Table of Contents
Pain .................................................................................................................................... 1
General ............................................................................................................... 1
Types .................................................................................................................. 1
Effects................................................................................................................. 1
Diagnosis ............................................................................................................ 2
Treatment ........................................................................................................... 2
Opioids ............................................................................................................................... 4
Addiction: The Addiction Process........................................................................ 4
Addiction: The Opioid Addiction Process ............................................................ 4
Misuse ................................................................................................................ 4
Overdose ............................................................................................................ 5
Withdrawal .......................................................................................................... 5
Deaths ................................................................................................................ 6
Solutions ............................................................................................................. 6
Other Substances ............................................................................................... 7
Economics .......................................................................................................... 7
Prescriptions ....................................................................................................... 8
The Opioid Crisis ................................................................................................ 8
Organizations, History, and Politics ..................................................................... 8
Stuff to Read A Few Times ................................................................................................11
Key Messages From SAMHSA TIP 63 ...............................................................11
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Pain
General
 Nearly any part of your body is vulnerable to pain.
 In addition, the brain’s opioid system, which includes naturally occurring opioid
molecules (i.e., endorphins, enkephalins, and dynorphins) and three types of opioid
receptors (i.e., mu, delta, and kappa), plays a key role in mediating the rewarding effects
of other addictive substances, including opioids and alcohol
 The belief that pain is an inevitable part of the human condition is widespread
 But for the estimated 100 million Americans currently living with chronic pain, more
than half report little to no control over their pain.
 About 9 in 10 Americans regularly suffer from pain, and pain is the most common reason
individuals seek health care
 Sufficient knowledge and resources exist to manage pain in an estimated 90% of
individuals with acute or cancer pain.
 Data from a 1999 survey suggest that only 1 in 4 individuals with pain receive
appropriate therapy.
 Acute pain is the most common reason why patients seek medical attention.
Types
Classified By Duration of Pain:
 Acute pain typically 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 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. In some
cases, such as with fibromyalgia, it's one of the defining characteristic of the disease.
Chronic pain can be the result of damaged tissue, but very often is attributable to nerve
damage.
Classified By Kind of Damage Which Causes It:
 Tissue/Nociceptive Pain: pain caused by tissue damage
o Feels like a sporadic or continuous aching, sharp stabbing, or throbbing.
o Most pain comes from tissue damage.
 Nerve/Neuropathic Pain: pain caused by nerve damage
o Feels like burning or prickling, sometimes further set off by hypersensitivity.
o Most is chronic.
 Psychogenic Pain: pain affected by psychological factors, most often originating from
other pain.
Classified By Type of Tissue Involved
 (Example) Muscular Pain
 (Example) Joint Pain
Classified By Part of Body Affected
 (Example) Chest Pain
 (Example) Back Pain
Effects
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Pain can affect and be affected by a person's state of mind.
Pain can include a feedback loop of physical pain and psychological consequences.
Breakthrough pain refers to flares of pain that occur even when pain medication is being used
regularly. Can be set off spontaneously or when medication wears off.
Diagnosis
Questions
 Medical History
 Current Health Condition
o Pain Assessment
o Physical Examination
Tests
 CT (Computed tompography) Scan
o Using x-rays and computers, this produces an image of a cross-section of the
body
 MRI (Magnetic Resonance Imaging)
o Without the use of x-rays, large magnet radio waves and computers make
images.
 Nerve Blocks
o Injecting anesthetics to nerve locations for numbing pain in order to find source
of pain
 Discography
o For pre-decision of back pain surgery, dye injected into disk thought to cause
pain which outlines damaged areas in x-rays
 Myelogram
o For back pain, a dye is injected into the spinal canal which aids in identifying
nerve compression
 EMG (Electromyogram)
o Fine needles placed in muscles which measure response to electrical signals
 Bone Scans
o Radioactive material injected into the bloodstream collects particularly in
abnormal bone areas.
 Ultrasound Imaging/Sonography
o High frequency sound waves which create images of the inside of the body.
Treatment
Components of an Effective Treatment Plan:
1. The goals of treatment
2. Possible constituents of the treatment plan
3. Patient/HCP Interaction
Psychological:
 Cognitive behavioral therapy
Physical:
 Physical Therapy
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Exercise
Acupuncture (decreases pain by increased release of endorphins when acu-points near
nerves stimulated)
 Massage/Chiropractic Treatment
Consumptive:
 Dietary
o Nutritional Supplements
o Herbal Remedies
 Drug Therapy:
o Non-prescription/Over-the-counter
o Prescription
o Patient-controlled analgesia (a pump button which allows patients to selfadminister a premeasured dose of pain medicine)
o Nerve Block
o Anesthesia
 Trigger Point Injections (injection of a local anesthetic sometimes with a
steroid into a trigger point)
Surgical Implants/Interventional Techniques
 Intrathecal Drug Delivery/Infusion Pain Pumps/Spinal Drug Delivery Systems (a pump
and catheter inserted under a pocket of skin for the direct and significantly more
effective/efficient administration of medicines directly to the spinal cord)
 Spinal Cord Stimulation Implants (low-level electrical signals are transmitted to the
spinal cord or specific nerves to block pain signals from reaching the brain through a
device surgically implanted in the body with a remote control used by the patient)
TENS: (Transcutaneous Electrical Nerve Stimulation Therapy, electrical stimulation of nerves in
affected area through a current applied on skin.)
Bioelectric Therapy: (blocks pain messages to brain and increases endorphins)
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Opioids
Addiction: The Addiction Process
The addiction process involves a three-stage cycle:
1. Binge/Intoxication, the stage at which an individual consumes an intoxicating substance
and experiences its rewarding or pleasurable effects;
2. Withdrawal/Negative Affect, the stage at which an individual experiences a negative
physical and emotional state in the absence of the substance; and
3. Preoccupation/ Anticipation, the stage at which one seeks substances again after a period
of abstinence.
Addiction: The Opioid Addiction Process
1. intense intoxication
2. the development of tolerance
3. escalation in use
4. withdrawal signs
Misuse
 Opioids can depress critical areas in the brain that control breathing, heart rate,
and body temperature and cause them to stop functioning.
 Substance use and misuse becomes increasingly likely across adolescence, with
rates peaking among people in their twenties, and declining thereafter.
 It is common for people who misuse opioids to misuse other substances or to
have multiple substance use disorders, childhood trauma, or co-occurring
physical and mental disorders.
 In 2014, more than 47,000 people died from a drug overdose. Included in this
number are nearly 30,000 people who died from an overdose involving
prescription drugs. This is more than in any previous year on record.
 In 2015, over 27.1 million people were current users of illicit drugs or misused
prescription drugs.
 Lifetime: 36 million persons (13.6%) aged 12 or older have misused pain
relievers in their lifetime. Past Year: 12.5 million persons (4.7 %) aged 12 or older
have misused pain relievers in the past year. • OxyContin®: 1.7 million persons
(0.7%) aged 12 or older have used OxyContin® non-medically in the past year.
 In 2015, 20.8 million people aged 12 or older in the United States had a
substance use disorder
 About 11.1 million people aged 12 and older had misused prescription pain
relievers in the past year. (2017)
 About 2.3 million people age 12 and older misused prescription opioids or heroin
for the first time (2017)
 About 1.7 million people aged 12 and older had a prescription pain reliever use
disorder in the past year. (2017)
 --Only 28.6 percent of those aged 12 and older with an opioid use disorder in the
past year received treatment for illicit drug use at a specialty treatment facility.
 Heroine
o About 953,000 people received treatment for the misuse of opioid pain
relievers. (2017)
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About 886,000 people aged 12 or older reported having used heroin in
the past year. (2017)
o 652,000 people aged 12 or older were estimated to have a heroin use
disorder. (2017)
o Only 54.9 percent of those aged 12 and older with heroin use disorder
received treatment for illicit drug use at a specialty treatment facility.
 About one in four people (28.6 percent) with this opioid use disorder received
specialty treatment for illicit drug use in the past year.
 About 12.2 percent of adults who need treatment for a substance use disorder
receive any type of specialty treatment.
 In 2015, nearly 7.7 million people needed treatment for an illicit drug use disorder
(3.8 percent for men and 2.0 percent for women).
 Additionally, 45.5 percent of people with a substance use disorder also have a
mental disorder, yet only about half (51.0 percent) receive treatment for either
disorder and only a small minority receive treatment for both.
 However, clinical reports suggest that women who use cocaine, opioids, or
alcohol progress from initial use to a disorder at a faster rate than do men (called
“telescoping”).
 OPIOID-RELATED inpatient hospital stays INCRdEASED 64% nationally from
2005–2014.2
 OPIOID-RELATED EMERGENCY DEPARTMENT visits nearly doubled from
2005–2014
Overdose
 Signs
o slow breathing
o blue lips and fingernails
o cold damp skin
o shaking
o vomiting or gurgling noise
 Prevention Strategies
o Encourage providers and others to learn how to prevent and manage opioid
overdose.
o Ensure access to treatment for individuals who have a substance use disorder.
o Ensure ready access to naloxone.
o Encourage the public to call 911
o Encourage prescribers to use state prescription drug monitoring programs
Withdrawal
 Signs
o Early Withdrawal is 8-24 or 0-36 hours for short- and long-acting opioids.
 Grade 1: Yawning, restlessness, insomnia
 Grade 2: Dilated pupils, muscle twitching, abdominal pain
o Fully Developed Withdrawal is 1-3 or 3-4 days for short- and long-acting
opioids.
 Grade 3: Hypertension, fever, anorexia or nausea, extreme restlessness
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Grade 4: Diarrhea, vomiting, dehydration, hypotension, curled-up
position
Newborns may experience NAS, a withdrawal syndrome following exposure to
drugs while in the mother’s womb
Deaths
 To curb the rise in opioid overdose deaths, CDC recommends screening for
substance use and substance use disorders before and during the course of
opioid prescribing for chronic pain, combined with patient education.
 Deaths in 2016 were 63,632 from drug/opioid overdoses.
 disabled Medicare beneficiaries, who accounted for nearly 25 percent of opioid
overdose deaths in 2008.
 Opioids were involved in 42,249 deaths in 2016—more than 115 deaths every
day, on average.
 47,872 people died from an opioid overdose in 2017.
 Opioid overdose deaths were five times higher in 2016 than in 1999. The majority
of these opioid overdose deaths were unintentional.
 In 2014, 47,055 drug overdose deaths occurred in the United States, and 61
percent of these deaths were the result of opioid use, including prescription
opioids and heroin.
 Heroin overdoses have more than tripled from 2010 to 2014.7 Heroin overdoses
were more than five times higher in 2014 (10,574) then ten years before in 2004
(1,878).
 The opioid misuse and overdose crisis touches everyone in the United States. In
2016, we lost more than 115 Americans to opioid overdose deaths each day,
devastating families and communities across the country.
 Preliminary numbers in 2017 show that this number continues to increase with
more than 131 opioid overdose deaths each day.
 Opioid overdose caused 42,249 DEATHS nationwide in 2016— this exceeded
the # caused by motor vehicle crashes.
 In addition, alcohol is involved in about 20 percent of the overdose deaths related
to prescription opioid pain relievers.
 By 2016, men accounted for 67.5% of all opioid-related deaths, and the median
(interquartile range) age at death was 40 (30-52) years.
Solutions
Alternatives
 The alternatives mentioned in the cards
 Methadone
o is a synthetic opioid agonist that has been used to treat the symptoms of
withdrawal from heroin and other opioids. More than 40 years of research
support the use of methadone as an effective treatment for opioid use disorder. It
is also used in the treatment of patients with chronic, severe pain as a therapeutic
alternative to morphine sulfate and other opioid analgesics. Many people,
including some policymakers, authorities in the criminal justice system, and
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treatment providers, have viewed maintenance treatments as “substituting one
substance for another
o Today, methadone treatment programs, now called Opioid Treatment Programs
(OTPs), must be certified by SAMHSA and registered by the U.S. Drug
Enforcement Administration (DEA).
Safe use of opioids
 Safe storage
 Dosing instruction
 Proper disposal of used and unused opioids
 Naloxone
Prevention
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The Institute of Medicine (IOM), now known as the National Academy of
Medicine, has described three categories of prevention interventions: universal,
selective, and indicated. With respect to substance use interventions, universal
interventions are aimed at all members of a given population (for instance,
population-level strategies); selective interventions are aimed at a subgroup
determined to be at high-risk for substance use (for instance, justice-involved
youth); and indicated interventions are targeted to individuals who are already
using substances but have not developed a substance use disorder
Other Substances
 Nearly 80 percent of people addicted to heroin started first with prescription opioids.
However, the transition to heroin use from prescription opioids is still rare; only about 4
percent of people who misuse prescription opioids use heroin.
 nearly 80 percent of recent heroin initiates reported that they began their opioid use
through the nonmedical use of prescription opioid medications.”
 Although only about 4 percent of those who misuse prescription opioids transition to
using heroin
 More than 80 percent of patients who are opioid dependent smoke cigarettes.
 An estimated 1.8M AMERICANS have opioid user disorder (OUD) related to opioid
painkillers;
 2.1 MILLION people in the U.S., ages 12 and older, had opioid user disorder (OUD)
involving PRESCRIPTION OPIOIDS, HEROIN, or both in 2016.
Economics
Substance misuse and substance use disorders cost the U.S. more than $442 billion
annually in crime, health care, and lost productivity.
 These costs are almost twice as high as the costs associated with diabetes,
which is estimated to cost the United States $245 billion each year.
 Alcohol misuse and alcohol use disorders cost the United States approximately
$249 billion in lost productivity, health care expenses, law enforcement, and
other criminal justice costs.
 The costs associated with misuse of illegal drugs and non-prescribed
medications and drug use disorders were estimated to be more than $193 billion
in 2007
 Pain costs Americans an estimated $100 billion each year
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The effects of the opioid crisis are cumulative and costly for our society—an
estimated $504 billion a year in 2015—placing burdens on families, workplaces,
the health care system, states, and communities.
 Substance misuse and substance use disorders are estimated to cost society
$442 billion each year in health care costs, lost productivity, and criminal justice
costs.
 Estimated cost of the OPIOID EPIDEMIC was $504 BILLION in 2015
Prescriptions
 Only about 21.5 percent of people with opioid user disorder (OUD) received
treatment from 2009 to 2013.8
 731.2 Opioid prescriptions per 1,000 people nationwide
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The over-prescription of powerful opioid pain relievers was associated with a
rapid escalation of use and misuse of these substances. The good news is that a
decrease in the amount of opioid pain relievers prescribed has been reported.20
However, the amount of opioids prescribed in 2015 remained approximately three
times higher than in 1999 and varied substantially across the country.
Opioid analgesic pain relievers are now the most prescribed class of medications
in the United States, with more than 289 million prescriptions written each year.4
For example, a recent study found that doctors continue to prescribe opioids for
91 percent of patients who suffered a non-fatal overdose, with 63 percent of those
patients continuing to receive high doses; 17 percent of these patients overdosed
again within 2 years.
Prescribing opioids for over a week for acute pain doubles the risk of long-term
use at one year (6% to 13%) and this risk doubles again (to 29.9%) if the initial
prescription lasts a month.
In Australia in 2013, over 15 million packs of over the counter opioids were sold.
Accounting for 36.6% of total opioid pack sales.
The Opioid Crisis
 The opioid crisis is being driven by three trends: (1) an increase of prescription
opioid overdose deaths since 1999; (2) the four-fold increase in heroin overdoses
since 2010; and (3) the tripling death rate for synthetic opioids like fentanyl since
2013
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Overdose deaths from opioid pain relievers and heroin have risen dramatically in
the past 14 years,80 from 5,990 in 1999 to 29,467 in 2014, and most were
preventable.
Organizations, History, and Politics
SAMHSA- Substance Abuse and Mental Health Services Administration
HRSA- Health Resources and Services Administration
AHRQ- Agency for Healthcare Research and Quality
CMS- Centers for Medicare and Medicaid Services
IOM-Institute of Medicine/ NAM- National Academy of Medicine
USPSTF- US Preventive Services Task Force
NIDA- National Institute on Drug Abuse
U.S. Department of Health and Human Services (HHS)
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In April 2017, federal legislation was introduced to limit the supply of opioid prescription
for acute pain to 7 days. By August 2017, 24 states have enacted legislation with a limit
guidance, or requirement related to opioid prescribing.
***HHS also brought a new level of awareness and commitment to the cause by
declaring the opioid crisis a nationwide Public Health Emergency on October 26, 2017.
HHS has invested $2 billion in opioid-specific funding for states, which encompasses the
State Targeted Response (STR) to the Opioid Crisis and the State Opioid Response
(SOR) grant programs administered by SAMHSA
Since January 2017, over 200 health centers have been engaged in a HRSAfunded
technical assistance opportunity through the Opioid Addiction Treatment Extension for
Community Healthcare Outcomes project, a virtual, national technical assistance effort to
enhance health center capacity to treat substance misuse.
The National Institutes of Health (NIH), in collaboration with other federal agencies, is
developing a study as part of the Helping to End Addiction Long-term (HEAL) Initiative
called the HEALing Communities Study. This comprehensive study will test the
implementation of an integrated set of addiction prevention and treatment approaches
across healthcare, behavioral health, justice systems, state and local governments, and
community organizations to prevent and treat opioid misuse and opioid use disorder.
The Agency for Healthcare Research and Quality (AHRQ) in investing in research grants
to discover how to best support primary care practices and rural communities in
delivering MAT for opioid use disorders
The HHS Center for Faith-Based and Neighborhood Partnerships created the Opioid
Epidemic Practical Toolkitto equip local communities—lay persons, faith groups,
nonprofits, and health care providers—with practical steps to bring hope and healing to
the millions suffering the consequences of opioid misuse.
some studies have begun to examine the impact of prescription drug monitoring programs
(PDMPs) on misuse of prescription medications.245 These state-initiated policies are
designed to curb the rate of inappropriate prescribing of opioid pain relievers through
various methods. Data from the U.S. Drug Enforcement Administration’s (DEA’s)
Automation of Reports and Consolidated Orders System (ARCOS)246 showed little
impact of these monitoring systems, perhaps because of the variability of the policies
controlling different state systems. Some studies associate state PDMPs with lower rates
of prescription drug misuse and altered prescribing practices, although evidence is mixed
and inconclusive.247 One reason for inconsistent findings may be low and variable
prescriber utilization of PDMPs. A 2016 study found that the implementation of a PDMP
was associated with 1.12 fewer opioid-related overdose deaths per 100,000 people in the
year immediately after the program was implemented, and if every state in the United
States had a robust PDMP, there would be an estimated 600 fewer overdose deaths per
year
In one of the most rigorous studies to date, Florida’s simultaneous institution of a
prescription drug monitoring system and “pill mill” control policies was compared to
Georgia, a state without either policy. This study demonstrated “modest reductions in
total opioid volume, mean morphine milligram equivalent per transaction, and total
number of opioid prescriptions dispensed, but no effect on duration of treatment. These
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reductions were generally limited to patients and prescribers with the highest baseline
opioid use and prescribing.”
In 2016, SAMHSA also provided $11,000,000 in funding to prevent prescription
drug/opioid overdose-related deaths among individuals aged 18 or older by training first
responders and other community stakeholders on prevention strategies.
Thirty-seven states and the District of Columbia have “Good Samaritan” statutes that
prevent prosecution for possession of a controlled substance or paraphernalia if
emergency assistance is sought for someone who is experiencing an overdose, including
an opioid-induced overdose.
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Stuff to Read A Few Times
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Behavioural, physical, and psychological treatments may be beneficial to some patients
suffering from chronic pain.
Physicians should move away from ‘quick fixes’ and instead turn to long term therapies
other than opioids.
The Opioid Crisis. Over-prescription of powerful opioid pain relievers beginning in the
1990s led to a rapid escalation of use and misuse of these substances by a broad
demographic of men and women across the country.1 This led to a resurgence of heroin
use, as some users transitioned to using this cheaper street cousin of expensive
prescription opioids. As a result, the number of people dying from opioid overdoses
soared—increasing nearly four-fold between 1999 and 2014.4
Key Messages From SAMHSA TIP 63
Addiction is a chronic, treatable illness
General principles of good care for chonics diseases can guide OUD (Opioid Use Disorder)
treatment
Patient-centered care empowers patients with information that helps them make better treatment
decisions with the healthcare professionals involved in their care.
Patients with OUD should have access to mental health services as needed, medical care, and
addiction counseling, as well as recovery support services, to supplement treatment with
medication.
There is no “one size fts all” approach to OUD treatment.
The science demonstrating the effectiveness of medication for OUD is strong.
This doesn’t mean that remission and recovery occur only through medication
Medication for OUD should be successfully integrated with outpatient and residential treatment.
Patients treated with medications for OUD can beneft from individualized psychosocial supports
Expanding access to OUD medications is an important public health strategy.
Improving access to treatment with OUD medications is crucial to closing the wide gap between
treatment need and treatment availability, given the strong evidence of effectiveness for such
treatments.
Data indicate that medications for OUD are cost effective and cost benefcial.
Increasing opioid overdose deaths, illicit opioid use, and prescription opioid misuse constitute a
public health crisis.
OUD medications reduce illicit opioid use, retain people in treatment, and reduce risk of opioid
overdose death better than treatment with placebo or no medication. • Only physicians, nurse
practitioners, and physician assistants can prescribe buprenorphine for OUD. They must get a
federal waiver to do so.
Only federally certifed, accredited opioid treatment programs (OTPs) can dispense methadone to
treat OUD. OTPs can administer and dispense buprenorphine without a federal waiver.
Any prescriber can offer naltrexone.
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OUD medication can be taken on a shortor long-term basis, including as part of medically
supervised withdrawal and as maintenance treatment.
Patients taking medication for OUD are considered to be in recovery.
Several barriers contribute to the underuse of medication for OUD
All healthcare practices should screen for alcohol, tobacco, and other substance misuse (including
opioid misuse).
Validated screening tools, symptom surveys, and other resources are readily available; this part
lists many of them.
When patients screen positive for risk of harm from substance use, practitioners should assess
them using tools that determine whether substance use meets diagnostic criteria for a substance
use disorder (SUD).
Thorough assessment should address patients’ medical, social, SUD, and family histories.
Laboratory tests can inform treatment planning.
Practitioners should develop treatment plans or referral strategies (if onsite SUD treatment is
unavailable) for patients who need SUD treatment.
OUD medications are safe and effective when used appropriately.
OUD medications can help patients reduce or stop illicit opioid use and improve their health and
functioning.
Pharmacotherapy should be considered for all patients with OUD. Reserve opioid
pharmacotherapies for those with moderate-to-severe OUD with physical dependence.
Patients with OUD should be informed of the risks and benefts of pharmacotherapy, treatment
without medication, and no treatment.
Patients should be advised on where and how to get treatment with OUD medication.
Doses and schedules of pharmacotherapy must be individualized.
Many patients taking OUD medication beneft f rom counseling as part of their treatment.
Counselors play the same role for clients with OUD who take medication as for clients with any
other SUD.
Counselors help clients recover by addressing the challenges and consequences of addiction.
OUD is often a chronic illness requiring ongoing communication among patients and providers to
ensure that patients fully beneft f rom both pharmacotherapy and psychosocial treatment and
support.
OUD medications are safe and effective when prescribed and taken appropriately.
Medication is integral to recovery for many people with OUD. Medication usually produces
better treatment outcomes than outpatient treatment without medication.
Supportive counseling environments for clients who take OUD medication can promote treatment
and help build recovery capital.
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https://opioids.thetruth.com/o/quizzes/opioids
1. Pain causes stress, and when combined with the inflammation process it can produce:
A. weight loss.
B. weight gain.
C. ulcers.
D. acne.
2. The most common opioid side effects include all of the following, EXCEPT:
A. loss of consciousness.
B. nausea.
C. vomiting.
D. mild sedation.
3. Experts recommend that patients suffering from chronic back and arthritis pain should try
what first?
A. opioids.
B. exercise.
C. aspirin.
D. nutritional supplements.
Summaries like these appear to be REALLY good from experience:
 https://www.mayoclinicproceedings.org/article/S0025-6196(17)30923-0/pdf
 http://americanpainsociety.org/uploads/education/section_1.pdf
2,975 seizures of illicit opioids in 2017
Average Age of Initiation Prescription Opioids: 25.8