Identifying Substance Abuse in Pain Treatment

1
Identifying Substance Abuse in Pain Treatment

• Mark Publicker, MD FASAM
• Medical Director,
• Mercy Recovery Center

2
Physician, 1894

• We have an army of women I America dying from
  the opiate habit _ larger than our standing army.
  The profession (medicine) is wholly responsible
  for the loose and indiscriminate use of the
  drug.

3
Physician, 1871

• With their characteristic anxiety for dosing
  themselves, Americans would overuse all new
  remedies.

4
North Carolina Physician, 1880

• On one patient I have use the hypodermic
  syringe between 2500 and 3000 times in a period
  of eighteen months, and so far see no signs of
  the opium habit.

5
Maine adolescent 30-day prescription drug abuse
2003

• 7th Grade 3.7
• 8th Grade 6.1
• 9th Grade 8.9
• 10th Grade 11.0
• 11th Grade 11.6
• 12th Grade 10.3

6
Is there a problem?
7
Maine admissions non-heroin, non methadone
opiates

• 1995 1996 1997 1998 1999 2000 2001 2002
• 85 100 131 231 429 777 1001 1229
• Maine admissions heroin
• 1995 1996 1997 1998 1999 2000 2001 2002
• 258 306 313 364 386 525 655 1025
• TDS data by primary problem

8
Is there a problem?

• Current NIDA estimate
• 4.4 million Americans addicted to prescription
  opioids
• 2.1 million Americans addicted to benzodiazepines
• Maine 2001 out of 90 drug deaths, 70 (78) were
  caused by a pharmaceutical.
• Maine 2002 out of 166 drug deaths, 148 (89)
  were caused by a pharmaceutical.

9
Distinguish between an addict and a patient with
pain?

• Patients with active addictions with painful
  conditions
• Recovering patients with painful conditions
• Patients who misuse
• Patients who abuse to get high
• Patients who abuse to self-medicate

10
Tolerance

• The need for an increased dosage of a drug to
  produce the same level of analgesia that
  previously existed. Tolerance also occurs when a
  reduced effect is observed with constant dose.
  Analgesic tolerance is not always evident during
  opioid treatment and is not addiction.

11
Pseudotolerance

• The need to increase dosage due to other factors
  such as
• Disease progression, new disease, increased
  physical activity, lack of compliance, change in
  medication, drug interaction, addiction, and
  deviant behavior.

12
Physical dependence

• Indicated by the occurrence of withdrawal
  symptoms after opioid use is stopped or quickly
  decreased without titration, or if an antagonist
  is administered
• Can be avoided by warning patients not to
  abruptly stop the medication and by using a
  tapering regimen
• Physical dependence is not addiction

13
Drug misuse

• Unintentional consumption of a drug in other than
  the commonly accepted manner.
• Physician mis-prescription
• Patient misunderstanding

14
Drug abuse

• Deliberate misuse of a drug.
• Self-medication of painful feelings and/or
  reality
• To get high

15
Pseudoaddiction

• Drug-seeking behavior that seems similar to
  addiction, but is due to unrelieved pain. This
  behavior stops once that pain is relieved, often
  through an increase in the opioid dose.
• Leads to inappropriately stigmatizing the patient
  with the label 'addict'.
• Prn dosing, short-acting opioids

16
Pseudoaddiction

• In the setting of unrelieved pain, the request
  for increases in drug dose requires careful
  assessment, renewed efforts to manage pain and
  avoidance of stigmatizing labels.

17
Addiction

• Compulsive use
• Loss of control
• Use despite known harm
• Non-medical use
• Aberrant drug behaviors

18
Addiction

• Psychological dependence on the use of substances
  for their psychic effects and is characterized by
  compulsive use.
• Addiction should be considered if patients no
  longer have control over drug use and continue to
  use drugs despite harm.

19
Addiction

• Addiction is a cycle of spiraling dysregulation
  of brain reward systems that progressively
  increases, resulting in compulsive drug use and a
  loss of control over drug taking George Koob

20
Medication overuse vs addiction

• Co-occurring personality disorders and poor
  coping skills can make these distinctions
  difficult
• The percentage of headache rebound patients with
  addictive disorders is actually low
• The patients willingness to collaborate with the
  physician is a good indicator

21
Addictive behavior vs Medical dependence Stimmel

• Relief of pain
• Constant dose and frequency with slow increases
  for tolerance
• Usually able to abruptly stop or if wd develops
  can be successfully managed

• Primary purpose euphoria
• Rapid dose escalation as tolerance develops
• Abstinence unlikely to be maintained despite
  frequent attempts

22
Addictive behavior vs Medical dependence

• Function frequent intoxication
• Behavior focus on drug-seeking to exclusion of
  socially productive activities

• Able to function productively in acute pain
  states slight sedation may occur
• Able to engage in productive activity due to
  relief of pain

23
Addictive behavior vs Medical dependence

• Side effects common due to dose and routes of
  administration continued use despite
  complications
• Polydrug use frequent

• Mild, manageable side effects
• Polydrug use rare unless prescribed by physician

24
Screening

• No good research-validated instruments
• High risk
• Prescription forgery, theft, alterations
• Pattern of repeated lost, stolen, damaged
  prescriptions
• Intoxication
• Stories

25
Substance abuse screening

• CAGE
• T-ACE
• Collateral sources (family, concerned others)
• Review of past medical care
• Pharmacy
• Prescription Drug Monitoring Program
  www.maineosa.org/data/pmp

26
Distinguish between an addict and a
patient with pain?

• Patients with active addictions with painful
  conditions
• Recovering patients with painful conditions
• Patients who misuse
• Patients who abuse to get high
• Patients who abuse to self-medicate

27
Urine drug screening/monitoring

• Know your labs methodologies and screening
  thresholds
• Drug-negative urines
• Establish your own limits
• Cannabis?
• Cocaine?
• Benzodiazepines?

28
Dealing with suspected drug abuse

• Intervention
• Consultation
• Addiction medicine
• Pain specialist
• Referral

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Case 1

• 39 year old woman with new diagnosis of
  rheumatoid arthritis with disabling foot pain
• How would you evaluate her substance abuse risk?

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Case 2

• 43 year old male, new patient to your practice.
• Presenting complaint intractable back pain from
  bulging disks, treated by his last doctor with
  methadone 120 mg three times a day plus rescue
  Roxicodone.

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Case 3

• 27 year old female patient with chronic
  headaches, prescribed Fioricet 4-6 per day, Xanax
  2 mg tid and oxycodone 30 mg prn
• Someone broke into my car and stole all of my
  prescriptions

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Case 4

• Chronically disabled 32 year old paraplegic male
  prescribed Oxycontin 80 mg tid for neuropathic
  pain. Screening UDS positive for cannabis.
• What if his UDS is positive for cocaine?
• What if his UDS is negative for opioids?

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Case 5

• 61 year old woman with diffuse osteoarthritis and
  fibromyalgia.
• You realize that you are prescribing her over 900
  mg of oxycodone daily along with over 6 mg of
  Xanax.

34
Case 6

• 44 year old recovering alcoholic with chronic
  pain from a torn rotator cuff. Pain is described
  as severe and not relieved by Tylenol or NSAIDs.

35
Case 7

• You receive a call from the local pharmacy
  informing you that one of your patients is also
  receiving pain and sedative medications from
  other physicians.

36

Dr. Paul Doctor, Alcoholic, Addict. AA Big
Book

• I never in my life took a tranquilizer, sedative
  or pep pill because I was a pill head. I always
  took it because I had the symptom that only that
  pill would relieve. Therefore, every pill was
  medically indicated at the time it was taken.

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Dr Paul, continued

• For me, pills dont produce the desire to
  swallow a pill they produce the symptoms that
  require that the pill be taken for relief. I had
  a pill for every ill, and I was sick a lot.

38
Some suggestions

• When in doubt, ask for help
• Dont rely on medication alone
• Everyone gets one good story
• Review the pharmacy record each time

39
Conclusions

• There is a role for opiates in the management of
  some patients with chronic non-malignant pain
• These patients need to be carefully selected, and
  the risks, benefits and alternatives to long-term
  opiate use explained.

40
Conclusions

• For some pain syndromes, such as migraines, there
  is a clear consensus that chronic or frequent
  acute opiate use is contraindicated and can
  worsen the pain disorder, rendering it
  intractable to acute and prophylactic treatment.

41
Conclusions

• When long-term opiates (LTOs) are found to be
  necessary for the management of CNMP,
  short-acting opiates should be avoided.
• Patients should be carefully screened for
  histories of alcoholism and other drug
  dependencies.

42
Conclusions

• Patients should be referred for treatment of
  primary or secondary depression or other
  psychiatric disorders.
• Utilize empathetic confrontation and intervention
  when addressing suspected substance abuse
  problems.

43
Oxycontin - Art van Zee, MDAnnals of Internal
Medicine April 6, 2004

• It might have been easier
• if OxyContin swallowed the mountains, and took
• the promises of tens of thousands of young lives,
• Slowly, like ever-encroaching kudzu.
• Instead,it engulfed us,
• gently as napalm would a school-yard

44
Oxycontin - Art van Zee, MD

• Mama said
• As hard as it was to bury Papa
• after the top fell
• in the mine up Caney Creek,
• it was harder yet
• to find Sis that morning
• cold and blue,
• with a needle stuck up her arm.