2 objectives understanding pain – acute vs chronic epidemiology risk: pain and death risk:...

2

Objectives Understanding Pain – acute vs chronic

Epidemiology

Risk: pain and death

Risk: medication and death

Underwriter considerations

Questions

What is pain?

3

What is pain?

4

Complex pain pathways

5

Chronic pain Causal pain:

chest pain Cancer RSD

More generalized pain Fibromyalgia Chronic regional pain syndrome

Musculoskeletal pain Osteoarthritis Inflammatory arthritis

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Chronic pain

7

Epidemiology of Chronic Pain

Common :20-30%+

Gender More women than men 55%/45%

Widespread by age Childhood Peak in the 60s for men, 80s for women

Long duration: 88% more than 2 years 46% more than 10 years

8

Understanding chronic pain

Chronic pain as a result/severity Cancer Cardiovascular Arthritis FMS

Chronic pain as comorbidity Obesity

Chronic Pain as inciting etiology (cause) Suicide Overdose

9

Chronic Pain as All Cause Mortality Indicator

10 years all cause mortality

UK- 5,800 people

Any chronic pain: HR 1.32

Severe chronic pain: HR 1.49

10

N Torrance et al, European J of Pain, 2009

Chronic pain and mortalitymeta analysischronic and widespread

11

Chronic pain – mortalitymeta analysis 10 studies Mild increase in mortality from cancer,

cardiovascular, fibromyalgia.

RR = 1.22

12

Chronic widespread pain HR 1.95

chronic pain, lifestyle factors, all cause mortality

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Chronic widespread painHR 1.95

Mortality related to smoking and level of daily physical activity and Sleep disturbance

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15

Chronic widespread pain and mortality

sampling differences

16

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5 year persistent pain Older population non cancer pain

Risk of death was lower in persons reporting moderate or greater pain than those with no or mild pain HR=0.85

Men with pain were not significantly more likely to die than men without pain to die HR=1.00

Women who reported non cancer pain as moderate or greater had lower mortality than women with less pain.

BUT, women with pain HR=0.40 had less risk of death than men without pain.

CONCLUSION: Older women with pain were less likely to die within 5 years than older women without pain, men in pain, or men without pain

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Musculoskeletal Pain and Cancer Mortality

8 years average follow-up

United Kingdom- 4,500 people

Regional pain: HR 1.3

Widespread pain: HR 1.8

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J McBeth et al, Rheumatology, 2009

Musculoskeletal Pain and Cardiovascular Mortality

8 years average follow-up

UK- 4,500 people

Regional pain: HR 1.1

Widespread pain: HR 1.3

20

J McBeth et al, Rheumatology, 2009

New Musculoskeletal Pain and Mortality

1 and 10 years mortality

No pain in prior 2 years

UK- 48,000 people

21

KP Jordan et al, Brit J of Gen Practice, 2010

New Musculoskeletal Pain and Mortality

1 year: Back SMR (age and sex) 2.07 Hip SMR 2.36 Shoulder SMR 1.42

10 year: Back SMR (age and sex) 1.17 Hip SMR 1.32

22

KP Jordan et al, Brit J of Gen Practice, 2010

New Musculoskeletal Pain and Cancer

1 year (cancer free at baseline): Back SMR (age and sex) 1.79 Hip SIR 1.36 (not significant at 95%)

10 year (cancer free at baseline): Back SMR (age and sex) 1.25 Neck SMR 1.20 Hip SMR 1.15

23

KP Jordan et al, Brit J of Gen Practice, 2010

What We Fear:

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US drug overdoses25 deaths/100,000

25

Top 3 Causes of Death 2005

15-24 25-34 35-44 45-54 55-64

Unint. injury

15,753

Unint. Injury

13,987

Unint. Injury 16,919

M. Neoplam 50,405

M. Neoplasm

99,240

Homicide 5,466

Suicide 4,990

M. Neoplasm 14,566

Heart Dis. 38,103

Heart Dis. 65,208

Suicide 4,212

Homicide 4,752

Heart Dis. 12,688

Unint. Injury

18,339

Chr Resp. 12,747

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From 10 leading causes of death, CDC

Top 3 Causes of Death 2008

15-24 25-34 35-44 45-54 55-64

Unint. injury

14.089

Unint. Injury

14,588

Unint. Injury 16,065

M. Neoplam 50,403

M. Neoplasm 104,091

Homicide 5,275

Suicide 5,300

M. Neoplasm 12,699

Heart Dis. 37,982

Heart Dis. 66,711

Suicide 4,298

Homicide 4,610

Heart Dis. 11,336

Unint. Injury

20,354

Chr Resp. 14,042

27

From 10 leading causes of death, CDC

The devil is in the Details: 15-24

2005 2008

Unint. MV 10,657

Unint. MV 8,647

Homicide 5,466

Homicide 5,275

Suicide 4,212

Suicide 4,298

Unint. Poisoning 2,484

Unint. Poisoning 3,188

M. Neoplasm 1,717

M. Neoplasm 1,663

Heat Dis.1,119

Heart Dis. 1,065

Unint. Drowning 649

Unint. Drowning 569 28

25-342005 2008

Unint. MV 7,047

Unint. MV 6,358

Suicide 4,990

Unint. Poisoning 5,946

Homicide 4,752

Suicide 5,300

Unint. Poisoning 4,386

Homicide 4,610

M. Neoplasm 3,601

M. Neoplasm 3,521

Heat Dis.3,249

Heart Dis. 3,254

HIV1,318

HIV975

29

35-442005 2008

M. Neoplasm14,566

M. Neoplasm12,699

Heart Dis. 12,688

Heart Dis.11,336

Unint. Poisoning6,729

Unint. poisoning7,545

Suicide6,550

Suicide6,703

Unint. MV6,491

Unint. MV5,446

HIV4,363

Homicide2,906

Homicide3,109

HIV2,838

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45-542005 2008

M. Neoplasm50,405

M. Neoplasm50,403

Heart Dis. 38,103

Heart Dis.37,892

Unint. Poisoning6,983

Unint. poisoning9,496

Liver Dis.7,517

Suicide8,287

Suicide6,991

Liver Dis.8,220

Cerebrovascular6,381

Cerebrovascular6,112

Unint. MV6,179

Unint. MV5,866 31

55-642005 2008

M. Neoplasm99.240

M. Neoplasm104,091

Heart Dis. 65.208

Heart Dis.66,711

… …

Unint. Poisoning2,007

Unint. poisoning3,547

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Unintentional Poisoning is not top 10

Painkiller nationpainkillers now kill more people than car crashes

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Painkiller nation Drug overdose leading cause of injury death in 2012

117% increase from 1999 to 2012

41,502 overdose deaths in 2012 (16,007 analgesics)

33,175 deaths in 2012 unintentional

5465 – suicidal intent

80 – homicides

2782 – undetermined

2.5 million ER visits – drug misuse and abuse

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Painkiller nationMore available drugs

+

More prescribers

=

More deaths

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More prescriptions

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Too many prescriptions

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Dose and Overdose

Opioid Dose HR Serious OD

None 0.19

1-19 mg/d 1.00 (ref)

20-49 mg/d 1.19

50-99 mg/d 3.31

100+mg/d 11.18

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Serious events only, KM Dunn et al, Annals of Int Med 2010

Better (?) Drugs

39

IA Dhalla, CMAJ 2009

Abuse among Unintentional

Pharmaceutical Overdose Deaths

Age group % of OD Deaths % of Gen Population

Ratio

18-24 15.3%

25-34 23.4% 12.3% 190%

35-44 25.4% 13.3% 191%

45-54 27.7% 15.2% 182%

55+ 8.1% 28.5% 28%

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Adapted from AJ Hall et al, JAMA 2008 (West Virginia 1999-2004)

Pain Clinics in Broward County FL

2007 : 4 clinics

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Interim Report of the Broward Count Grand Jury, Spring 2009

Pain Clinics in Broward County FL

2007 : 4 clinics

2008: 47 clinics

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Interim Report of the Broward Count Grand Jury, Spring 2009

Pain Clinics in Broward County FL

2007 : 4 clinics

2008: 47 clinics

2009: 115 clinics

During the first 6 months of 2008, the top 25 dispensing doctors of Oxycodone in the nation where in the state of Florida ,… 18 of the top 25 in Broward County”

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Interim Report of the Broward Count Grand Jury, Spring 2009

Drug Overdose Deaths FL 2003

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Death rates per 100,000 population

MMWR 60:26 July 8, 2011

Drug Overdose Deaths FL 2009

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Death rates per 100,000 population

MMWR 60:26 July 8, 2011

Prescription Drug Overdose FL

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Top Drugs Primary Cause of Deaths FL

2009 Oxycodone 1,185

Alprazolam 822

Methadone 720

Ethyl Alcohol 559

Cocaine 529

Hydrocodone 265

Diazepam 248

Cannabinoids 0

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Top Drugs Most Common FL 2009

Ethyl Alcohol 4,046

Alprazolam (Xanax) 1,963

Oxycodone (OxyContin) 1,948

Cocaine 1,462

Methadone 985

Diazepam (Valium) 892

Hydrocodone 865

Cannabinoids 817

Heroin (only illicit opioid) 111

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Top Drugs Most Lethal FL 2009

Heroin (only illicit opioid) 86%

Methadone 73%

Oxycodone 61%

Fentanyl (Durgesic, Actiq) 57%

Morphine 45%

Alprazolam 42%

Cocaine 36%

Diazepam 28%

49Fl Dept of Law Enforcement – Medical examiners commission 2010

Prescribing MD in Ontario 2006

50IA Dhalla, Can Fam Physician 2011

More Usage: Oxycodone 2009

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Rank Country Relative Consumption

per Capita

1 United States of America 33.6

2 Canada 24.2

3 Australia 11.8

4 Denmark 11.2

5 United Kingdom 6.7

10 Germany 4.3

15 Israel 2.3

20 Austria 1.0

http://www.painpolicy.wisc.edu/internat/opioid_data.htmlAnother neat website: http://ppsg-production.heroku.com/chart

Abuse among Unintentional

Pharmaceutical Overdose Deaths

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AJ Hall et al, JAMA 2008 (West Virginia 1999-2004)

Overdose and Prescribed Opioids

Men 123 Women 112

Age 18-44 119 45-64 92 65+ 151

Hx of depression: Yes 239 No 77

Hx of subst. abuse: Yes 274 No 107

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Serious events only, unit is per 100,000 Person Years, KM Dunn et al, Annals of Int Med 2010

CDC - Risk factors

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And Do Opioid Work for Non-Cancer Chronic Pain?

“Critical research gaps on use of opioids for chronic non-cancer pain include: lack of effectiveness studies on long term benefits and harms of opioids…”(1)

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(1) R Chou et al, Research Gaps on Use of Opioids for Chronic Noncancer Pain…, J of Pain, 2009

Opioid Use: Screening Tools

“There was not a single screening tool that can be applied universally to all patients who are on opioid therapy for chronic non-cancer pain”(1)

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(1) DR Solanki et al, Pain Physician 2011

Treating Chronic Pain: a Balancing Act

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GO Localized

Recent

No depression

No recreational drugs

Good function

Good support

Low doses

One MD

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Caution Morphine

Xanax

Alcohol

Past recreational drugs

Depression

No evidence of non-drug pain management

Low doses

Multiple MDs

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STOP

Polypharmacy

Increasing dosage

Disability

Depression

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Ratings

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MILDMILD•Mild impairmentMild impairment

•Stable medsStable meds•No depressionNo depression•Narcotics for Narcotics for

flare-upsflare-ups

Ratings

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MILDMILD•Mild impairmentMild impairment

•Stable medsStable meds•No depressionNo depression•Narcotics for Narcotics for

flare-upsflare-ups

MODERATEMODERATE•Localized painLocalized pain

•ActiveActive•ADL OkADL Ok

•Good social Good social networknetwork

Ratings

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MILDMILD•Mild impairmentMild impairment

•Stable medsStable meds•No depressionNo depression•Narcotics for Narcotics for

flare-upsflare-ups

MODERATEMODERATE•Localized painLocalized pain

•ActiveActive•ADL OkADL Ok

•Good social Good social networknetwork

SEVERESEVERECombo of:Combo of:•DisabilityDisability

•ImpairmentImpairment•Multiple medsMultiple meds

•Increasing Increasing dosagedosage

•Depression Depression

Chronic pain ratings

Chronic pain ratings

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RATINGS

Case 1 MR. Max Pain is a 54 yo male who injured his lower back a

few months ago while golfing

Imaging by MRI etc ruled out maliganancy, arthritis, disc disease, or spinal stenosis.

He was prescribed PT, analgesics, and told to top golf for a few months.

He is an VP of multibillion dollar corp based in Dallas TX

History of anxiety and poor sleep in past, currently on no medication for either.

Admits to one martini nightly, never hx of ETOH abuse in past

67

Case 1 Married, two successful children, and 2 grandchildren.

Attends church every Sunday, and does volunteer work with his wife of 25 years when time allows.

He returns to his PCP after 6 months with no relief. Pain is 4/10 on good days and 7/10 on bad days usually worse at the end of the day

PCP prescribes Tramadol and Hydrocodone for use on the when pain is at its worst.

He tries acupuncture in addition.

Also, the CLBP has caused some sleep disruption and he asks his PCP for a sleeping pill.

68

Case 1 He returns to his PCP 3 and six months later and

reports improvement, but still uses opoid and sleeping pill PRN.

Questions at this point? Function – golf etc Stability of dose of percoset Any depression? Alcohol Side effects

69

Case 2 MR. Max Pain is a 54 yo male who injured his lower

back a few months ago while golfing

Imaging by MRI etc ruled out malignancy, arthritis, disc disease, or spinal stenosis.

He is an VP of multibillion dollar corp based in Dallas TX

History of anxiety and poor sleep in past and was treated with Paxil.

Admits to two martini nightly, 2 -3 nightly on weekends

70

Case 2 Divorced with two children, one a successful attorney

the other a successful doctor who has been in and out of rehab several times for substance abuse. His son the doctor and the divorce have been difficult for him

He works 15 hour days, no exercise, eats mostly in restaurants, his BMI is 34.

He currently self medicates with GABA and melatonin 6 mg nightly to help sleep. He has been prescribed Xanax for occasional use and has to take about 5 xanax 0.75 mg a month to sleep. He tries to keep the xanax use to a minimum.

71

Case 2 His PCP prescribes COX2 inhibitor Tramadol and PT.

He is told he needs to stop golf for several months, lose 50 pounds and control stress.

He LOVES golf

He returns to his PCP after 6 months with mild improvement, but the pain has disrupted his sleep and he is taking more xanax for sleep and anxiety.

He has lost 20 pounds, still can’t play golf and is feeling a a little depressed about it. Otherwise he is fully funcitonal and still goes to the office 15 hours a day

72

Case 2 His PCP offers encouragement and positive

reinforcement about the weight loss and renews his xanax, COX2 inhibitor and Tramadol. f/u six months

?

73

Case 3 MR. Max Pain is a 54 yo male who injured his lower back a

few months ago while golfing

Imaging by MRI etc ruled out maliganancy, arthritis, disc disease, or spinal stenosis.

He was prescribed PT, analgesics, and told to top golf for a few months.

He is an VP of multibillion dollar corp based in Dallas TX

History of anxiety, depression and poor sleep in past, currently on no prescription medication.

Admits to one martini nightly, never hx of ETOH abuse in past

74

Case 3 Divorced with two children, one a successful attorney

the other a successful doctor who has been in and out of rehab several times for substance abuse. His son the doctor and the divorce have been difficult for him

He works 15 hour days, no exercise, eats mostly in restaurants, his BMI is 34.

He currently is self medicates with melatonin 6 mg nightly to help sleep. He has been prescribed Xanax for occasional use and has to take about 5 xanax 0.75 mg a month to sleep. He tries to keep the xanax use to a minimum.

75

Case 3 His PCP prescribes COX2 inhibitor Tramadol, percocet and PT.

He is told he needs to stop golf for several months, lose 50 pounds and control stress.

He LOVES golf

He returns to his PCP after 6 months with mild improvement, but the pain has disrupted his sleep and he is taking more xanax for sleep and anxiety.

He has lost 5 pounds, still can’t play golf and is feeling a a little depressed about it. Otherwise he is functional but has cut his work schedule at the office 7 hours a day due to fatigue

76

Case 3 His PCP offers encouragement and positive

reinforcement about the weight loss and renews and increases his xanax dose, COX2 inhibitor and Tramadol, percocet and prescribes a SSRI for depression.

?

77

Case 4 34 yo female with a history of rheumatoid arthritis and FMS

RA,, onset 4 years ago in remission with MTX and NSAID for 2 years.

RA limited to small joints of the hands.

Minimal morning stiffness of joints.

FMS is treated with Lyrica for 7 years.

She c/o fatigue, poor sleep, and lack of motivation

Works parttime as – phone marketing from home

?

78

Questions?

79

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