States Develop? - Uncoupling of pain from peripheral stimuli - Membrane excitability,