Walking the Fine Line of Pain Management in Addiction

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Walking the Fine Line of Pain Management in
Addiction

• Safdar I. Chaudhary, MD
• Medical Director
• S'eclairer

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For more information

• On this subject and others
• General psychiatry, Forensic psychiatry,
  Addiction psychiatry, Geriatric psychiatry
• Contact at 724-468-3999
• Email safdar3_at_gmail.com
• www.seclairer.com

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Objectives

• Signs of addictive behaviors in primary care
  setting
• Literature review for treating pain in patients
  with addictions
• Review risk management safety concerns for
  treating pain disorders in addicts.

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Pain

• Is truly a pain
• Pain in the .

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Or pain as

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Pain and emotions
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But what if you felt no pain?

• Physical pain is a marvelous alarm system that
  prevents further damage. It tells us "You'd
  better change what you're doing!"
• Emotional pain gives us a similar message, eg. 
  "You'd better change how you're thinking!"

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With both physical and emotional pain

• When we keep doing the same thing, it keeps
  hurting!
• A blister on our foot is a message to change our
  shoes.
• With emotional pain - which feels like a blister
  on the brain - the message is usually to change
  our thinking.
• By Andrew Matthews'

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Erythroxylon coca bush
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Coca-Cola used to contain cocaine

• Coca-Cola was named back in 1885 for its two
  "medicinal" ingredients extract of coca leaves
  and kola nuts. Just how much cocaine was
  originally in the formulation is hard to
  determine, but the drink undeniably contained
  some cocaine in its early days.
• Coca-Cola didn't become completely cocaine-free
  until 1929, but there was scarcely any of the
  drug left in the drink by then.

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Injection of cocaine into the nucleus accumbens
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Localization of cocaine "binding sites"
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Positron emission tomography (PET) scan of a
person on cocaine
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Introduction to the Reward System
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Gateway Theory According to Kandel ( 1982)

• Four stages of drug use.
• Beer or wine consumption
• Cigarette Smoking or hard liquor consumption
• Marijuana use.
• Other illicit drug use.

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Domains of Chronic Pain

• Quality of Life Physical functioning, ability to
  perform activities of daily living, work,
  recreation
• Social Consequences Marital / family relations,
  intimacy/ sexual activities, social isolation
• Psychological Morbidity Depression, Anxiety,
  anger, sleep disturbances, loss of self-esteem
• Socioeconomic Healthcare costs, disability

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Opioid Sites of Action

• Opioids are thought to act by blocking the
  sensation of pain, from wherever it starts, and
  its transmission to somatosensory areas in the
  brain. The opioids tend to be most effective at
  the dorsal horn of the spinal cord -- the first
  synaptic connection -- where the injury is
  transmitted to the brain.
• May have an anti-inflammatory effect

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Efficacy of Opioids

• Osteoarthritis pain
• Neuropathic Pain
• Back Pain
• Cancer Pain

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Pain Assessment

• Intensity, onset, location, duration, quality
• Treatment response
• Provocative and palliative factors
• Variability of pain

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Patients with history of

• Personal or family history of abuse or addiction
• An affiliation with substance abusing subculture
• A significant premorbid psychopathology

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The Boston Collaborative Drug Surveillance Project

• Evaluated 11,882 inpatients who had no prior
  history of addiction and were administered an
  opioid while in hospital
• Only four cases of addiction could be identified
  subsequently
• Porter J, Jick H. Addiction rare in patients
  treated with narcotics. N Engl J Med 1980
  302-123.

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A Survey of US burn Units

• 10,000 patients without prior drug abuse history
  who were administered opiod for pain- no cases of
  addiction were noted
• Perry s, Heidrich G. Pain 1982 13267

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Drug Dependency in patients with chronic Headache

• In a study by Medina JL, Diamond S Drug
  Dependency in patients with chronic headaches
  Headache 1977 1712
• Only 3 patients were found to be abusing
  narcotics in a sample of 2,369 patients admitted
  for treatment.

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Pain Assessment

• Should one use opioid therapy ?
• Previous treatments
• Risk of opioid therapy
• Benefit of opioid therapy

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Assessment of Pain Intensity

• Verbal Pain Intensity Scale from no pain to
  worst possible pain
• Visual Analog scale
• Numeric pain Intensity scale 0- 10
• Faces Scale

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Activities Impaired by Increasing Pain Severity

• Patients report high levels of pain, even though
  they look pretty good to you in the office. How
  can patients have a level of 9 out of 10 and
  still laugh and talk to you? They move around the
  room as if they were in no pain, and you may
  think that, maybe, pain levels do not affect
  activity or that they are not directly
  correlated.

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When to be concerned

• Identify drug(s) of choice for emotional
  symptoms.
• Formal treatment for substance abuse
• Family history of substance abuse and /or other
  psychiatric disorders.

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Associated with Substance use Disorders

• Medical history findings associated with
  substance abuse Hep C, HIV, TB, Cellulites,
  sexually transmitted diseases, elevated LFTs
• Social history Motor vehicle accidents, DUIs,
  domestic violence, legal history, loss of
  property in fire
• Psychiatric history.

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Primary Diagnosis

• Medical diagnosis and potential primary treatment

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When to Refer

• Previous failures with opioids or other
  analgesics
• Significant psychosocial issues
• Conviction of a drug related crime
• Regular contact with drug high risk groups
• Current use of illicit drugs
• History of substance abuse/dependence

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Goals of Therapy

• How you are going to gauge the success of that
  treatment ?
• Is the goal just to decrease pain? Is it to
  eliminate pain? Is it to increase function? How
  are you going to measure success?

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Goals of Treatment

• If the patient is in a disrupted family situation
  or depressed, are you going to suggest
  counseling?
• Are you going to enter into an agreement or
  contract with that patient?

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Realistic Goals

• Shared goals of treatment
• Complete pain relief rarely achieved
• Common goals include
• -Pain reduction
• -Improvement in selected area of function
• -Improved mood
• -Improved work

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Therapeutic Touch
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Agreements and Informed Consent

• One modality in a multifaceted approach
• Expectations between patient and doctor,
  prohibited behaviors and grounds for tapering,
  limitation on prescriptions, emergency issues,
  refills and dose-adjustment procedures
• Exit strategy

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Exit Strategy

• Criteria for failure of the trial
• Document method for tapering opioids
• Common failure criteria includes
• Lack of significant pain reduction
• Lack of improvement in function
• Persistent side effects
• Persistent noncompliance

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Urine Toxicology

• Detection time 1- 3 days, longer if drug is
  lipophilic
• Types of urine drug testing
• Make sure the labs know what you are looking for

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When it is not that obvious
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Urine Toxicology
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Physical Dependence

• Physical dependence means that when a patient
  takes a medication, he becomes physically
  dependent upon the drug. When the patient comes
  off the medication, he will have symptoms of
  withdrawal, such as jitteriness, sweating, and
  possibly nausea and vomiting.

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Tolerance

• If a patient needs to take more drug to get the
  same effect, that is tolerance. Tolerance occurs
  with the opioids very commonly. Tolerance occurs
  at different rates in different opioids.

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Addiction

• Genetic, psychosocial and environmental
• Cravings
• Compulsive use
• Impaired control
• Use despite harm

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Differential Diagnosis

• Addiction
• Psudoaddiction (inadequate analgesia)
• Drug diversion
• Other psychiatric diagnosis
• Personality disorder
• Depression
• Anxiety disorders

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Regulatory Issues

• Risks of regulatory censure low if simple
  procedures are followed and documented
• Relevant regulations include DEA and State
  policies
• Useful model guidelines from federation of State
  Medical Boards. Available at www.fsmb.org

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Doctors create guidelines for painkillers

• Leading U.S. pain experts have collaborated with
  the Drug Enforcement Administration on a set of
  frequently asked questions and answers designed
  to improve pain treatment while attacking the
  growing problem of prescription-drug abuse.
• The authors of the document, released this past
  week, say they hope it will alleviate doctors'
  concerns that they'll jeopardize their career if
  they prescribe narcotic painkillers, or opiates.
  USA today August 15, 2004

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New DEA Guidelines

• "Prescribers, in general, view DEA as a
  potentially scary organization that doesn't have
  any idea what the medical imperatives are," says
  the project's lead pain expert, Russell Portenoy
  of New York's Beth Israel Medical Center. "In my
  experience, there's nothing like this (document)
  that has ever been done before."

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New DEA Guidelines

• About 30 percent of the U.S. population has
  chronic pain, and a third of them are disabled by
  it, says Portenoy, chair of pain medicine and
  palliative care at Beth Israel.
• He says opioids "appear to be very much underused
  and stigmatized," leading to "an epidemic of
  chronic pain." About 40 percent of people with
  pain related to life-threatening illnesses such
  as cancer and AIDS are not receiving adequate
  relief, he says.

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DEA Guidelines

• David Joranson, head of the Pain and Policy
  Studies Group at the University of Wisconsin,
  Madison, says, "the regulatory environment for
  pain management seems to be worsening."

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DEA Guidelines cont

• Patricia Good of the DEA's diversion control
  office says there are many misconceptions about
  her agency's role, leading to "unwarranted fear"
  that doctors will be targeted if they prescribe
  opiates. Last year, she says, the DEA arrested
  only 50 doctors for improperly prescribing
  narcotics or other controlled substances for
  abuse, Good says.

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Case 1

• 55 years old white male patient had a history of
  Heavy Alcoholism and Drug dependence, to the
  point that he suffered several medical
  complications, including Cirrhosis of
  liver,including Cirrhosis of liver.
• Various consultant recommended discontinuation of
  narcotics and sedatives/ hypnotic. PCP however
  continued use of Bezodiazipines and narcotics for
  more than 6 years (Klonopin, Librium, Talwin Nx,
  Vicodin)

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Recommendations

• . Available records dating back from June 93 to
  Sept 96 indicated multiple prescriptions were
  given on a regular basis for Schedule IV
  medications. This practice of PCP does not meet
  medical standards of practice and defies all
  rational clinical practices guidelines.

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Case 2

• 51 years old WF , pain along L-S Spine
  prescription for Vicodin 40, also given
  script for Soma 40, Vistaril 25 mg po 40.
•  2-9-98 Vicodin ES 40,1-29-98 Vicodin ES
  40 tabs
•  ER At Frick Hospital 8-24-97 for pain
  control received Demerol and Vistaril.

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Case 2 Cont

• The Cleveland Clinic Foundation consult March
  2, 1993.Fluctuating essentially constant
  headaches progressing daily for years. She tends
  to go to emergency rooms for two Demerol
  injections at a time MRI films done 1-8-93
  normal for a women of this age. In his report
  this early on Dr.-- recommended that she be
  treated with an antidepressant , perhaps starting
  Amitriptyline. if she continues Vicodin and
  Demerol, she runs the risk of becoming addicted.

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Case 2 Cont

• Mapper time period from 10-10-92 to 11-19-96 and
  subsequent progress notes for patient indicate
  long term use of Narcotics mainly Vicodin, with
  gradual increment in its use.  
• There is not enough justification for the
  prolonged use of Narcotics for pain control.
  This is clearly reflected by the consultants
  caution at the onset of treatment and later on by
  another neurologists report, which is available
  in the chart.

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Behaviors indicative of drug abuse- dependence

• Prescription forgery
• Concurrent abuse of related illicit drugs
• Recurrent prescription losses
• Selling prescription drugs
• Multiple unsanctioned dose escalation
• Stealing or borrowing another patients drugs,
  obtaining prescriptions from non-medical sources.

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