addiction issues in chronic pain management

8/7/2019 Addiction Issues in Chronic Pain Management

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Addiction Issues in ChronicAddiction Issues in ChronicPain ManagementPain Management


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StatisticsStatistics

Base rate of addictive disease in generalBase rate of addictive disease in generalpopulation:population:

AlcoholAlcohol 15%15%

Cocaine/HeroinCocaine/Heroin ---- 5%5%

10% of adults in US have genetic10% of adults in US have genetic

susceptibility to addictionsusceptibility to addiction


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In 2003, 4.7 million Americans usedIn 2003, 4.7 million Americans usedprescription drugs nonprescription drugs non--medically:medically:

2.5 million2.5 million analgesicsanalgesics

1.4 million1.4 million sedatives/tranquilizerssedatives/tranquilizers

761 000761 000 stimulantsstimulants


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Vicodin: Most commonly prescribedVicodin: Most commonly prescribedprescription analgesic in USprescription analgesic in US

Vicodin: Most prescribed medication ofVicodin: Most prescribed medication ofany category (>100 million Rxs)any category (>100 million Rxs)


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>50 million Americans suffer from chronic pain>50 million Americans suffer from chronic pain

Overall rate of prescription analgesicOverall rate of prescription analgesicabuse/addiction in pain patients = 3.3%abuse/addiction in pain patients = 3.3%

0.19% without a past or current substance0.19% without a past or current substanceabuse disorder experienced problems withabuse disorder experienced problems withopioids for painopioids for pain

Overall rate of concurrent addiction (allOverall rate of concurrent addiction (allsubstances) in chronic pain patients is the samesubstances) in chronic pain patients is the sameas in general population 6as in general population 6--10%10%


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Proper definitions areProper definitions areimportant!important!


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Basic TerminologyBasic Terminology

Abuse = Abnormal use, nonAbuse = Abnormal use, non--therapeutictherapeutic

Addiction is a form of abuseAddiction is a form of abuse

Addiction = Drug AbuseAddiction = Drug Abuse

Drug AbuseDrug Abuse {{ Addiction, but can imply itAddiction, but can imply it


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The 4 Cs of AddictionThe 4 Cs of Addiction

Loss ofLoss ofCControlontrol

CCompulsive Useompulsive Use

CCravingraving

CConsequences (Use Despite Harm)onsequences (Use Despite Harm)

Definitions related to the use of opioids for the treatment of pain. AConsensus Statement on Pain and OpioidsASAM, APS, AAPM, April 2001

http://www.painmed.org/productpub/statements/pdfs/definition.pdf


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In a Patient With Pain onIn a Patient With Pain on

OpioidsOpioids

Physical DependencePhysical Dependence {{ AddictionAddictionToleranceTolerance {{ AddictionAddiction

High doseHigh dose {{ AddictionAddiction

RD Jovey, J Ennis, J Gardner-Nix, B Goldman, H Hays, M Lynch, D Moulin. Use of opioid analgesics for the treatment of chronicnoncancer pain A consenus statement and

guidelines from the Canadian Pain Society, 2002. Pain Res Manage 2003;8(Suppl A):3A-14A.


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DSMDSM--IVIV--TR Substance DependenceTR Substance Dependence

1.1. ToleranceTolerance

2.2. Physical dependence/withdrawalPhysical dependence/withdrawal

3.3. Used in greater amounts or longer than intendedUsed in greater amounts or longer than intended

4.4. Unsuccessful attempts to cut down or discontinueUnsuccessful attempts to cut down or discontinue5.5. Much time spent pursuing or recovering from useMuch time spent pursuing or recovering from use

6.6. Important activities reduced or given upImportant activities reduced or given up

7.7. Continued use despite knowledge of persistentContinued use despite knowledge of persistent

physical or psychological harmphysical or psychological harm

Sees and Clark, J Pafter Savage, 2004

3/7 required for diagnosis

4/7 common in non-addicted pain patients


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DSMDSM--IVIV--TR Substance AbuseTR Substance Abuse

1.1. Recurrent use affecting daily participation inRecurrent use affecting daily participation inmajor obligations at work, school or homemajor obligations at work, school or home

2.2. Recurrent use in physically hazardous settingsRecurrent use in physically hazardous settings(driving)(driving)

3.3. Recurrent substanceRecurrent substance--related legal issuesrelated legal issues

4.4. Continued use despite recurrent or persistentContinued use despite recurrent or persistent

social or interpersonal consequencessocial or interpersonal consequences

Sees and Clark, J Pafter Savage, 2004

1/4 required for diagnosis

Exclusionary for substance dependence


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Addiction:

A Biopsychosocial Illness

*NeurobiologyGeneticsAcquired

Drug

Environment

Reinforcement

Psychology Availability

& Milieu

*Manifestation ofthe disease ofaddiction

Adapted from JD Haddox, DDS, MD.


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Tomkin & Sellers, CMAJ, 2001

Brain Circuits of AddictionBrain Circuits of Addiction

Planning,Judgment

Prefrontalcortex

frontalcortex

Nucleusaccumbens

Medial forebrainbundle

Ventral tegmentalarea

Reward

Amygdala

Emotions,conditioned effects


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Pain Patient vs. Opioid AbuserPain Patient vs. Opioid Abuser

Controls medsControls meds

Meds improve QOLMeds improve QOL

Complains of side effectsComplains of side effects Concerned re: risk ofConcerned re: risk of

addictionaddiction

Follows agreed uponFollows agreed upontreatment plantreatment plan

Left over meds, does notLeft over meds, does notrun out of or lose medsrun out of or lose meds

Cant control medsCant control meds

Meds decrease QOLMeds decrease QOL

Wants meds despite S/EWants meds despite S/E

Denies possibility ofDenies possibility ofaddictionaddiction

Does not follow treatmentDoes not follow treatmentplanplan

Seldom has meds leftSeldom has meds leftoverover excuses for lostexcuses for lostmedsmeds

Schnoll, J Law Med Ethics.1994

Heit, Eur J Pain 2001


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Ambiguous drug behavioursAmbiguous drug behaviours

MoreMore suggestive of addictionsuggestive of addiction Rx drug: selling, stealing, forgeryRx drug: selling, stealing, forgery

Injecting oral formulationsInjecting oral formulations

Obtaining Rx drugs from the streetObtaining Rx drugs from the street Concurrent abuse of ETOH or illicit drugsConcurrent abuse of ETOH or illicit drugs

Repeated nonRepeated non--compliance despite warningscompliance despite warnings

Double doctoringDouble doctoring

DrugDrug--related deterioration in functionrelated deterioration in function

Resistance to change in therapy despite evidence ofResistance to change in therapy despite evidence ofadverse drug effectsadverse drug effects

Passik, Portenoy, 2004


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Ambiguous drug behavioursAmbiguous drug behaviours

LessLess suggestive of addictionsuggestive of addiction

Asking for more pain meds or specific medsAsking for more pain meds or specific meds

Drug hoardingDrug hoarding

Openly getting meds from other MDsOpenly getting meds from other MDs Occasional dose escalation or other nonOccasional dose escalation or other non--compliancecompliance

Treating another symptom with opioidsTreating another symptom with opioids

Unintentional psychic effectsUnintentional psychic effects

Resistance to change in therapy that is workingResistance to change in therapy that is working Intense anxiety about recurrent symptomsIntense anxiety about recurrent symptoms

Passik, Portenoy, 2004


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PseudotolerancePseudotolerance

Occurs when a patient with chronic pain treated withOccurs when a patient with chronic pain treated withopioids increases activity levels resulting in more painopioids increases activity levels resulting in more pain

OROR

there is a worsening of the underlying pain conditionthere is a worsening of the underlying pain condition

This pain is relieved when the dose of opioid is increasedThis pain is relieved when the dose of opioid is increased

Tends to occur during the initial titration phase or at a time thatTends to occur during the initial titration phase or at a time that

the patient undergoes a significant change in activity level orthe patient undergoes a significant change in activity level ordisease activitydisease activity

Jackson KC, 2003

Heit H, 2005


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PseudoaddictionPseudoaddiction

An iatrogenic misinterpretation caused byAn iatrogenic misinterpretation caused byundertreatment of pain that isundertreatment of pain that ismisidentified by the clinician asmisidentified by the clinician asinappropriate druginappropriate drug--seeking behaviourseeking behaviour

Behaviour ceases when adequate painBehaviour ceases when adequate painrelief is providedrelief is provided

Not a diagnosis, rather a description of aNot a diagnosis, rather a description of aclinical interactionclinical interaction

Weissman DE, Haddox JD. Pain. 1989;36:363-6.


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Addiction versusAddiction versus

PseudoaddictionPseudoaddiction AddictionAddiction

Dx made prospectively:Dx made prospectively:

Patients behavior and compliance withPatients behavior and compliance with

treatment agreement becomestreatment agreement becomes aberrantaberrantdespite Rational Pharmacotherapy.despite Rational Pharmacotherapy.

PseudoaddictionPseudoaddiction

Dx made retrorespectivelyDx made retrorespectively Patients behavior and compliance with thePatients behavior and compliance with the

treatment agreementtreatment agreementnormalizesnormalizes withwithRational Pharmacotherapy.Rational Pharmacotherapy.

Gourlay, 2005


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Concurrent Pain & AddictionConcurrent Pain & Addiction

Both pain and addiction can coBoth pain and addiction can co--exist in theexist in thesame patientsame patient

Addiction can be to prescription medications,Addiction can be to prescription medications,illicit narcotics and/or alcoholillicit narcotics and/or alcohol

This does not necessarily preclude the use ofThis does not necessarily preclude the use ofopioid therapy, but does require more attentionopioid therapy, but does require more attention(and time)(and time)


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Treatment of Pain & OpioidTreatment of Pain & OpioidAddictionAddiction

InpatientInpatient

OutpatientOutpatient

SubstitutionSubstitution MethadoneMethadone

Suboxone (buprenorphine/naloxone)Suboxone (buprenorphine/naloxone)

DiscontinuationDiscontinuation

Tapering (Rapid vs Gradual)Tapering (Rapid vs Gradual)

Narcanon/CounsellingNarcanon/Counselling


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Treatment of Pain & OpioidTreatment of Pain & OpioidAddictionAddiction

Methadone: 2 indicationsMethadone: 2 indications

Treating heroin/opioid addictionTreating heroin/opioid addiction

Treating chronic pain with or without addictionTreating chronic pain with or without addiction

Suboxone:Suboxone:

Addiction treatment as a substitute for MethadoneAddiction treatment as a substitute for Methadone

Safer with less substituteSafer with less substitute--addiction potentialaddiction potential


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Underwriting PointsUnderwriting Points

Differentiate between abuse and addiction asDifferentiate between abuse and addiction asthere are different outcome implicationsthere are different outcome implications

Use of cocaine recreationally constitutes abuseUse of cocaine recreationally constitutes abuse

Habitual use of marijuana likely constitutes addictionHabitual use of marijuana likely constitutes addiction

(as with tobacco)(as with tobacco)

Abuse (illicit substances) without addiction hasAbuse (illicit substances) without addiction haslegal/criminal ramificationslegal/criminal ramifications

Addiction has more health related consequencesAddiction has more health related consequences


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Consider comorbidities, specificallyConsider comorbidities, specificallypsychiatric/psychological (depression/anxiety)psychiatric/psychological (depression/anxiety)

Watch for unusual health outcomes (CVA, MI,Watch for unusual health outcomes (CVA, MI,COPD) not associated with risk factors andCOPD) not associated with risk factors andoutside ageoutside age--appropriate ranges for occurrenceappropriate ranges for occurrence

Frequent ER visits for unspecified diagnosesFrequent ER visits for unspecified diagnoses(chest pains)(chest pains)


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If there is chronic pain with a history ofIf there is chronic pain with a history ofsubstance abuse/addictionsubstance abuse/addiction

Determine past treatment historyDetermine past treatment history

Assess current statusAssess current status

UDTs in APSUDTs in APS


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Virtually any prescription drug can beVirtually any prescription drug can bemisused/abused but psychotropic drugs are themisused/abused but psychotropic drugs are thefocus of concern especially with addictionfocus of concern especially with addiction

Trends temporally and geographicallyTrends temporally and geographically

Media biasesMedia biases


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Opioids of choice:Opioids of choice: HydrocodoneHydrocodone

OxycodoneOxycodone

MethadoneMethadone

Benzodiazepines of choice:Benzodiazepines of choice:

AlprazolamAlprazolam

ClonazepamClonazepam


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ENDEND

addiction issues in chronic pain management

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