Prevalence of Recurrent and Persistent Pain in the US

•  1 in 4 Americans suffer from recurrent pain (day-long bout of pain/month)

•  1 in 10 Americans report having persistent pain of at least one year’s duration

•  1 in 5 individuals over the age of 65 report pain persisting for more than 24 hours in the preceding month

– 6 in 10 report pain persisting > 1 year

•  2 out of 3 US armed forces veterans report having persistent pain attributable to military service

– 1 in 10 take prescription medicine to manage pain

American Pain Foundation. http://www.painfoundation.org. Accessed March 2010.

National Institutes of Health. New Directions in Pain Research. Sept 1998. PA-98-102.

DAWN 2009   Heroin 213,118 visits   Narcotic Pain Relievers: 397,160 visits

  Oxycodone/combinations – 175,949 visits   Hydrocodone/combinations – 104,490 visits   Fentanyl/combinations – 22,143 visits   Buprenorphine/combinations – *12,544   Alcohol involvement: 32% of visits Source: Drug Abuse Warning Network, National Estimate, 2010; The Drug Abuse Warning Network

(DAWN) is a public health surveillance system that monitors drug-related morbidity and mortality. DAWN uses a probability sample of hospitals to produce estimates of drug-related emergency department (ED) visits for the United States and selected metropolitan areas annually. DAWN also produces annual profiles of drug-related deaths reviewed by medical examiners or coroners in

selected metropolitan areas and States.

*estimate may be low because buprenorphine is not specifically queried

The majority of unintentional overdose deaths were related to opioid use including oxycodone, hydrocodone, and methadone, often in combination with other drugs and/or alcohol. Source: Methadone Mortality Conference, CSAT/SAMHSA, July 2010 http://www.cdc.gov/HomeandRecreationalSafety/pdf/poision-issue-brief.pdf

A Common Dilemma in Medicine

Lithium Stimulants Antipsychotics Beta-blockers

O Antidepressants Anticonvulsants Alpha blockers BZDs

NSAIDS Opioids Acetominophen Steroids

A-delta (myelinated) and C (unmyelinated) afferents with cell bodies in dorsal root ganglion act as nociceptors: sensitive to noxious stimuli: heat, mechanical, irritating chemicals Sensitization in local tissue with release of prostaglandins, bradykinins, leukotrienes Nociceptors can cause release of Substance P resulting in further local inflammation

Axons of primary afferent nociceptors enter spinal cord via the dorsal root terminating in dorsal horn of spinal gray matter

Spinal neurons then transmit pain signals to brain: thalamus which projects to somatosensory cortex (ascending transmission)

Projections to cortical regions (cingulate and frontal lobe) linked to emotional responses resulting in unpleasant emotional perceptions

Pain can be modulated via a descending circuit that has links in hypothalamus, medulla, and midbrain. Selectively controls spinal pain transmission neurons; contains endogenous opioids

Anatomy of Pain

Pain  

Diet/Exercise/PT   Anticonvulsant

s  

Surgery  

Chiropractic  Treatment  

Acupuncture  

TENS  

Cognitive  Behavioral  Therapy  

Massage/Yoga  

Nerve  Block  

Trigger  Point  Injections  

Opioid  Risk  Tool  (ORT)  •  Administration  •  On  initial  visit  •  Prior  to  opioid  therapy  

•  Scoring  •  0-­‐3:  low  risk  (6%)  •  4-­‐7:  moderate  risk  (28%)  

•  >  8:  high  risk  (>  90%)  

Webster & Webster. Pain Med. 2005;6:432.

Opioids  for  Pain  Management  

Passik SD, Kirsh KL. J Supportive Oncology, 2005.

Clinical Support Systems Sponsored by Center for Substance Abuse Treatment/SAMHSA

References