TREATING TWO DISEASES

1
TREATING TWO DISEASES

• CHRONIC PAIN SYNDROMES
• AND THE DISEASE OF
• ADDICTION
• Bruce C. Springer, M.D.
• Pine Rest Addiction Services

2
PAIN

• Pain is an unpleasant sensory and emotional
  experience that is associated with potential or
  actual tissue injury or is described in terms of
  such injury.
• (Intl Assoc for the Study of Pain, 1979)
• An experience influenced by
• culture, temperament

3
PAIN

• past experience, memory
• anticipation, beliefs
• emotional factors, co-occurring health
• cognitive factors, gender, age
• The experience of pain is different from
  individual to individual and within the same
  person at different times

4
PAIN

• The pain signal is transmitted from nociceptors
  along peripheral nerves to the dorsal root
  ganglion and then to the dorsal horn of the
  spinal cord.
• The spinothalamic tract carries the impulse up to
  the thalamus and to the somato- sensory cortex
  and limbic system to be experienced and
  interpreted.

5
CHRONIC PAIN

• Tissue damage releases chemicals which sensitize
  nerve fibers and alter gene expression.
• Regeneration of nerve fibers into a neuroma which
  generates pain signals.
• Injury to and degeneration of pain inhibitory
  pathways.
• Sleeplessness, anxiety and depression trigger
  more pain

6
PAIN MODULATION

• Descending pathways originating in the ventral
  medulla, periaqueductal and periventricular gray
  matter are stimulated by endogenous and exogenous
  opioids.

7
PAIN MODULATION

• These pathways interact with sensory spinal
  neurons inhibiting pain impulse transmission.
  This involves numerous chemicals and
  neurotransmitters, including endorphins, GABA,
  norepinepherine, serotonin, enkephalins, and
  oxytocin.

8
PAIN MODULATION

• Increases in inhibitory input on sensory neurons
  in the spinal cord is in response to opioid
  binding to receptors on neurons in the midbrain
  and medulla.
• This gives us insight into how opiates function
  in the CNS to alleviate pain.

9
PAIN MODULATION

• This pain modulation system may not work well in
  patients with the disease of addiction to
  opiates.
• Indeed addicted patients may well have a more
  intense pain experience.

10
ADDICTION

• A DISEASE
• primary
• neurophysiologic
• chronic
• FACTORS
• genetic
• psychosocial
• environmental

11
ADDICTION

• Affects about one in ten Americans
• Loss of control over a substance or behavior and
  inability to stop despite negative consequences
• Mesolimbic dopamine system is home to the reward
  and reinforcement of behaviors essential to
  survival

12

• WWW.DRUGABUSE.GOV

13
ADDICTION

• Opiates bind to mu receptors in the
  periaqueductal gray and other areas described
  above and help modulate pain.
• They also bind to mu receptors in the VTA and
  increase dopamine release in the NA.

14
ADDICTION

• Thus opiates are rewarding and reinforcing.
• Tolerance produced by neuroadaptation to a
  substance where the individual must use more to
  achieve the desired result or no longer benefits
  from the original effective dose.

15
ADDICTION

• Physical Dependence is a result of
  neuro-adaptation where there is experienced a
  characteristic abstinence syndrome when the drug
  is stopped, decreased abruptly or when an
  antagonist of this drug is given.
• Patients can develop both of these and not have
  the disease of addiction.

16
CONSEQUENCES

• More people die from prescription drug overdoses
  than in car accidents in Michigan.
• In 2007 someone died of an overdose every 19
  minutes.
• Prescription drug abuse is the fastest growing
  substance abuse problem in the U.S.
• For every OD death, 9 people are admitted to
  treatment facilities, 35 visit ERs, 161 report
  abuse or addiction and 461 report non medical use
  of opiates.

17
PAIN IN ADDICTED PATIENTS

• Increased pain sensitivity in opiate addicted
  patients on methadone maintenance.
• Evidence supports an opiate-induced hyperalgesia.
• This hypersensitive state improves with opiate
  detoxification.

18
PAIN IN ADDICTED PATIENTS

• Addiction may serve to facilitate the pain
  experience
• Inability to experience pleasure
• Chaotic lifestyle
• Sleep disorders
• Anxiety, irritability,
• Loss of social support, interpersonal
  conflicts
• Noncompliance with past treatment plans

19
PAIN IN ADDICTED PATIENT

• Addicted patients alternate between intoxication
  and withdrawal states thus activating the
  neurochemical stress response, chronic negative
  emotional state and increasing the pain
  experience
• Anhedonia
• Irritability
• Dysphoria

20
PAIN IN ADDICTED PATIENTS

• Dopamine depletion and perhaps decreased
  dopamine receptors in reward pathways.
• Depression.
• Pain assessment in patients with substance
  use disorders is complicated.

21
ASSESSMENT of PATIENTS

• Look for a recent history of substance use
  disorder,
• prescription abuse, problems with opiates
• non involvement in AA or NA,
• little or no family support or too much support
• Allergies to multiple opiate and non-opiate
  analgesics

22
ASSESSMENT of PATIENTS

• Be aware of patients at higher risk for
  addiction
• family history of addiction,
• smokers,
• current problems with drugs,
• other compulsive behaviors,
• gambling addiction
• cannabis use legal vs. illicit

23
ASSESSMENT of PATIENTS

• The addicted patient (vs. the legitimate chronic
  pain patient) will
• crave drugs, use opiates compulsively,
• increase the dose on their own,
• have social and relational problems,
• severe withdrawal symptoms, be intoxicated,

24
ASSESSMENT of PATIENTS

• use other substances,
• often use higher doses
• seek early refills
• shun personal responsibilities.

25
ASSESSMENT of PATIENTS

• Decreasing function and increased complaints of
  pain despite medication titration
• Persistent negative affective states, anxiety,
  depression and irritability

26
RED FLAGS

• Reports of lost or stolen prescriptions
• Appearance at office without appointment and in
  distress
• Frequent visits to ERs to request drugs
• Family reports overuse or intoxication
• Failure to comply with non-drug pain therapies
• Fails to keep appointments

27
RED FLAGS

• Not interested in rehabilitation
• Reports no effect of non-opiate interventions
• Seeks prescriptions from other providers
• In Michigan you may use the MAPS form to get
  prescription information from the MI Dept. of
  Community Health

28
PAIN PATIENT

• History and physical rule out a worsening
  organic lesion as the cause of worsening pain.
• Look for pain facilitating problems such as sleep
  disturbance, mood disorders, disability, stress,
  drug addiction or abuse.
• What studies are needed?
• Get as many old records as possible.
• Communicate with previous health care providers.

29
PAIN PATIENT

• Rule out a worsening organic lesion as the cause
  of worsening pain.
• Be open to potential signals of addiction or
  pseudo-addiction.
• Substance abusing patients may over report pain
  out of fear or desire to divert drugs.
• Recovering addicted patients may under report
  pain over fear of relapse

30
APPROACHING the ADDICTED PATIENTS

• Be matter-of-fact in your questions about your
  worried about your relationship with some of
  these medications and what it is doing to your
  life and your pain treatment.
• Ask about nicotine, caffeine then alcohol next
  before asking more about opiates, etc.

31
APPROACHING the ADDICTED PATIENT

• Honest answers are vital for us to make a good
  treatment plan for your pain and your life
  better.
• You did not volunteer for chronic pain and you
  did not volunteer to lose control over these
  drugs.
• I hope you will volunteer to treat both.

32
SOAPE GLOSSARY
Summary

• Reinforce the patient-physician relationship in
  the midst of this chronic illness.
• We need to work together on this.
• This requires a team effort and you and I are
  two members of the team.

33
SOAPE GLOSSARY

• Optimism
• Remember the patient may well expect failure
• People with these diseases cant do all this by
  themselves.
• with help you will do well
• no one deserves the pain and humiliation these
  diseases bring
• treatment works
• you can expect improvement in most areas of
  your life

34
SOAPE GLOSSARY

• Absolution
• Guilt, shame and weakness are paralyzing and can
  lessen the patients ability to take on sobriety.
• Your pain and addiction problem are not your
  fault. They are diseases and it is our
  responsibility to work together toward your
  recovery from both.
• Recovery is likely.

35
Plan cont

• What will their insurance cover?
• What is the patient ready for?
•  

• What do you think you can do at this point
• There are many things we can do to pursue
  recovery from addiction and pain

36
SOAPE GLOSSARY

• Explanatory Model
• Ask the patient, What is your idea of a person
  with addiction?
• Try to understand what the patient understands
  about addiction.
• This is an illness that responds to medical
  intervention and treatment, but not to willpower
  alone.

37
PAIN PATIENT

• Patient must sign release forms to other care
  providers including PT/OT, counselors,
  psychologists, psychiatrists, pain specialists
  and PCP etc.
• Encourage free exchange of information among all
  providers and with the patient.

38
PAIN PATIENT

• Establish clear treatment goals
• Analgesia
• Improvement in other symptoms
• Restoration of function

39
ADDICTION

• The diagnosis of addictive disease is made by
  yourself or another provider.
• It is a prospective diagnosis made over time
• It is important for the patient to realize that
  without treating addiction their pain will never
  be adequately treated.

40
ADDICTION

• Institute a Recovery Program
• Discuss with an addiction specialist
• Introduce to a treatment program
• Keep a list of local NA meetings
• Be willing to stay engaged with the patient
• Formulate a treatment agreement with the patient
  that has at its core the patients continued
  steadfast recovery from addiction while pain is
  treated.

41
ADDICTION RECOVERY and PAIN TREATMENT AGREEMENT

• Treatment agreement
• Pill counts
• Urine drug screens
• One provider for opiates (if needed)
• One pharmacy
• No missed appointments
• No lost scripts.
• Attendance of 12-step meetings

42
ADDICTION RECOVERY and PAIN TREATMENT AGREEMENT

• Complete cooperation with non pharmacologic
  treatment and non opiate treatments.
• Cooperation with counseling, physical therapy,
  treatment of mood disorders.
• Complete abstinence from other addictive
  substances.
• Strict use of meds as prescribed and no use of
  other peoples meds.

43
ADDICTION RECOVERY

• The patient must consent to be held accountable
  by a team of people including possibly a
  Narcotics Anonymous sponsor.

44
12-STEP PROGRAMS

• Founded in 1935 by two hopeless alcoholics Bill
  Wilson and Robert Smith M.D.
• Discovered that by talking to others with the
  same disease they could stay sober.
• AA meetings found in most countries.
• AA Big Book published in many languages.

45
PSYCHOLOGICAL INTERVENTIONS

• Deep relaxation
• Biofeedback
• CBT
• Guided Imagery
• Treat mood disorders, antidepressants tx
• Family/Relationship therapy
• Functional Rehabilitation

46
ON GOING CARE

• The goal should be to remain engaged with the
  patient regarding pain while continuing to
  encourage and support their recovery from
  addiction.
• Must constantly reinforce the patients active
  role in their treatment.
• Move gently to eliminate unnecessary dependence
  on medications tapering, replace opiates with
  buprenorphine, detox.

47
DISCONTINUING OPIATES

• Pain has resolved.
• Side effects are unmanageable.
• Opiates are not stabilizing the patient or
  improving function.
• Patient loses control over the opiate pain med.
• Patient using other substances such as ETOH,
  benzodiazepines, cannabis, etc.
• Patient is diverting the opiates.

48
WITHDRAWAL SIGNS AND SYMPTOMS

• Dysphoria
• Insomnia
• Severe craving
• Irritability
• Lacrimation
• Dilated pupils
• Rhinorrhea

• Nausea and vomiting
• Diarrhea
• Cramping abdominal pain
• Joint aching
• Muscle cramping
• Hot and cold flashes

49
WITHDRAWAL SIGNS AND SYMPTOMS

• Sweating
• Goose flesh
• Yawning

• Elevations of blood pressure
• Tachycardia
• Mild fever

50
PAIN IN ADDICTED PATIENTS OPIATE INDUCED
HYPERALGESIA

• Increased pain sensitivity in opiate addicted
  patients on methadone maintenance.
• Evidence supports an opiate-induced hyperalgesia.
  
• This hypersensitive state improves with opiate
  detoxification.

51
OPIATE INDUCED HYPERALGESIA

• Receptor desensitization. Uncoupling of
  intracellular G protein from receptor.
• Up-regulation of cAMP pathway.
• Facilitation of pain by descending pathways.
• Hyperactivity of the stimulating NMDA receptors.

52
NON-OPIOID ANALGESICS

• ACETAMINOPHEN
• NSAIDs
• SNRIs
• TRICYCLIC ANTIDEPRESSANTS
• ANTICONVULSANTS
• TOPICAL AGENTS
• MUSCLE RELAXANTS (avoid Soma)

53
BUPRENORPHINE

• Consider Suboxone for chronic pain

• buprenorphine and naloxone
• a partial agonist, harder to O.D.
• binds strongly to mu opiate receptor.
• good analgesic.
• safer than other full opiate agonists.
• milder withdrawal symptoms.
• FDA approved for opiate addiction
  maintenance therapy.

54
THE TEAM

• Decide who needs a copy of the medication
  agreement.
• Decide who will help hold the addicted pain
  patient accountable. Case workers, addiction
  specialists, addition counselors, pain
  specialists, primary care physicians, physical
  therapists, pharmacists, etc.
• All health care professionals involved must be
  constantly vigilant with the addicted pain
  patient.

55
ADDICTION TREATMENT

• Medicare Patients Sparrow/St. Lawrence in
  Lansing or Brighton Hospital in Brighton.
• In the case of noninsured and Medicaid you must
  call Network 180. Kent County residents must go
  through them (Gatekeeper). If from another
  County, call that counties CMH.

56
ADDICTION TREATMENT

• For patients addicted to other substances and
  behaviors, refer to Addiction Therapists at Pine
  Rest (281-7500), Arbor Circle (459-7215), Network
  180 (336-3909), Project Rehab (776-0891).
• Use the Find Treatment Website at SAMHSA.

57
ADDICTION/PAIN TREATMENT

• SPECTRUM HEALTH Corey Waller, M.D.
• The Center for Integrative Medicine
• 75 Sheldon Blvd SE, Suite 100
• Grand Rapids, MI 49503
• 616-391-6120

58
Case workers, Physical Therapists, Nursing Staff,
Addiction Counselors, Pharmacists

• Very important role in keeping the patient
  engaged in their own care
• Opportunities and needs of the addicted pain
  patient missed by others may be recognized by
  these providers
• The addicted pain patient may be held accountable
  for many aspects of their lives.

59
THE ADDICTED PAIN PATIENT

• THANK YOU!
• QUESTIONS?
• Principles of Addiction Medicine, ASAM, 4th
  Edition
• TIP 54 Managing Chronic Pain in Adults With or
  in Recovery From Substance Use Disorder, SAMHSA,
  Rockville, MD 20857