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Slide 2 Medication Misuse and Comorbid Disorders Slide 3 Objectives Understand which disorders are frequently found among medication misusers Understand the impact of these disorders on pain treatment Understand prescription medications can be used to self medicate Know resources available for help for patients Slide 4 Prescription Medication Misuse Definition Taking medications for non-intended uses, differently than prescribed, without a prescription or with interacting substances. Slide 5 PMM and Co-morbid Psychiatric Disorders Patients may attempt to self medicate through symptoms of depression or anxiety Khantzian E. The self medication theory of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry 1985; 142: 1259-64. Survey showing only a small percentage of medication misuse is for recreational reasons only - 13% (civilian data no data on Service Members) McCabe S, Boyd C, Teter C. Subtypes of nonmedical prescription drug use. Drug and Alcohol Dependence. 2009, 102: 63-70. May also be due to shared vulnerability for depression or anxiety or a combination of both Slide 6 Disorders Frequently Found In Patients Who Misuse Prescription Medication - Potential Triggers for Self Medication Post traumatic stress disorder Anxiety disorder Depression Bipolar Disorder Slide 7 PTSD and PMM Evidence of a Relationship Higher rates of PTSD among medication misusers Higher rates of PMM among individuals with PTSD Simultaneous increases in PTSD and PMM rates among Service Members Certain groups of Service Members are higher risk for both PMM and PTSD Slide 8 PTSD Among Medication Misusers Data from Service Members survey not reported for US population (only reported as serious mental illness and depression in civilian survey) Higher possible PTSD rate among Service Members who misuse medications than those who dont Possible PTSD rate in medication misusers is 19% Possible PTSD rate in other Service Members is 8.5% 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. Research Triangle Institute, Research Triangle Park NC 2009 Possible PTSD rate in Service Members who misuse medications was comparable to possible PTSD rate among heavy drinkers and smokers PTSD rate in heavy drinkers 18.1% vs. 7.9% in non-drinkers PTSD rate in heavy smokers 22% vs. 7.9% in non-smokers 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. Research Triangle Institute, Research Triangle Park NC 2009 Table 4.43 Slide 9 PMM Among Patients with PTSD Individuals with PTSD are at higher risk for misusing medications - observational study of pain patients in civilian health care systems OR 2.45 (CI 1.88-3.19) White AG, Birnbaum HG, Shiller M, Tang J, Katz NP. Analytic models to identify patients at risk for prescription opioid abuse. Am J Manag Care. 2009; 15: 897-906. High rate of SUD (including PMM) among civilian patients with PTSD - 21-46% Jacobsen LK, Southwick SM, Kosten TR. Substance Use Disorders in Patients With Posttraumatic Stress Disorder: A Review of the Literature Am J Psychiatry 2001; 158: 11841190 Higher rate with combat related PTSD - 75% Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS: Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. New York, Brunner/Mazel, 1990 Slide 10 PTSD and PMM Rates Rising in Service Members Evidence of a Relationship PMM rates increasing since 2002 1.8% in 2002 11.1% in 2008 Possible PTSD prevalence among Service Members increasing as well 10.4% of Service Members may have PTSD on 2008 survey Up from 6.7% in 2005 2008 Department of Defense survey of health related behaviors among military personnel, Research Triangle Institute, Research Triangle Park NC 2009, Table 4.22 Slide 11 PTSD and PMM Service Member Selective Sub-groupings Show a Possible Relationship Deployed vs. non-deployed Females at higher risk for both Slide 12 Higher Rates of PTSD and PMM Among Service Members Who Have Been Deployed Also Suggests A Relationship Higher rate of PMM in Service Members who have been deployed to Iraq or Afghanistan 12% higher PMM rates in SMs who have been deployed (17% in SMs who have not deployed, 19% in SMs who have deployed) 2008 Department of Defense survey of health related behaviors among military personnel, Research Triangle Institute, Research Triangle Park NC 2009 Up to 17 percent of troops screened after deployment may have PTSD (compared to 10% of all SMs) Hogue C, Castro C, Messer S, McGurk D, Cotting D, and Koffman R. Combat duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. NEJM. 2004; 351: 13-22. Slide 13 Higher Rates of PTSD and PMM Among Female Service Members Also Suggests Relationship Female Service Members at increased risk for PTSD OR 2.33, CI 1.8-3.03 LeardMann CA, Smith TC, Smith B, Wells TS, Ryan MA. Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: prospective US military cohort study. BMJ. 2009; 338: b1273. Female Service Members also had higher rate of PMM 13.2% of female Service Members 11.2% of male Service Members 3.2% of females in the US population 2008 Department of Defense survey of health related behaviors among military personnel, Research Triangle Institute, Research Triangle Park NC 2009 Slide 14 PTSD and PMM Evidence suggests a link between the two Causal? Bidirectional? Likely self medication of PTSD with medications Slide 15 PTSD and PMM Does treating PTSD reduce the risk for PMM? Unknown possible based on data on treating ISA and PTSD treatment Slide 16 Treating PTSD and the Potential Effect on PMM Rates Treating PTSD may be beneficial in reducing PMM based on evidence of impact with illicit substance abuse (ISA) PTSD responsive to treatment renders patients less prone to substance abuse Ouimette P, Brown P, Najavits L. Course and treatment of patients with both substance use and posttraumatic stress disorders. Addict Behav 1998; 23:785795 Substance abusers with unremitting PTSD had more relapses and felt less able to prevent relapses Ouimette P, Coolhart D, Funderburk J, Wade M, Brown P. Precipitants of first substance use in recently abstinent substance use disorder patients with PTSD. Addict Behav. 2007. 32(8):1719- 27. Slide 17 PTSD Treatment Specific serotonin reuptake inhibitors (SSRIs) are effective Viewig, WV; Et al. Posttraumatic stress disorder: clinical features, pathophysiology, and treatment. Am J Med 2006; 119: 383-390. Most effective when continued for 9-12 months after symptom remission. Ursano RJ, Bell C, Eth S, et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry 2004;161:331. Cognitive behavioral therapy (CBT) lead by a consulting psychiatrist is also effective. Stein DJ, van der Kolk BA, Austin C, et al. Efficacy of sertraline in posttraumatic stress disorder secondary to interpersonal trauma or childhood abuse. Ann Clin Psychiatry 2006;18: 2439. Slide 18 PTSD and PMM Patients with active PTSD are high risk for PMM and should only be managed in close consultation with a psychiatrist and preferentially by the appropriate specialist (pain management, psychiatrist, etc.) PCMs must still be engaged in patient care and aware of medical interactions which could impact the pharmacology of potentially misused medications PCMs must also be able to identify PTSD and properly risk stratify patients Slide 19 Depression and PMM Depressive symptoms may trigger PMM Review evidence of a direct link Review possible evidence of an indirect link through the interaction of depression with PTSD and chronic pain Slide 20 Direct Link between Depression and PMM Patients with depression are at an increased risk for PMM (civilian data from chronic pain patients receiving chronic opioid therapy) Probable Depression increases the risk for PMM OR 2.4 (CI 1.6-3.4) MDD increases the OR to 3.2 (CI 2.9-3.6) Any mood disorder increases the risk for PMM OR 3.5 (CI 3.1-3.9) Major references on depression and PMM: Becker W, Fiellin D, Gallagher R, Barth K, Ross J, Oslin D. The association between chronic pain and prescription drug abuse in Veterans. Pain Medicine 2009; 10: 531-536. Martins S, Keyes K, Storr C, Zhu H, Chilcoat H. Pathways between nonmedical opioid use/dependence and psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions Drug and Alcohol Dependence. 2009: 1624. Survey data (National Survey on Drug Use and Health) shows a strong relationship between a major depressive episode and PMM Slide 21 Indirect Relationship Between Depression and PMM Through Chronic Pain Depression may indirectly increase PMM through its interactions with chronic pain Patients with depression experience more severe pain and pain catastrophizing and are more likely to develop an SUD Jamison R, Link C, and Marceau L. Do pain patients at high risk for substance misuse experience more pain? A longitudinal outcomes study. Pain Med. 2009 Sep;10(6):1084-94. Patients with chronic pain and comorbid depression have worse outcomes and potentially greater drive to self medicate Eicsson M, Poston W, Linder J, Taylor J, Haddock C, and Foreyt J. Depression predicts disability in long term chronic pain patients. Disabil Rehabil 2002; 24: 334-340. Providers must be aware that depression and comorbid pain may increase the risk of suicidal ideation/attempts Spiegel B, Schoenfeld P, Naliboff B. Systematic review: the prevalence of suicidal behaviour in patients with chronic abdominal pain and irritable bowel syndrome. Aliment Pharmacol Ther. 2007 Jul 15;26(2):183-93. Slide 22 Treating Depression Impact on PMM Treating depression will possibly reduce PMM Impact on PMM inferred from studies on the impact of treating depression in illicit substance use Adherence to depression treatment leads to a lowered rate of substance abuse among drug users Stein M, Herman D, Solomon D, Anthony J, Anderson B, Ramsey S, and Miller I. Adherence to treatment of depression in active injection drug users: the Minerva study. J Subst Abuse Treat. 2004. 26(2):87-93. Nunes E and Levin F. Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. JAMA 2004; 291 (15): 1887-1896 Slide 23 Depression and PMM These patients are high risk for PMM and should be managed by a specialist in the appropriate discipline in conjunction with a psychiatrist and the PCM Providers must be able to screen for depression to identify need for specialty care Providers must know interactions between medications prescribed to avoid interactions Slide 24 TBI and PMM Service Members who have sustained a TBI in combat may be at increased risk for PMM No studies exist Anecdotal evidence Personal communications Media reports Some evidence that patients with a combat related TBI may have an increased drive for self medication due to increased incidence of chronic pain, PTSD and depression Slide 25 TBI and PMM Civilians may suffer a TBI as a result of intoxication and then have a decrease in substance abuse rates Ponsford J, Whelan R, Bahar-Fuchs A. Alcohol and drug use following traumatic brain injury: a prospective study. Brain Inj. 2007. (21):13851392 Military TBI patients have different circumstances leading to the injury Slide 26 TBI and PMM Suicide Risk TBI patients have a 2-4 fold increased suicide rate, particularly with depression or substance use disorders danger for fatal prescription medication misuse Simpson G, Tate R. Suicidality after traumatic brain injury: demographic, injury and clinical correlates. Psychol Med. 2002;32:687697. Irresponsibly prescribed medications may be the equivalent of a loaded gun Slide 27 Conclusion Many gaps but evidence suggestive that PTSD, depression, chronic pain, and TBIs may predispose patients to PMM These patients are high risk for PMM PCMs must be able to identify these disorders PCMs must interact with specialists involved in caring for these patients to ensure optimal care Slide 28 Patient Scenario Sam Coleman Present Complaint A 35 year old female patient with an unremarkable physical exam presents complaining of chronic headaches. She also complains of insomnia, waking frequently and difficulty falling asleep five nights a week. She avoids eye contact, sits low in the chair and is tearful in between heavy sighing. The patient would like a refill for oxycodone which was prescribed to her for a recent sprained ankle, since it helps with her headache pain. Slide 29 Sam Coleman History The patient has had insomnia for 2 years. She is in a difficult custody battle for a young daughter, who lives with her ex-husband. He was mentally and physically abusive during their marriage. She alludes to possible sexual assaults by her husband as well. She has not seen her daughter in two years. She is a lab director working long hours under high pressure. She has little time for friends and her current husband. The patient does not drink alcohol, but smokes one pack of cigarettes per day. Slide 30 Sam Coleman - Questions What are her risk factors for prescription medication misuse? Do you think this patient might also suffer from depression? If so, what treatment plan would you consider? Medications? Therapy? Complementary medicine? What are the symptoms of depression? What are the symptoms of post-traumatic stress disorder? What impact do depression and/or PTSD have on pain? Would you refill her oxycodone? How would you treat the insomnia? Slide 31 Military Resources Military Homefront Support 800-342-9647 www.militaryonesource.com Branch Specific Support is also available: Army Substance Abuse Program (ASAP) Navy Alcohol and Drub Abuse Prevention (NADAP) Marine Substance Abuse Combat Center (SACC) Air Force Alcohol and Drub Abuse Prevention and Treatment (ADAPT) Slide 32 Non-Military Resources Substance Abuse and Mental Health Services Administration (SAMSHA) www.findtreatment.samsha.govwww.findtreatment.samsha.gov 1-800-662-HELP National Suicide Prevention Lifeline 800-273-TALK National Alliance on Mental Illness www.nami.orgwww.nami.org Mental Health America www.mentalhealthamerica.netwww.mentalhealthamerica.net American Academy of Addiction Psychiatry www.aaap.orgwww.aaap.org American Academy of Child and Adolescent Psychiatry www.aacap.org www.aacap.org National Drug Abuse Clinical Trials www.drugabuse.gov/CTN/ or www.clinicaltrials.govwww.drugabuse.gov/CTN/ www.clinicaltrials.gov Narcotics Anonymous www.na.org/www.na.org/ Alcoholics Anonymous www.aa.orgwww.aa.org