Chronic Pain in Women and its

Relationship to Opioid Addiction

Advancing Addiction Science

Wilson M. Compton, M.D., M.P.E.Deputy Director

National Institute on Drug Abuse

OPIOIDS are Powerful Analgesics for Treating Many Types of Pain…BUT

• They can result in addiction

• Tolerance can develop, necessitating increasing dose to achieve desired effect

• Recent data indicate that the prescribing of opioids by clinicians has increased threefold in the last 20 years, contributing to the problem of prescription opioid abuse

• They can produce significant (and sometimes lethal) side effects (including constipation, nausea and respiratory depression)

Evolution of Drivers of Opioid Overdose Deaths: Analgesics Heroin Fentanyl

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

17,087 Prescribed

19,413 “Fentanyl”

Source: NCHS WONDER, NCHS Data Brief 294

15,469 Heroin

Women Have Higher Rates of Opioid-Related Hospitalizations in Most States

Source: Agency for Healthcare Research and Quality (AHRQ), Center for Healthcare Delivery, Organization and Markets. Healthcare Cost and Utilization Project (HCUP), HCUP Fast Stats, Opioid-Related Hospital Use (www.hcup-us.ahrq.gov/faststats/landing.isp)based on the HCUP National (nationwide) Inpatient Sample (NIS) and the Nationwide Emergency Department SAMPLE (NEDS).

Opioid-related hospital stays increased 75% for women from 2005-2014 compared to 55% for men

30.9

4.6

1.3

35.7

3.6

1.2

0

5

10

15

20

25

30

35

40

ANY USE IN PAST YEAR PAST YEAR MISUSE PAST MONTH MISUSE

MALE FEMALE

Use or Misuse of Prescription Pain RelieversAmong Persons 12 or Older, By Gender, 2017

Pe

rce

nt

2017 NSDUH, SAMHSA, 2018.

Recommendations included addressing disparities in the experience of pain

Rates of U.S. Adults 18 and Older Reporting PainIn Selected Areas, by Sex, 2015

Source: CDC and NCHS, 2015

9.9

27.6

13.9

21.4

30.4

17.4

0

5

10

15

20

25

30

35

Severeheadache or

migraine

Low back pain Neck pain

Men Women

And women’s reports of pain were more likely to be dismissed

Women appeared to suffer more pain in many categories

Source: CDC Vital Signs July 2013.

• Women are more likely to have chronic pain, be prescribed prescription painkillers, be given higher doses, and use them for longer time periods than men

• Women may become dependent on prescription painkillers more quickly than men

The Prescription Painkiller Problem Affects Women In Different Ways Than Men

• Women may be more likely than men to engage in “doctor shopping”

What Should We Be Working On to Achieve Safer and More Effective Treatment?

• Learning more about the neural mechanisms underlying chronic pain

• Exploring genomic underpinningsof chronic pain and its treatment

• Developing less abusable analgesics

• Identifying effective non-pharmacologicalinterventions for chronic pain

•Affects prenatal andpostnatal growth

• Increases the risk ofdevelopmental and behavioral deficits

Drug Abuse During Pregnancy…

Increasing Neonatal Opioid WithdrawalIncreasing NICU Admissions for Neonatal

Abstinence Syndrome NAS (per 1000

Admissions)

Source: Tolia VN, Patrick SW, et al., NEJM 2015;372:2118-2126.

Source: Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SM.. Pediatrics. 2018;141(4):e20173520

Increasing Costs for Neonatal Exposure

NIH Helping to End Addiction Long-term (HEAL) Initiative

• $500M/year funding provides opportunity to:– Improve prevention and treatment strategies,

both in clinic and real world settings, for opioid misuse and addiction

– Enhance pain management by furthering understanding of neurobiology of pain, developing non-addictive treatments, and building a Clinical Trial Network for pain

– Develop shared platforms through public and private partners

• Coordinating with Surgeon General, other HHS agencies, local government officials

All Hands on Deck!

HEAL Research Projects on Opioid Use Disorder (OUD)• Develop new treatments for opioid addiction, including more flexible

medications options and novel immunotherapies to opioids

• Advance clinical trials for Neonatal Opioid Withdrawal syndrome to improve short- and long-term outcomes for infants and children

• Enhance the NIDA Clinical Trials Network to build linkages with primary care, emergency departments, and the justice system

• Establish a Justice Community Opioid Innovation Network

• Optimize effective treatments for OUD in the field through the HEALingCommunities Study

Francis S. Collins, Walter J. Koroshetz, Nora D. Volkow. JAMA July 10, 2018

HEAL Research Projects on Pain Management

• Pinpoint acute to chronic pain signatures to identify those at risk for transition to chronic pain

• Discover and validate novel treatments for pain

– Work across entire NIH to include all therapeutic development programs

– Identify potential small molecules, biologics, devices, and natural products

– Develop preclinical screening platforms for testing

– Move successful compounds/devices to clinical trials

Francis S. Collins, Walter J. Koroshetz, Nora D. Volkow. JAMA July 10, 2018

Health Services and Observational Studies of Non-Pharmacological Approaches to Managing Pain and Co-Morbid Conditions in U.S. Military Personnel, Veterans, and their Families

• Longitudinal Study of Post-deployment CAM Pain Management Using DoD and VA Data

• Pain Care Quality And Integrated And Complementary Health Approaches

• Longitudinal Mixed Method Study Of Chronic Pain, PTSD, & CAM In OEF/OIF Veterans

• RCT of TDCS-Augmented CBT for Veterans with Pain and Opioid Misuse

• Collaborative Care For Veterans With Spine Pain And Mental Health Conditions

NIH Initiatives With a Military and Veteran Focus (e.g.)

Prevention and Health Promotion Interventions to Prevent Alcohol and Other Drug Abuse and Associated Physical and Psychological Health Problems in U.S. Military Personnel, Veterans and their Families

• Preventing Alcohol/Prescribed Drug Misuse in the National Guard: Web and Peer BI

• Quality Delivery Of Evidence-based Programs For National Guard And Reserve Families

NIH Initiatives With a Military and Veteran Focus (e.g.)

www.drugabuse.gov