HOSA Biomedical Debate

Growing focus upon the individual set the scene for the introduction of surgical anesthesia (date)

1846

What the US Congress declared as the "Decade of Pain Control and Research" (date)

2001-2010

Transforming practice of medicine initiated the tension between the desire to make available the medicinal benefits of these drugs and recognition that the development of abuse and addiction can lead to devastating consequences (date)

19th century

Morphine was extracted from opium by Friedrich Serturner of Germany (date)

1803

A major change occurred. The use of opioids for chronic pain began to increase. (date)

1990s

Codeine rescheduling prevented consumers accessing over-the-counter opioids without a prescription. (date)

February 2018

Dr. Charles Wood

Scottish physician, invented the hypodermic needle and used it to inject morphine to relieve pain from neuralgia

Dr. Eduard Livenstein

German physician, produced the first accurate and comprehensive description of addiction to morphine, including the withdrawal syndrome and relapse, and argued that craving for morphine was a physiological response.

Acute pain

Pain that comes on suddenly and has a limited duration. It's frequently caused by damage to tissue such as bone, muscle, or organs, and the onset is often accompanied by anxiety or emotional distress

Chronic pain

Chronic pain lasts longer than acute pain and is generally somewhat resistant to medical treatment. It's usually associated with a long-term illness, such as osteoarthritis. Often is attributable to nerve damage. Doctors often define chronic pain as any pain that lasts for 3 to 6 months or more.

Breakthrough pain

temporary flare-up of moderate to severe pain that occurs even when the patient is taking around-the-clock medication for persistent pain

Nociceptive pain

pain caused by tissue damage

Neuropathic pain

chronic pain caused by nerve damage

Psychogenic pain

pain that is affected by psychological factors (usually has a physical origin of tissue or nerve damage)

Myofascial Pain Syndrome (MPS)

pain that is set off by trigger points located in the muscles

central pain syndrome

chronic pain that stems from damage to the central nervous system

complex regional pain syndrome

chronic pain that follows a serious injury

diabetic peripheral neuropathic pain

pain that comes from nerve damage in the feet, legs, hands, or arms caused by diabetes

Shingles (Postherpetic Neuralgia)

a localised infection caused by the same virus that causes chickenpox. common complication in which the pain from shingles lasts more than a month

trigeminal neuralgia

pain as a result of inflammation of a facial nerve

chronic pain causes

past injuries or surgeries, back problems, migraines, arthritis, nerve damage, infections, fibromyalgia

difference in addiction vs dependency

Addiction will lead to physical withdrawl symptoms if supply is cut off while there is no chance of physical withdrawl symptoms from a dependency

chronic pain causes

past injuries or surgeries, back problems, migraines, arthritis, nerve damage, infections, fibromyalgia

What are some causes of chronic pain?

*disease

*nerve damage

*injuries that have not healed properly

*Rheumatoid arthritis

*osteoarthritis

*fibromyalgia

*cancer

*multiple sclerosis

*stomach ulcers

*AIDS

*gallbladder disease

How do doctors find the cause of pain?

Asking about your symptoms and your medical history, including any illness, injury, or surgery. Your doctor will also examine you and may order blood tests or X-rays.

Tests that pinpoint the cause of pain:

*CT scan

*MRI

*Nerve blocks

*Discography:

*Myelogram

*EMG

*Bone scans

*Ultrasound imaging

Milder forms of pain may be relieved by...

over-the-counter medications such as Tylenol (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen.

Stronger medications for pain relief

muscle relaxants, anti-anxiety drugs (such as diazepam [Valium]), antidepressants (like duloxetine [Cymbalta] for musculoskeletal pain), prescription NSAIDs such as celecoxib (Celebrex), or a short course of stronger painkillers (such as codeine, fentanyl [Duragesic, Actiq], oxycodone and acetominophen (Percocet, Roxicet, Tylox) or hydrocodone and acetominophen (Lorcet, Lortab, and Vicodin). A limited number of steroid injections at the site of a joint problem can reduce swelling and inflammation. An epidural might be given for spinal stenosis or lower back pain.

Patient-controlled analgesia (PCA)

a drug delivery system that uses a computerized pump with a button the patient can press to deliver a dose of an analgesic through an intravenous catheter

Trigger Point Injection

A procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. A healthcare professional, using a small needle, injects a local anesthetic that sometimes includes a steroid into a trigger point. With the injection, the trigger point is made inactive and the pain is alleviated.

OnabotulinumtoxinA (Botox)

A toxin that blocks signals from the nerves to the muscles. It can also be injected to alleviate chronic migraine headaches.

How do opioids work?

Opioid drugs bind to opioid receptors in the brain, spinal cord, and other areas of the body. They tell your brain you're not in pain. They are used to treat moderate to severe pain that may not respond well to other pain medications

Types of opioids:

Codeine (only available in generic form)

Fentanyl (Actiq, Duragesic, Fentora, Abstral, Onsolis)

Hydrocodone (Hysingla, Zohydro ER)

Hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)

Hydromorphone (Dilaudid, Exalgo)

Meperidine (Demerol)

Methadone (Dolophine, Methadose)

Morphine (Kadian, MS Contin, Morphabond)

Oxycodone (OxyContin, Oxaydo)

Oxycodone and acetaminophen (Percocet, Roxicet)

Oxycodone and naloxone

What are the side effects of opioids?

*Constipation

*Drowsiness

*Nausea and vomiting

What's the difference between addiction and tolerance?

After taking opioid pain medication for a while, you might find that you need more and more of the drug to achieve the same effect in easing pain. This is called tolerance. It's not the same as addiction, which involves a compulsive use of a drug

What are the withdrawl symptoms of opioids?

*Diarrhea, nausea, and vomiting

*Muscle pain

*Anxiety

*Irritability

symptoms of unrelieved pain after surgery

*increased heart rate

*systemic vascular resistance

*circulating catecholamines, placing patients at risk of myocardial ischemia, stroke, bleeding, and other complications

A prevalence study in Australia revealed...

a strong association between chronic pain and being unemployed for health reasons and receiving disability benefits

the 3 propositions for the necessity of pain management that make a 'call to arms'

1. pain, acute or chronic, is inadequately addressed for a variety of cultural, educational, political, and religious reasons. 2. inadequately treated pain has major physiological, psychological, economic, and social ramifications for patients, their families, and society. 3. it is within the capacity of all developed and many developing countries to significantly improve the treatment of pain.

what coherent international consensus is emerging for medicine?

the unreasonable failure to treat pain is poor medicine, unethical practice, and is an abrogation of a fundamental human right

if you live with chronic pain, how much more likely is it to also suffer from depression or anxiety?

4x

with therapeutic intervention, how many postoperative patients still report inadequate pain relief, or pain of greater intensity

40%

what % of adults suffer from chronic pain? how much does that increase in adults over 65?

15-25%. by 50%

what % of Americans who rated their pain as severe or unbearable had not visited any health care professional because they did not think that anyone could relieve their suffering

18%

how many cases of cancer are diagnosed annually?

10 million

what mentality of opioids is associated with advancing age, lower levels of education, and lower incomes?

high levels of concern

how much does the U.S. spend annually on the direct and indirect costs of chronic pain?

$600 billion

how many Americans currently living with chronic pain report little to no control over their pain?

100 million, more than half

what are 3 questions a patient should ask their doctor before trying opioids?

1. Why am I being prescribed an opioid? (What is the goal and what is the endpoint?)

2. What are the risks of taking this medication?

3. Are there alternative treatment options?

how do doctors find the cause of pain?

CT scan, MRI, Nerve Blocks, Discography, Myelogram, EMG, Bone Scans, Ultrasounds Imaging

who developed the quality of life scale for pain?

The American Chronic Pain Association (ACPA)

what does the quality of life scale for pain assess?

your mood, your ability to work, socialize, exercise, and perform household chores

how does the quality of life scale for pain work?

you're asked to rank your quality of life on a scale of zero (non-functioning) to 10 (normal quality of life)

TENS Therapy

a small, battery-operated device delivers low-voltage electrical current through the skin via electrodes placed near the source of pain. The electricity from the electrodes stimulates nerves in the affected area and sends signals to the brain that "scramble" normal pain perception. TENS is not painful and may be effective therapy to mask pain such as diabetic neuropathy. However, TENS for chronic low back pain is not effective and cannot be recommended, the American Academy of Neurology (AAN) now says.

Intradiscal Electrothermal Therapy (IDET)

intervertebral discs act as cushions between the vertebrae. Sometimes the discs can become damaged and cause pain. IDET uses heat to modify the nerve fibers of a spinal disc and to destroy pain receptors in the area. In this procedure, a wire called an electrothermal catheter is placed through an incision in the disc. An electrical current passes through the wire, heating a small outer portion of the disc to a temperature of 90 degrees Celsius. IDET is performed as an outpatient procedure while the patient is awake and under a local anesthesia.

Radiofrequency Discal Nucleoplasty

radiofrequency discal nucleoplasty is a newer procedure which utilizes a radio frequency probe instead of heating wire to disintegrate a small portion of the central disc material. The result of this intervention is partial decompression of the disc, which may help relieve pain caused by bulging discs pressing on nearby spinal nerve roots.

What Conditions Are Treated With Bioelectric Therapy?

Complex regional pain syndrome, also known as reflex sympathetic dystrophy or RSD, Back pain, Muscle pain, Headaches and migraines, Disorders of blood flow in the upper and lower limbs, Arthritis, Temporomandibular joint (TMJ) syndrome (which affects the jaw), Disorders of the nervous system, such as diabetic neuropathy, Pain and ulcers of the skin resulting from poor circulation or scleroderma (a chronic condition that can cause thickening or hardening of the skin)

When is Bioelectric Therapy not recommended?

Have a pacemaker, Are pregnant, Have thrombosis (blood clots in the arms or legs), Have a bacterial infection

what are the different types of therapies?

non-pharmacological and pharmacologic

what does non-pharmacological therapy include?

includes psychological (cognitive behavioral therapy), physical rehabilitative (physical therapy, occupational therapy) , surgical approaches; and complementary therapies (acupuncture, chiropracty)

what does pharmacological therapy include?

non-opioid, opioid, and adjuvant medications

what are the important aspects of a patient assessment?

Patient history, the use of screening tools (determine risk of developing chronic pain and/or misuse), pain assessment, functional assessment (physical or emotional), physical examination, psychosocial evaluation, diagnostic studies (cause of pain and appropriate response), proper documentation.

what should a treatment plan layout include?

the types of therapies planned, the goals of treatment, and an explanation of the patient and prescriber roles and responsibilities, goals related to pain interfering with life activities such as school, work, and social activities.

what is the difference between abuse and misuse?

Abuse: taking an opioid to get high

Misuse: taking more than prescribed for pain or giving to someone else in pain

what are some strategies to avoid abuse?

Dosing instructions, safe storage, proper disposal, encouraging availability of naloxone, and seeking immediate medical treatment if overdose occurs.

what should HCPs should be knowledgeable about when it comes to opioid rotation?

the concept of incomplete cross-tolerance when converting patients from one opioid to another, the concepts and limitations of the conversion charts in labeling and the limitations of equianalgesic dosing tables in literature, patient adherence to the treatment plan, especially with regard to misuse and abuse.

how can pain be categorized?

according to its duration, underlying pathophysiology of the original insult, and whether a central sensitization component has developed.

What is the main opioid receptor?

Mu

What is an opioid agonist?

Opioids that activate and bind receptors

What is an opioid antagonist?

Opioids that occupy but do not activate. They reverse the effects of agonists. Ex: naloxone

What is an agonist-antagonist drug?

A drug that is an agonist at one receptor and an antagonist at another

What are the two types of chronic pain?

Nociceptive and neuropathic

how many deaths were opioid related in 2016?

1 in 65

in what age group is the burden of opioid deaths in the united states the highest?

25-35 years

since opioid misuse and death is increasing among adults 50 and older, what is that number expected to do between 2004 and 2020?

double

what are some practical steps for a holistic treatment for chronic pain

-Regular use of validated brief outcome tools (just asking patients how bad their pain is out of 10)

-Assessing cognitive aspects (ask what the patient is concerned about or fears the most regarding their pain)

-Assessing physical activity (use the Five Times Sit to Stand Test)

what happens to the risk of long-term opioid usage at one year after a prescription for one week for acute pain?

it doubles (6% to 13%)

what happens to this risk against if the prescription lasts a month?

it doubles again (to 29.9%)

what happens to pain intensity after patients consider meaningful chronic pain relief?

it reduces by 50%

what is frequently associated with chronic pain?

obesity

what has been hypothesised to be the nexus between the Western diet and the maladaptations in the nervous, immune and endocrine systems?

the gut microbial profile or microbiome

recent animal and human studies indicate that what could be directly linked to chronic pain?

opioids

what condition causes a perceived increase in pain and a need for dose escalation?

tolerance

HHS Five-Point Opioid Strategy: Point 1

strengthening public health surveillance

HHS Five-Point Opioid Strategy: Point 2

advancing the practice of pain management

HHS Five-Point Opioid Strategy: Point 3

improving access to treatment and recovery services

HHS Five-Point Opioid Strategy: Point 4

targeting availability and distribution of overdose-reversing drugs

HHS Five-Point Opioid Strategy: Point 5

supporting cutting-edge research

how much money did STR grants spend fighting the opioid crisis in the fiscal years 2017 & 2018?

$500 million per year

Medically supervised withdrawal

(formerly called detoxifcation)Using an opioid agonist (or an alpha-2 adrenergic agonist if an opioid agonist is not available) in tapering doses or other medications to help a patient discontinue illicit or prescription opioids.

Opioid misuse

The use of prescription opioids in any way other than as directed by a prescriber; the

use of any opioid in a manner, situation, amount, or frequency that can cause harm to self or others

Opioid treatment program (OTP)

An accredited treatment program with SAMHSA certifcationand Drug Enforcement Administration registration to administer and dispense opioid agonist medications that are approved by FDA to treat opioid addiction. Currently, these include methadone and buprenorphine products. Other pharmacotherapies, such as naltrexone, may be provided but are not subject to these regulations. OTPs must provide adequate medical, counseling, vocational, educational, and other assessment and treatment services either onsite or by referral to an outside agency or practitioner through a formal agreement

Opioid use disorder (OUD)

Per DSM-5, a disorder characterized by loss of control of opioid use, risky opioid use, impaired social functioning, tolerance, and withdrawal. Tolerance and withdrawal do not count toward the diagnosis in people experiencing these symptoms when using opioids under appropriate medical supervision. OUD covers a range of severity and replaces what DSM-IV termed "opioid abuse" and

"opioid dependence." An OUD diagnosis is applicable to a person who uses opioids and experiences at least 2 of the 11 symptoms in a 12-month period. (See Exhibit 2.13 in Part 2 for full DSM-5 diagnostic criteria for OUD.)

Recovery

A process of change through which individuals improve their health and wellness, live selfdirected lives, and strive to reach their full potential. Even individuals with severe and chronic SUDs can,

with help, overcome their SUDs and regain health and social function. Although abstinence from all

substance misuse is a cardinal feature of a recovery lifestyle, it is not the only healthy, prosocial feature. Patients taking FDA-approved medication to treat OUD can be considered in recovery.

how much money do STR grants plan to spend fighting the opioid crisis in the fiscal year 2019?

$1 billion

Relapse

A process in which a person with OUD who has been in remission experiences a return of

symptoms or loss of remission. A relapse is different from a return to opioid use in that it involves more than a single incident of use. Relapses occur over a period of time and can be interrupted. Relapse need not be long lasting. The TIP uses relapse to describe relapse prevention, a common treatment modality.

Remission

A medical term meaning a disappearance of signs and symptoms of the disease.7 DSM-5

defnes remission as present in people who previously met OUD criteria but no longer meet any OUD criteria (with the possible exception of craving).8 Remission is an essential element of recovery.

The three FDA-approved medications used

to treat OUD improve patients' health and

wellness by:

• Reducing or eliminating withdrawal

symptoms: methadone, buprenorphine.

• Blunting or blocking the effects of

illicit opioids: methadone, naltrexone,

buprenorphine.

• Reducing or eliminating cravings to

use opioids: methadone, naltrexone,

buprenorphine.

Methadone

(agonist) A synthetic analgesic drug that is similar to morphine in its effects but longer acting, used as a substitute drug in the treatment of morphine and heroin addiction.

How many patients who are opioid dependent smoke cigarettes?

More than 80 percent