Treatment of Pain in Patients with Substance Abuse

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Treatment of Pain in Patients with Substance Abuse

• Sidney H. Schnoll, M.D., Ph.D.

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Physicians prescribe medications about which they
know little for diseases about which they know
less for patients about whom they know
nothing. Voltaire

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Addiction
A primary, chronic, neurobiologic disease, with
genetic, psychosocial, and environmental factors
influencing its development and manifestations.
It is characterized by behaviors that include
one or more of the following impaired control
over drug use compulsive use continued use
despite harm and craving.
AAPM, APS, ASAM - 2001
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Neuroadaptation

• Physical dependence
• A state of adaptation that is manifested by a
  drug class specific withdrawal syndrome that can
  be produced by abrupt cessation, rapid dose
  reduction, decreasing blood level of the drug,
  and/or administration of an antagonist.
• Tolerance
• A state of adaptation in which exposure to a drug
  induces changes that result in diminution of one
  or more of the drugs effects over time.

AAPM, APS, ASAM - 2001
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Scope of the Problem

• Equal opportunity disorder
• 25-40 of all hospital admissions
• 10-16 of outpatients seen in general medical
  practice
• Primary care physician is often the first to see
  the problem
• All physicians must be able to recognize and
  initiate treatment

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Economic Costs of Smoking, Drinking and Drug Abuse
Cost in billions of dollars
McGinnis, JAMA, 1993 Purdue Pharma, L.P., 2002
CDC, 2003
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Annual Cost Per Drug Addict
2.722
3.5
12.46
16.69
39.6
43.2
Cost in thousands of dollars
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State Substance Abuse Spending
Regulation and compliance (0.5)
Prevention, treatment and research (3.7)
Justice, education, health, child/family
assistance, mental health/developmentally
disabled, public safety, and state workforce
(95.8)
CASA, 2001
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Federal Substance Abuse Spending
Demand reduction Treatment, research, prevention
Supply side reduction
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Relationship Between Drug Use and Drug Problems
Drug Use
None
Light
Moderate
Heavy
At Risk
Problem
Addicted
Low Risk
Severe
Moderate
Small
None
Drug Problems
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Recognizing the Drug Abuser

• If you dont think about it, you wont recognize
  it
• Screen as part of your routine examination
• Be nonjudgmental in your approach
• Use simple nonthreatening screening tools

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Recognizing the Drug Abuser

• CAGE Questions
• Have you ever tried to Cut down on your alcohol
  or drug use
• Do you get Annoyed when people comment about your
  drinking or drug use
• Do you feel Guilty about things you have done
  while drinking or using drugs
• Do you need an Eye-opener

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Recognizing the Drug Abuser

• Trauma test
• Since your 18th birthday have you
• had any fracture or dislocations of your bones or
  joints (excluding sports injuries)
• been injured in a traffic accident
• injured your head (excluding sports injuries)
• been in a fight or been assaulted while
  intoxicated
• been injured while intoxicated
• 2 or more positive responses or 2 or more
  accidents

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Recognizing the Drug Abuser

• CRAFFT questions for teens
• Have you ridden in a Car with someone who is
  drinking or high, or have you driven in a car
  when drinking or high?
• Do you drink or get high to Relax or feel more
  sociable?
• Do you ever drink or get high Alone?
• Do you ever Forget things that happen when you
  are drinking or get high?
• Are your Family or Friends concerned about your
  drinking or drug use?
• Have you gotten into Trouble because of your
  drinking or drug use?

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Recognizing the Drug Abuser

• Complaints of sexual dysfunction with no other
  cause found
• Sexually and needle transmitted infections
• endocarditis
• hepatitis
• HIV/AIDS
• TB
• Needle marks and/or tracks
• Atrophy or perforated nasal septum

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Recognizing the Drug Abuser

• Laboratory findings
• elevated MCV
• abnormal liver enzymes
• positive urine toxicology screen
• positive tests for needle and sexually
  transmitted diseases

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Recognizing the Drug Abuser Behaviors

• Most predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or borrowing drugs from another patient
• Injecting oral formulations

• Most predictive
• Obtaining prescription drugs from nonmedical
  sources
• Concurrent abuse of related illicit drugs
• Multiple unsanctioned dose escalations
• Repeated episodes of lost and/or stolen
  prescriptions

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Recognizing the Drug Abuser Behaviors

• Less predictive
• Aggressive complaining about the need for higher
  doses
• Hoarding drug during periods of reduced symptoms
• Requesting specific drugs
• Obtaining prescriptions from multiple physicians

• Less predictive
• Unsanctioned dose escalation
• Unapproved use of the drug
• Reported psychic effects not intended by the
  physician
• Use of multiple pharmacies

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Readiness for Change

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance

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OPIOPHOBIA
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Pseudoaddiction

• Seeks more medication for appropriate treatment
  of pain
• Watches clock because medication prescribed at
  inappropriate dosing intervals
• Does not respond to what physician feels is
  maximum dose
• To avoid these problems - trust patient

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Reasons for Undertreament of Pain

• Lack of knowledge of modern pain treatment
• Difficulty in addressing psychological aspects of
  pain
• Inadequate training in treating chronic diseases
• Fear of prescribing opioid medication

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Myths About Opioids and Pain

• Opioids cause addiction in pain patients
• Opioids cause relapse in recovering patients
• Give pain medication prn to reduce abuse
• Give lowest possible dose at longest possible
  interval to reduce addiction
• Tolerance leads to continual increase in doses

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Effects of Regulations

• Physicians dont understand CSA
• dont know what the schedules mean
• agree that it causes undertreatment of problems
  (70)
• 86 treat less aggressively because of
• hassle
• government oversight
• fear of addiction

Adams
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Prescription Drug AbuseWhat do we know?

• Very few prospective studies
• Most data are inferred
• Is the problem overprescribing or
  underprescribing
• Physicians are taught very little about
  prescribing controlled substances

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Existing Studies

• Addiction rare in acute and chronic cancer pain
  treatment Kanner and Foley, Chapman and Hill
• Boston Collaborative Project 11,882 patients
  with no prior history of addiction, 4 cases of
  addiction Porter and Jick
• Few problems when treating chronic non-malignant
  pain, no dose escalations Jamison et al,
  Portenoy
• 10,000 burn unit patients who received opioids,
  no problems Perry and Hedrick

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Existing Studies

• Review of 24 papers
• Only 7 used adequate diagnostic criteria
• Incidence of abuse, physical dependence and
  addiction ranged from 3.2-18.9
• Conclusion addictive behavior not common in
  general chronic pain population

Fishbain et al, 1992
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Existing Studies

• Study of patients on opioids for pain
• Chart review of 59 patients
• Mean follow up
• 36 months
• 34 complete relief
• 69 developed tolerance
• 56 abused opioids (used more than prescribed)
• 24 diagnosed as addicts
• Criteria for diagnosis of addiction not specified

Bouckoms et al, 1992
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Medication Compliance is Not Addiction
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Prescription Drug Abuse

• Most surveys use illicit abuse model to determine
  rates of prescription abuse
• DSM designed for illicit drug abuse not
  prescription abuse
• Criteria can easily be misapplied to prescription
  drug users.

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Modified-Release vs Short-Acting Analgesics

• Adherence rates better for ATC analgesics than
  PRN Miaskowski et al, JCO, 2001
• Improved pain management with MRA vs SAA Ferrell
  et al, Onc. Nurs. Forum, 1989
• CRA vs SAA provide equal analgesia with lower
  side effects with CRA Caldwell et al, J. Rheumot,
  1999
• CRA improve mood without impairment of cognitive
  function Haythornthwaite et al, JPSM, 1998

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Guidelines to Prescribing Drugs with Abuse
Liability

• Give enough medication plus rescue doses
• Ask patient to bring in all original medication
  bottles with or without medication.
• date filled
• pharmacy
• prescribing physician
• number of pills dispensed
• number of remaining pills

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Guidelines to Prescribing Drugs with Abuse
Liability

• Monitor for lost or stolen prescriptions
• Obtain random urine screens. Know the drugs for
  which the laboratory screens.
• Use adjunctive medications as necessary
• Document, document, document

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Guidelines to Prescribing Drugs with Abuse
Liability

• See the patient as frequently as needed
• Work with significant others
• Know how to withdraw the patient from the
  medication
• Know the pharmacology of the drugs being
  prescribed
• duration of action
• parenteral to oral conversion ratio

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Guidelines to Prescribing Drugs with Abuse
Liability

• Bring patient in for unscheduled visits
• Obtain release to contact other health care
  providers
• Limit prn medications since this promotes drug
  seeking behavior
• Adequately treat the condition to avoid problems
  of pseudoaddiction

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the physician should not treat the disease,
but the patient who is suffering from it.

• Maimonides