Problem%20Patient%20or%20Problem%20Prescription?

1
Problem Patient or Problem Prescription?

• Ken Roy, MD
• Tulane Department of Psychiatry
• Addiction Recovery Resources of New Orleans
• 504-780-2766
• www.arrno.org

2
Scope

• Problem patients
• Problem prescriptions
• Classes of addicting drugs
• Recognition of addiction
• What to do about problem patients

3
Potential Problem Patients

• Family history of alcoholism
• External locus of control
• Pain persistent or out of proportion
• Litigation
• Multiple meds

4
Problem Prescriptions

• Soma, Fiorinal, Valium, Xanax
• Ritalin, Adderall
• Vicodin, Percodan, Ultram, OxyContin

5
Classes of Addicting Drugs

• Related to the reinforcing pathway
• Three main classes
• Sedative hypnotics and opioids contain the vast
  majority of problem prescriptions

6
Sedative Hypnotics

• Active in the GABA system
• Alcohol
• Benzodiazepines (Rohypnol)
• Barbiturates (Fiorinal)
• Anxiolytics Hypnotics (Ambien, Soma, Sonata)

7
Opiates

• Active in the endorphin systems
• Vicodin, other oxy hydro codones
• Especially ES formulations OxyContin
• Ultram
• Methadone

8
Stimulants

• Active in the dopamine system
• Amphetamines (Adderall)
• Others (Ritalin, Cylert)
• Decongestants

9
The Case AgainstChronic Sedative Hypnotics

• Short term anxiolytic in non-recovering patients
• No controversy
• Effects on the GABA system
• Effects on mood, anxiety and insomnia
• Alternatives

10
The GABA System

• Cause tolerance (40,42,43)
• Down regulate receptors (36,37,38)
• And receptor function (39,40)
• Decrease effect of endogenous anxiolytics (41)
• Cause physical dependence (59)

11
Mood, Anxiety and Insomnia

• Paradoxical anxiety with long term use (45)
• Cause depression (54,55,56,57)
• Not effective long term for sleep (44)
• Make opiates less effective (58)
• No evidence of long term efficacy for PTSD (60)

12
Alternatives to Sedative Hypnotics (Benzos)

• SSRIs and TCAs
• Better for GAD (46,47,48,49)
• Better for panic (49,50,51,52)
• Better for agoraphobia (53)
• Better for stress (61)
• Quetiapine, Trazodone, Doxepin, etc.

13
The Case Against Chronic Opiates in
Chronic Pain

• Acute vs. chronic pain
• The effects on the endogenous opiate system
• The effects on the perception of pain
• The effects on activity and behavior
• Alternatives to chronic opiate analgesia

14
Acute vs.Chronic Pain

• Acute - perioperative, traumatic, infectious
• No controversy (except monitoring for relapse)
• Chronic
• Malignant or progressive
• No controversy
• Non malignant
• Huge controversy (1)

15
Chronic Non-Malignant Pain

• Subjective pain relief
• Few studies
• Urban - 5 patients (2)
• Taub Tennant - both anecdotal (3,4)
• Portnoy - reduced perception of pain in 1/3 (5)
• Improvement in function
• Not demonstrated (1,6)

16
It Doesnt Work

• Overall, the use of opioids in chronic pain of
  non malignant origin will achieve analgesic
  benefit in some patients, while improved function
  has not yet been adequately demonstrated.(1)
• Until opioid therapy can be shown to yield long
  term outcomes that are superior, we cannot
  endorse it as a treatment of choice for chronic
  non cancer pain. (7)

17
Even in Non Addicts

• In patients with treatment resistant chronic
  regional pain of soft tissue or musculoskeletal
  origin, nine weeks of oral morphine in doses of
  up to 120 mg daily may confer analgesic benefit
  with a low risk of addiction, but is unlikely to
  yield psychological or functional benefit. (6)

18
The Endogenous Opiate System

• Tolerance
• B-Endorphin neurons become tolerant after chronic
  morphine administration (8)
• Release of Pro-opiomelanocortin-derived peptides
  decreased in tolerance (9)
• Pro-opiomelanocortin synthesis and B-Endorphin
  utilization down-regulated in morphine tolerance
  (10,11)

19
The Perception of Pain

• Chronic opiates cause sensitization
• Hyperalgesia caused by noxious stimulation is
  similar to hyperalgesia caused by chronic opiates
  (15)
• Thermal hyperalgesia develops in morphine
  tolerance (16)

20
Activity and Behavior

• Depression
• Opiates and opiate system implicated in model of
  learned helplessness (17,18)
• Opiates cause depression (19,20)
• Potential for relapse
• Opiate use increases potential for relapse
  (21,22,23)

21
Alternatives

• Multidisciplinary chronic pain treatment programs
• Nerve Blocks (24)
• Psychotherapy (25,26,27,28,29)
• Acupuncture (30)
• Exercise (25,31,32)
• Spiritual growth and recovery (33)

22
Substance Abuse

• Ubiquitous
• Social problem
• Legal problem
• Economic Problem

23
Criteria for Substance Abuse

• Recurrent use affecting role obligations
• Recurrent use where hazardous
• Recurrent use causing legal problems
• Recurrent use causing social or interpersonal
  problems

24
Prevalence

• Almost 50 of persons age 21 abuse alcohol
• 70 drink
• 22 of persons 18 22 years of age use illicit
  drugs
• 76 are employed
• Rate in college students 21

25
Treatment

• Harm reduction strategies
• Designated Driver
• Education and conversation
• Response to behavior
• Dont excuse behavior
• Dont remove consequences
• Most people discontinue SUBSTANCE ABUSE unless
  they develop SUBSTANCE DEPENDENCE

26
Criteria for Substance Dependence

• A maladaptive pattern of use, causing significant
  impairment or distress as manifested by three (or
  more) of the following seven criteria, occurring
  at any time in the same twelve months
• Tolerance, as defined by
• a need for increased amounts to achieve effect
• markedly diminished effect from using the same
  amount

27
Substance Dependence continued

• withdrawal, as manifested by
• characteristic withdrawal syndrome
• the same substance is used to avoid or relieve
  withdrawal symptoms
• the substance is taken in larger amounts or over
  a longer period than was intended
• there is a persistent desire or unsuccessful
  efforts to cut down or control use

28
Substance Dependence continued

• a great deal of time is spent in activities
  necessary to obtain or use the substance or
  recover from its effects
• important social, occupational, or recreational
  activities are given up or reduced because of
  substance use

29
Substance Dependence continued

• the substance use is continued despite knowledge
  of having a persistent or recurring physical or
  psychological problem that is likely to have been
  caused or exacerbated by the substance (ulcer,
  depression, etc.)

30
Incidence of Substance Dependence

• 14.1 National Comorbidity Study 1994
• Other drug dependencies in 7.5 of these
• 5 to 15 is the range in previous studies

31
Substance Dependence Shorthand

• Compulsion
• Loss of Control
• Continued use in the face of adverse consequences

32
The Disease of Addiction

• Criteria for a disease
• Recognizable symptoms
• Predictable Course
• Common Cause

33
The Course of Addictive Disease

• Progressive
• Affects all organ systems
• Associated with the cause of death
• A disease of relationships
• Disturbance in the relationship with self and
  others
• Based on dishonesty in the form of denial

34
The Cause of Addictive Disease

• Genetic
• Experience - Family History
• Family Studies
• Twin Studies
• Adoption Studies

35
Importance of Disease Orientation

• Cause - not Effect of Something Else
• Therefore a primary illness
• Helps to understand Denial
• Providers dont blame their patients
• Patients Have a Healthy Target to Work on

36
Impact on Treatment

• Abstinence is the Only Reasonable Goal
• Use Alters Neurotransmitters
• Denial is the Primary and Universal Symptom
• Preserves the Right to Drink or Use
• Identification With Others Possible
• OK Not to Have Coping Skills
• Treatment Takes Time
• Levels of Care can provide time

37
Contribution of Environment

• Similarity to TB
• Impact of Using on Emotional Development

38
Abstinence

• Similarity to Diabetes
• AA/NA/GA/RR not MM
• Common Experiences
• Fellowship
• Impact on Emotional Development

39
Getting Help

• Public Sector
• Overcrowded, under funded, restrictive
• 32 Detox beds 900 waiting for treatment
• Private Sector
• Effective, welcoming, shame reducing
• Requires Parity (Non-discrimination) for maximal
  effectiveness
• Current insurance coverage inadequate and often
  inappropriate

40
So, what do I do?

• Call it like you see it
• Dont shame the patient
• May point out consequences
• Be realistic, dont try to scare the patient
• Refer to appropriate addiction specific practices
• JPSAC
• Public
• ARRNO
• Private Insurance, etc

41
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