P & A Course Addresses Opioid Overdose Epidemic

Attendees look for seats following breakfast at the start of Thursday's Pain & Addiction Course, "Common Threads XIV—When Opioids Fail."

Attendees look for seats following breakfast at the start of Thursday’s Pain & Addiction Course, “Common Threads XIV—When Opioids Fail.”

This year’s Pain & Addiction Course, “Common Threads XIV—When Opioids Fail,” tackled the epidemic of prescription painkiller addiction with daylong sessions that included FDA-approved education on extended-release and long-acting (ER/LA) opioid analgesics.

“In 2010 and 2011 more people died from accidental overdose of opioids than died in auto accidents,” said Herbert Malinoff, MD, FACP, FASAM, citing the statistic that puts the problem in perspective for physicians. “And for every opioid overdose death there are eight to 10 nonfatal overdoses.”

Dr. Malinoff, Medical Director of Pain Recovery Solutions, PC, Ypsilanti, Mich., co-chaired the course with Edwin A. Salsitz, MD, FASAM, Medical Director, Office-based Opioid Therapy, Beth Israel Medical Center, New York.

“ASAM certainly is very concerned with the overdoses and overdose deaths, and the surge in addiction,” Dr. Salsitz said.

ASAM is one of 10 partner-organizations in the Collaborative for REMS Education (CO*RE) that will provide the Risk Evaluation and Mitigation Strategy (REMS), following the FDA’s blueprint for ER/LA opioid analgesics. ASAM has received funding to train more than 2,000 prescribers from June 1, 2013, to April 2014. The goal of REMS is to reduce serious adverse outcomes and abuse of the medications while maintaining patient access to pain medications.

REMS education took up the first half of the Pain & Addiction Course and covered the full range of ER/LA opioids analgesic treatment from assessing patients; initiating, managing, and discontinuing therapy; and counseling patients about safe use. This was followed by drug information for ER/LA opioids and Dr. Salsitz’s presentation “Is My Patient Opioid Addicted?—Diagnosis and Management.”

The morning concluded in a hard-hitting game of opioids “Jeopardy” with a panel of experts and interactive audience participation.

The afternoon course’s title, “When Opioids Fail,” is telling.

“There are hundreds of thousands of cases of opioids being a failure,” Dr. Malinoff said. “When opioids fail there, can be death, nonfatal overdose, theft or diversion of prescription opioids, and side-effects of the drugs, such as drowsiness, sleeplessness, respiratory disorders, and chronic pain.”

The most successful use of opioids is in treating acute pain, but physicians are less trained in using opioids in chronic pain,” he said.

Treating chronic pain has become an ongoing controversy, which Dr. Malinoff likens to the use of cortisone in the 1950s, when patients crippled with rheumatoid arthritis rose from their wheelchairs only later to suffer severe side effects from chronic use.

“Fifteen years ago we said ‘yes,’ to using opioids for chronic pain, and now we’re reaping that harvest with overuse of the medications,” Dr. Malinoff said. “The tragedy is teenagers taking their friends’ moms’ pills and dying.”

The same principle needs to be applied to ER/LA opioid prescribing for chronic pain as was done with prednisone and chronic inflammatory conditions, he said—not all people with pain should be on them and no one should be on them forever.

The failure of opioids in chronic pain was covered in theory during the afternoon sessions, with a basic science lecture on changes in the brain’s neurocircuitry that predict pain “chronification.” Other presentations focused on interventional techniques and the psychological evaluation and management of chronic pain/addiction patients.

The afternoon sessions also focused on the connection between tobacco use and pain. “Nicotine and tobacco have a huge role in perpetuating chronic pain,” Dr. Malinoff said. People who smoke have a lower threshold for pain.

“Smoking is an active addiction and a red flag for people on pain medication. Science suggests that we address each addiction up front, at the same time to get a better outcome,” he said.

Patients with pain and opioid addiction are complex cases. Excepting palliative care at end-of-life, the single most important use of, and reason for, ER/LA opioids is the objective improvement in function, Dr. Malinoff said.

“You need to assess the patient’s current function and what is the goal, and are we achieving the goals. If the patient on opioids is still sitting all day watching television, that is not an improvement in function. Improvement in function is employment, volunteerism, or being active, and not just a pain score,” he said.