Saying “Farwell” to Pain-Topics.org

At the end of January, the Pain-Topics.org website was permanently shut down. However, most of the Pain-Topics.org resources, including proprietary research/review articles, will be moved to The Pain Community (TPC) website — at http://paincommunity.org — allowing continued and free access by all interested persons.

The Pain-Topics News/Research UPDATES will continue to be posted on a periodic basis at http://pain-topics.blogspot.com. If you would like to receive notification of when the UPDATES are posted you can subscribe via FeedBurner at: http://feedburner.google.com/fb/a/mailverify?uri=PainTopicsUpdates&loc=en_US

Source: PainTopics.org – January 2014

New Resources Available From SAMHSA

Based on TIP 53: Addressing Viral Hepatitis in People with Substance Use Disorders – A Quick Guide for Clinicians and Administrators

Offers clinicians information to address viral hepatitis when working with people with substance use disorders. Covers hepatitis prevention, screening, treatment, and service coordination, and guides administrators on how to add or improve hepatitis services.

http://atforum.com/addiction-resources/documents/TIP53QuickGuide_000.pdf


Based on TIP 54: Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders – A Quick Guide for Clinicians and Administrators

Summarizes guidelines for clinicians treating chronic pain in adults with a history of substance abuse. Covers patient assessment, chronic pain management, managing addiction risk in patients treated with opioids, and patient education.

http://atforum.com/addiction-resources/documents/TIP54QuickGuide.pdf

Source: Substance Abuse Mental Health Services Administration – November 2013

Poorly Managed Pain Relief Can Have Devastating Consequences for Addicts

pain“Research led by King’s College London’s National Addiction Centre (NAC) calls for systemic attempts to reduce stigma and raise awareness amongst healthcare professionals when treating current or former addicts

The mismanagement of pain in current and former addicts can have disastrous, life-threatening consequences, according to a report published today by researchers from King’s NAC.

The report, which was commissioned by Action on Addiction and is endorsed by the Royal College of Psychiatrists, warns that current and former addicts are at risk of relapse to addiction, compromised medical care and potentially fatal overdose when being treated for pain in hospitals and doctors’ surgeries. The report, entitled The management of pain in people with a past or current history of addiction, identifies the stigma surrounding addiction as the main barrier to safe and effective pain relief.”

http://www.healthcanal.com/substance-abuse/39786-poorly-managed-pain-relief-can-have-devastating-consequences-for-addicts.html

Source: HealthCanal.com – June 13, 2013

New Poll Ranks Chronic Pain Well Below Drug Addiction As A Major Health Problem

“A new national public opinion poll commissioned by Research!America shows only 18% of respondents believe chronic pain is a major health problem, even though a majority of Americans (63%) say they know someone who experienced pain so severe that they sought prescription medicines to treat it. Chronic pain conditions affect about 100 million U.S. adults at a cost of approximately $600 billion annually in direct medical treatment costs and lost productivity.

Most Americans are concerned about the misuse of pain medication to treat chronic pain. A high percentage (82%) believes that taking prescription painkillers for long-term, chronic pain could result in addiction, which nearly 50% of Americans describe as a major health problem. An overwhelming majority (85%) are very concerned or somewhat concerned that prescription pain medication can be abused or misused. Indeed, 40% believe that prescription medication abuse and addiction is a major problem in their community.”

http://www.medicalnewstoday.com/releases/258897.php

Source: MedicalNewsToday.com – April 12, 2013

Chronic Pain in Opioid Treatment Program Patients Typically Untreated

Many patients in opioid treatment programs (OTPs) are likely to have chronic pain, but in many, that pain will not be adequately treated, in part because there are so many problems balancing the methadone they are given for opioid dependence with the types of medications needed to treat pain.

“Most physicians in an OTP have experience treating addiction and pain, I can guarantee that,” said Nicholas Reuter, MPH, senior public health analyst with the Center for Substance Abuse Treatment (CSAT) at the federal Substance Abuse and Mental Health Services Administration (SAMHSA). “I go in and inspect the programs, and I can see patients who obviously have some chronic pain issues. They’re not hard to identify—they have canes, walkers, and scars.”

But OTPs cannot be pain management clinics because of regulations, said Randy Seewald, MD, medical director of the methadone maintenance treatment program at Beth Israel Medical Center in New York City.  “If a patient comes to us and says, ‘I just want methadone once a day for pain,’ we can’t admit them,” said Dr. Seewald, who has a fellowship in pain management. Sometimes patients may say this because they don’t want to admit that they are addicted.

Methadone needs to be given multiple times each day for pain relief. And the federal regulations allow OTPs to dose only once a day, which is adequate to prevent withdrawal.

At Beth Israel, the first OTP in the country, many patients are older, noted Dr. Seewald. “In general as people age, they are more likely to develop chronic pain,” she said, adding that many Beth Israel patients have had significant illnesses, including HIV and hepatitis C. She defines chronic pain as pain lasting 6 months or more.

Study: Epidemiology of Pain in MMT Programs

“We know this is a vulnerable population of chronic pain patients,” said Lara K. Dhingra, PhD, Co-chief of the Research Division in the Department of Pain Medicine and Palliative Care at Beth Israel. “Patients who are on methadone for treatment of their addictive disorder may still require treatment for their chronic pain, and at present there aren’t any guidelines for protocols we should be following with respect to the medication regimen,” said Dr. Dhingra, who works with Dr. Seewald. “The majority of patients are likely to not have their pain treated.”

Dr. Dhingra is the lead author of “Epidemiology of pain among outpatients in methadone maintenance treatment programs,” part of a larger study funded by the National Institute on Drug Abuse (R01DA020781, R01DA020841), published in the August 27 issue of Drug and Alcohol Dependence. Her study (Dr. Seewald and Russell K. Portenoy, MD, chairman of the Department of Pain Medicine and Palliative Care, are among the co-authors) was based on sites in New York and San Francisco in which all patients had hepatitis C. Of the 489 patients in the study, 237 (48.5 percent) had clinically significant pain.

The patients treated their pain with prescribed opioids (38.8 percent of patients), non-opioids (48.9 percent) and self-management approaches, including prayer (33.8 percent), vitamins (29.5 percent), and distraction (12.7 percent). (Some patients used more than one approach.)

The same steps that are followed for people who are not opioid dependent should be followed for OTP patients with chronic pain, said Dr. Seewald. This means diagnosing and trying to treat the cause if possible, starting with non-drug therapies and nonopioid drugs, and considering opioids only if an assessment indicates that these drugs are likely to be safe and effective, and taken in a responsible way over time. In this population, opioids often are viewed as the last resort, but for many OTP patients who have hepatitis C, acetaminophen, with its liver effects, would not be appropriate, and NSAIDs have a high risk of gastrointestinal bleeding, she said.

The primary care provider (PCP) is generally in charge of pain management, said Dr. Seewald. But she noted that the OTP sees the patients much more frequently than either the pain specialist or the PCP, and the OTP is required by the Joint Commission to assess pain at every visit.

Methadone for Pain

Interestingly, methadone can be a great medication for pain in general, because it does not produce the euphoria or rush of other opioids in patients who may be predisposed to this effect, said Dr. Seewald. “Methadone is challenging to use for pain, however, and doctors who do not have experience in using it this way should obtain help before doing so.” 

Although Dr. Seewald did a fellowship in pain management—precisely because so many OTP patients have pain—she does not treat patients for pain alone, even in her private practice. “I’m also a pain specialist, but if I have someone with pain and addiction, I will work with another pain specialist,” she said. “You don’t want to be the only one involved.”

 Need for Training on Opioids and Pain

“The federal regulations don’t say anything about pain treatment,” said Mr. Reuter. “They’re really tailored toward treating dependence.” But OTPs are ideal, in many ways, for dealing with patients who need opioids. With all of the training given to OTP physicians about the pharmacology of methadone treatment, said Mr. Reuter, these physicians would be likely to have more knowledge about opioids and their risks than average physicians. “Methadone is one of the most complicated opioids there are,” he said.

Primary care physicians need to know more about medication-assisted treatment of addiction, but it works both ways—OTPs need to know more about pain, said Dr. Seewald. “I worked in drug treatment with methadone patients for 20 years before I took my pain fellowship. We were never trained to treat pain.”

Perspective: Docs Feel Pressure to Give Addicts Opioids

doctors“A push to treat chronic pain and financial disincentives for treating addiction may pressure clinicians into prescribing opioids for patients who are already addicted, a researcher suggested.

Over the past decade, there’s been a perfect storm of changing clinician attitudes toward pain treatment and patient attitudes towards suffering, combined with a lack of compensation for time-consuming clinic visits such as addiction counseling, Anna Lembke, MD, of Stanford University, wrote in a perspective in the New England Journal of Medicine.”

http://www.medpagetoday.com/Psychiatry/Addictions/35539

The full perspective can be accessed at: http://www.nejm.org/doi/full/10.1056/NEJMp1208498

Source: MedPageToday.com – October 24, 2012

3Qs: When Painkillers Kill

The U.S. Food and Drug Administration recently introduced a series of safety measures designed to reduce the risk of extended-​​release and long-​​acting opioid medications. Northeastern University news office asked drug policy expert Leo Beletsky, an assistant professor of law and health sciences at Northeastern University, to expound upon the threat posed by opioid analgesics, 22.9 million prescriptions of which were dispensed last year. The Q & A’s include:

  • Why has opioid abuse increased over the last decade?
  • How has President Barack Obama’s 2011 Prescription Drug Abuse Prevention Plan fared in curbing the abuse of prescription drugs, the second-most abused category of drugs after marijuana?
  • What would be your strategy for improving the safe use of opioids while ensuring access to prescription drugs for patients in pain?

http://www.northeastern.edu/news/2012/08/opioids/

Source: MedicalExpress.com – August 3, 2012

Vital Signs: Risk for Overdose from Methadone Used for Pain Relief — United States, 1999–2010

According to a new report from the Centers for Disease Control and Prevention (CDC) prescription painkiller overdoses were responsible for more than 15,500 deaths in 2009. While all prescription painkillers have contributed to an increase in overdose deaths over the last decade, methadone has played a central role in the epidemic. More than 30% of prescription painkiller deaths involve methadone, even though only 2% of painkiller prescriptions are for this drug. Six times as many people died of methadone overdoses in 2009 than a decade before.

The report also acknowledged that methadone has been used safely and effectively to treat drug addiction for decades. It has been prescribed increasingly as a painkiller because it is a generic drug that can provide long-lasting pain relief. But as methadone’s use for pain has increased, so has nonmedical use of the drug and the number of overdoses.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm61e0703a1.htm?s_cid=mm61e0703a1_w

http://www.cdc.gov/VitalSigns/MethadoneOverdoses/

Source: The Centers for Disease Control and Prevention - July 6, 2012

Heroin Addicts Have Higher Pain Sensitivity, Even During Treatment

Heroin addicts often have an increased sensitivity to pain, and this sensitivity does not subside over the course of treatment with methadone or other opioids, new research finds.

Researchers from the University of California-Los Angeles sought to determine how increased sensitivity to pain might change as a heroin addict moves from drug abuse to stabilization and eventually to maintenance on a pain-treatment opioid such as methadone or buprenorphine.

http://health.usnews.com/health-news/news/articles/2012/04/25/heroin-addicts-have-higher-pain-sensitivity-even-during-treatment

Source: USNews.com– April 25, 2012

Veterans of Iraq, Afghanistan Wars with Mental Health Diagnoses More Likely to Receive Prescription Opioids for Pain

Iraq and Afghanistan war veterans with mental health diagnoses, particularly posttraumatic stress disorder, are more likely to receive prescription opioid medications for pain-related conditions, have higher-risk opioid use patterns and increased adverse clinical outcomes associated with opioid use than veterans with no mental health diagnoses, according to a study in the March 7 issue of the Journal of the American Medical Association (JAMA).

Greater exposure to combat coupled with improvements in battlefield medicine and protective gear have resulted in large numbers of veterans of Iraq and Afghanistan surviving injuries that would have been fatal in prior wars. Veterans are returning home with co-existing mental and physical health problems, and posttraumatic stress disorder (PTSD) is the most prevalent mental health disorder. “Nationwide, the prescription of opioid analgesics has nearly doubled since 1994 because of a greater recognition of the importance of treating pain. At the same time, rates of prescription opioid misuse and overdose have increased sharply, and prescription opioids are now a leading cause of death in the United States. Iraq and Afghanistan veterans with pain- and PTSD-prescribed opioids may be at particularly high risk of prescription opioid misuse given the high co-occurrence of substance use disorders among veterans with PTSD,” according to background information in the article.

Karen H. Seal, MD, MPH, of the San Francisco Veterans Affairs Medical Center, and colleagues examined the association between mental health disorders and patterns of opioid prescription use, related risks, and adverse clinical outcomes, such as accidents and overdose, among a national sample of 141,029 Iraq and Afghanistan veterans. The study included veterans who received at least one non-cancer-related pain diagnosis within one year of entering the Department of Veterans Affairs (VA) health care system from October 2005 through December 2010.

Additional information on the study is available at: http://pubs.ama-assn.org/media/2012j/0306.dtl#1

Journal of the American Medical Association – March 6, 2012

SAMHSA Issues New Treatment Improvement Protocols (TIPS) on Hepatitis and Chronic Pain

TIP 53: Addressing Viral Hepatitis in People with Substance Use Disorders

This TIP was developed to assist behavioral health professionals who treat people with substance abuse problems in understanding the implications of a diagnosis of hepatitis. The TIP discusses screening, diagnosis, and referrals and explains how to evaluate a program’s hepatitis practices.

http://atforum.com/addiction-resources/documents/TIP53.pdf

TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

TIP 54 was developed to help equips clinicians with practical guidance and tools for treating chronic pain in adults with a history of substance abuse. The document discusses chronic pain management, including treatment with opioids, and offers information about substance abuse assessments and referrals.

http://www.atforum.com/addiction-resources/documents/TIP54.pdf

Source: The Substance Abuse and Mental Health Services Administration – December 2011 & January 2012

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