Calmare Therapeutics Inc (fka CTTC)

[powderbum]

NIH WANTS To SEE some changes in CHRONIC PAIN MANAGEMENT

https://prevention.nih.gov/docs/programs/p2p/ODPPainPanelStatementFinal_10-02-14.pdf

NATIONAL INSTITUTES OF HEALTH
Pathways to Prevention Workshop:
The Role of Opioids in the Treatment of Chronic Pain
September 29–30, 2014
EXECUTIVE SUMMARY
The National Institutes of Health (NIH) workshop is co-sponsored by the NIH Office of Disease Prevention (ODP),
the NIH Pain Consortium, the National Institute on Drug Abuse, and the National Institute of Neurological
Disorders and Stroke. A multidisciplinary Working Group developed the workshop agenda, and an evidence report
was prepared by an Evidence-based Practice Center through a contract with the Agency for Healthcare Research
and Quality to facilitate the workshop discussion. During the 1½-day workshop, invited experts discussed the body
of evidence, and attendees had opportunities to provide comments during open discussion periods. After weighing
evidence from the evidence report, expert presentations, and public comments, an unbiased, independent panel
prepared this draft report, wprepared this draft report, which identifies research gaps and future research priorities. This draft report was
posted on the ODP website and public comments were accepted for 2 weeks. The final report was then released to
coincide with publication in a peer-review journal.
Introduction
Chronic pain affects an estimated 100 million Americans, or one-third of the U.S. population,
although estimates vary depending upon how pain is defined and assessed. Approximately 25
million people experience moderate to severe chronic pain with significant pain-related activity
limitations and diminished quality of life. In addition to the burden of suffering, pain is the
primary reason Americans are on disability. The societal costs of chronic pain are estimated at
between $560 and $630 billion per year as a result of missed work days and medical expenses.
Although numerous treatments are available for treatment of chronic pain, an estimated 5 to 8
million Americans use opioids for long-term management of chronic pain. Moreover, workshop
speakers presented data from numerous sources that indicate a dramatic increase in opioid
prescriptions and use over the past 20 years. For example, the number of prescriptions for

opioids written for pain treatment in 1991 was 76 million; in 2011, this number reached
219 million. This striking increase in opioid prescriptions has paralleled the increase in opioid
overdoses and hospital admissions. In fact, hospital admissions for prescription painkillers have
increased more than fivefold in the last two decades. Yet, evidence also indicates that 40 to 70%
of people with chronic pain are not receiving proper medical treatment, with concerns for both
over- and under-treatment of chronic pain. Together, the prevalence of chronic pain and the
increasing use of opioids have created a “silent epidemic” of distress, disability, and danger to a
large percentage of Americans. The overriding question is whether we, as a nation, are currently
approaching chronic pain in the best possible manner that maximizes effectiveness and
minimizes harm. Several workshop speakers indicated that 80% of all opioid prescriptions
worldwide are written in the United States. This suggests, in part, that other countries have found
different treatments for chronic pain.
On September 29–30, 2014, the National Institutes of Health (NIH) convened a Pathways to
Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Specifically, the
workshop addressed four key questions:
1. What is the long-term effectiveness of opioids?
2. What are the safety and harms of opioids in patients with chronic pain?
3. What are the effects of different opioid management strategies?
4. What is the effectiveness of risk mitigation strategies for opioid treatment?

Biased media reports on opioids also affect patients. Stories that focus on opioid misuse and
fatalities related to opioid overdose may increase anxiety and fear among some stable, treated
patients that their medications could be tapered or discontinued to “prevent addiction.” For
example, one workshop presentation indicated that a typical news story about opioids was likely
to exclude information about the legitimate prescription use of opioids for pain, focusing instead
on overdose, addiction, and criminal activity.

However, the panel also wanted to emphasize what was reflected in numerous presentations at
the workshop: Many patients have been compliant with their prescriptions, and some feel that
their pain is managed adequately to the point of satisfactory quality of life. However, many
patients using opioids long-term continue to have moderate to severe pain and diminished quality
of life. While many physicians feel that opioid treatment can be valuable for some patients,
physicians also feel that patient expectations for pain relief may be unrealistic and that long-term
opioid prescribing can complicate and impair their therapeutic alliance with the patient.
The patient perspective is incredibly important, and yet it is only one aspect of the problem.
Another equally important consideration is how prescription opioids used in the treatment of
chronic pain create public health problems. In other words, although some patients experience
substantial pain relief from prescription opioids and do not suffer adverse effects, these benefits
have to be weighed against problems caused by the vast number of opioids now prescribed.
According to the Centers for Disease Control and Prevention, there were approximately 17,000
overdose deaths involving opioids in 2011. From 2000 to 2010, the number of admissions for
addiction to prescription opioids increased more than four-fold, to over 160,000 per year.
Different age groups are affected differently. For example, in 2010, one out of eight deaths of
25- to 34-year-olds was opioid-related. There are also collateral deaths from those who have
been prescribed opioids. In a 3-year period (2003 to 2006), more than 9,000 children were
exposed to opioids; this figure is based on data from toxicology centers, and the actual number
may be higher. Of these, nearly all children ingested the opioid (99%), and the ingestion
occurred in the home (92%). A small number of children died (n=8), but 43 children suffered
major effects, and 214 suffered moderate effects. Neonatal narcotic withdrawal also has

increased, with an estimated 29,000 infants affected. Both short-term physiological problems as
well as long-term behavioral consequences result from this withdrawal.
There is some concern that opioids are now becoming gateway drugs for heroin use. For
example, one study found that among individuals with a heroin addiction in the 1960s, the most
common first opioid used (the entry drug into heroin) was heroin itself. However, by the year
2000, the most common entry drug to heroin use was a prescription opioid
Treatment Options
Despite what is commonly done in current clinical practice, there appear to be few data to
support the long-term use of opioids for chronic pain management. Several workshop speakers
stressed the need to use treatment options that include a range of progressive approaches that
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might initially include. nonpharmacological options, such as physical therapy, behavioral therapy,
and/or proven complementary and alternative medicine approaches with demonstrated efficacy,
followed by pharmacological options, including non-opioid pharmacotherapies. The use of and
progression through these treatment modalities would be guided by the patient’s underlying
disease state, pain, and risk profile as well as clinical and functional status and progress.
However, according to a workshop speaker, lack of knowledge or limited availability of these
nonpharmacological modalities and the ready availability of pharmacological options and
associated reimbursement structure appear to steer clinicians towards the use of pharmacological
treatment and, more specifically, opioids.
One area of clinical importance the panel reviewed was the notion that pain type could influence
pain management. Data were presented on three distinct pain mechanisms: (1) peripheral
nociceptive—caused by tissue damage or inflammation, (2) peripheral neuropathic—damage or
dysfunction of peripheral nerves, and (3) centralized—characterized by a disturbance in the
processing of pain by the brain and spinal cord. Individuals with more peripheral/nociceptive
types of pain (e.g., acute pain due to injury, rheumatoid arthritis, cancer pain) may respond better
to opioid analgesics. In contrast, those with central pain syndromes—exemplified by
fibromyalgia, irritable bowel syndrome, temporal-mandibular joint disease and tension
headache—do not respond as well to opioids, as to centrally acting neuroactive compounds
(e.g., certain antidepressant medications, anticonvulsants). In particular, there is strong evidence
for non-opioid interventions in treatment of fibromyalgia, one of the most common conditions
presenting in primary care and pain clinics. In fact, the workshop presented interesting
preliminary evidence that if an initial evaluation for pain demonstrated even a few signs of
fibromyalgia (not meeting criteria for the full syndrome), the patient was at risk for poor
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response to opioids and a worse long-term course of pain. In addition, speakers presented
evidence that nearly all chronic pain may have a centralized component, and it was suggested
that opioids may promote progression from acute nociceptive pain to chronic centralized pain.
However, several speakers and audience members cautioned against making blanket statements
about who is or is not likely to benefit from opioids, again highlighting the importance of
individualized patient assessment and management. The health care system would benefit from
additional research on these different mechanisms of pain and the optimal approaches for each,
including the value of individualized versus general approaches; identifying risk factors for
patients most likely to develop chronic pain after an acute or subacute pain syndrome, and ways
to mitigate or reduce the risk of transitioning to a chronic pain syndrome.