Hi, welcome back. On the module on lifestyle factors and chronic pain. And this part five, we're going to talk about chemicals, medications, smoking, alcohol and recreational drug use. And how does that play a role with regard to chronic pain. And we know that if you have any of these risky behaviors, whether it's smoking, drug abuse sexual risky behaviors et cetera. You tendency have not only chronic pain, but many other problems associated with them. So smokers for instance have a two times higher rate of chronic pain. They have a four times higher rate of drug, drug and alcohol abuse. They have a two times higher rate of physical and sexual abuse. And they have a two times higher rate of suicide and depression. And a two times higher rate of illicit drug use. And have a much higher prevalence of be, behav, barriers to health. Including for instance, lack of transportation, obtaining and eating healthy food, and housing. So, each of these sort of create a problem for those individuals, and chronic pain is just one of the problems that are associated with people with high risk behaviors. Tobacco itself creates a significant problem for somebody. And, and we know that depression mediates the effect of smoking on chronic pain. So smoking doesn't directly relieve the chronic, but it leads to depression which increases the possibility of chronic pain. And the central sensitivation that turns the volume up, as I've mentioned, on the pain. So, they find that smoking rate is higher in pain populations. That patients who use smoking as a way to kind of reduce their stress to some extent, and distracts them from the pain. And heavy smokers report more pain locations and a higher pain intensity than normal controls. So, look at this combination of risk factors within adolescent high school students. Now, you can see that, that here is risk factors associated with carrying a weapon, cigarette use, alcohol use, sexually active, watches television three or more hours per day. And is physically active at least 60 minutes per day on the fewer end. These different colors are people who mostly get A's, B's, C's, or D's and F's. And you could see that the correlation between higher risk behaviors correlates with poor grades. And that's where we need to focus a lot of our attention with regard to the risky behaviors, because frequently these are also the people who will develop over time not only chronic pain and other illnesses but depression disability and, and other problems for, that effect themselves as well as the people around them. So, this is where we need to really train our students, not only about risky behaviors of course but to really encourage and provide the support they need to improve grades. So, alcohol and chronic pain is also a significant factor, and withdrawal from chronic alcohol increases pain sensitivity. And so patients frequently do mix alcohol and pain medications to help deal with their chronic pain. They also use doses, dosages of medications as well as alcohol in a higher amount than what is recommended for safe daily use. And it doesn't really have an analgesic effect in itself. Alcohol itself at least for a period of time makes you forget about the pain, but it has no direct analgesic effect. However it's frequently used to self-medicate. But drug abuse can really ruin you, and that includes alcohol itself. And I think you can see from this series of pictures of what can happen when drug abuse involves and impacts a persons with regard to their, their facial appearance anyways and the rest of their body is in the same situation. It increases a significant amount of chronic pain and other illnesses. So, illicit drug use can drive people to having more chronic pain and vice versa. So it does sensitize you to pain but also frequently chronic pain will drive people to use more illicit drugs. So here's a study of 100 chronic pain patients in Kentucky, and found that opioid abuse was seen in about 9% of those patients. Illicit drug use 16%, and you can see the distribution, 77% had at least one drug abuse behavior. And the most common interestingly enough were in the younger individuals, younger than 45. They also had more motor vehicle injuries, and those with three or more pa pain areas and past history of illicit drug use. So those are the most common characteristics. Now, adverse events from medications are also a significant problem. So we are often given medications for a variety of different problems that we have, and particularly chronic pain, headaches, et cetera. And obviously, you don't need to re, re, read all of these lists of the adverse events related to the most common pain medications that are used, but just kind of review them a little bit and realize that as this cartoon demonstrates, that there is a lot of adverse events. And sometimes unfortunately medications are given for the adverse effects from another medication. Like, for instance, the use of SSRIs causes clenching and grinding at night. Well, frequently a muscle relaxant is used to add to decrease that side effect from the SSRI. So, in this situation perhaps the SSRI helps with the depression, and then the medication helps, or the, the benzo, or the muscle relaxant helps with the paroxysm. But perhaps a patient is better off without the medications, and that needs to be evaluated. So, is the risk of adverse events greater than the, the benefits gained from taking the medication is a very important question. And Opioid medications have a significant number adverse events, and you can see the number of adverse events on the left side of this graph. And you can see the percentage of adverse events with opioid medications. With dry mouth being the highest and, of course, with dry mouth you get dental caries and periodontal disease associated with it, and frequently lose teeth if you have on opioids over a period of time. But opioid abuse can have many other problems too, and what happens now is opioids are relatively easy to get from, from health providers, from physicians, and dentists. And those opioids are spread to other people. And the number of overdose deaths from opioids have been very high in the last few years increasing significantly unintentional overdose deaths. Non-medical use of prescriptions. Related cost to insurers. Emergency room visits from adverse events, and total workers compensation costs. And an interesting statistics is that more people are dying from opioid overdose than motor vehicle accidents, at least in Minnesota. The study just came out. So opioids in itself, not only increases sensitization to pain but has lots of adverse events and complications if it's taken over a period of time. So, the Take Home message of this part is that pain patients often use controlled substances, medications, illicit drugs, alcohol, are smokers and a variety of different risky behaviors. And we need to be cautious and aware of that possibility. Some of the guidelines that we follow with regard to that as we work closely with patients on preventing inappropriate or illicit drug use. We so have them sign an agreement with us to define the goals, expectations, consequences. We use opioids for intractable pain, not for routine pain. We try to minimize it for any acute or early stage chronic pain problem. We review state pharmacy registry so that we know the patients are getting the medication from one pharmacy, from one physician and there's not multiple prescribers. We also make sure that all controlled substances are stored in a locked cabinet so that or if they have it with them. That they only have a small number of pills with them during the day, because frequently they will be stolen. And maintain regular visits with the prescribers. There are no phone refills. We discinue, discontinue use if agreement is broken. So there are some guidelines to help in minimizing complications from opioids. But still, the bottom line is that we need to be very cautious with the use of them. But later on I will have an interview with a patient that is on long term opioids. What is the rationale, how she controls that, how, how does she really maintain good opioids over time so that she can be functional and happy, and maintaining her thought, her lifestyle with minimal problems as a result of using the opioids. So, thank you for your attention. [SOUND]
