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2
Objectives Understanding Pain – acute vs chronic
Epidemiology
Risk: pain and death
Risk: medication and death
Underwriter considerations
Questions
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What is pain?
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What is pain?
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Complex pain pathways
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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
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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
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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
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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
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Chronic pain and mortalitymeta analysischronic and widespread
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Chronic pain – mortalitymeta analysis 10 studies Mild increase in mortality from cancer,
cardiovascular, fibromyalgia.
RR = 1.22
12
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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
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Chronic widespread pain and mortality
sampling differences
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17
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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
19
J McBeth et al, Rheumatology, 2009
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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
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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
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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
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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
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What We Fear:
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US drug overdoses25 deaths/100,000
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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
26
From 10 leading causes of death, CDC
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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
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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
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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
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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
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55-642005 2008
M. Neoplasm99.240
M. Neoplasm104,091
Heart Dis. 65.208
Heart Dis.66,711
… …
Unint. Poisoning2,007
Unint. poisoning3,547
32
Unintentional Poisoning is not top 10
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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
34
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Painkiller nationMore available drugs
+
More prescribers
=
More deaths
35
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More prescriptions
36
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Too many prescriptions
37
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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
38
Serious events only, KM Dunn et al, Annals of Int Med 2010
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Better (?) Drugs
39
IA Dhalla, CMAJ 2009
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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%
40
Adapted from AJ Hall et al, JAMA 2008 (West Virginia 1999-2004)
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Pain Clinics in Broward County FL
2007 : 4 clinics
41
Interim Report of the Broward Count Grand Jury, Spring 2009
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Pain Clinics in Broward County FL
2007 : 4 clinics
2008: 47 clinics
42
Interim Report of the Broward Count Grand Jury, Spring 2009
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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”
43
Interim Report of the Broward Count Grand Jury, Spring 2009
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Drug Overdose Deaths FL 2003
44
Death rates per 100,000 population
MMWR 60:26 July 8, 2011
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Drug Overdose Deaths FL 2009
45
Death rates per 100,000 population
MMWR 60:26 July 8, 2011
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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
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Prescribing MD in Ontario 2006
50IA Dhalla, Can Fam Physician 2011
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More Usage: Oxycodone 2009
51
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
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Abuse among Unintentional
Pharmaceutical Overdose Deaths
52
AJ Hall et al, JAMA 2008 (West Virginia 1999-2004)
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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
53
Serious events only, unit is per 100,000 Person Years, KM Dunn et al, Annals of Int Med 2010
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CDC - Risk factors
54
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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)
55
(1) R Chou et al, Research Gaps on Use of Opioids for Chronic Noncancer Pain…, J of Pain, 2009
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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)
56
(1) DR Solanki et al, Pain Physician 2011
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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
61
MILDMILD•Mild impairmentMild impairment
•Stable medsStable meds•No depressionNo depression•Narcotics for Narcotics for
flare-upsflare-ups
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Ratings
62
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
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Ratings
63
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
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Chronic pain ratings
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Chronic pain ratings
65
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RATINGS
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Questions?
79
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80
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