Download Pain and Chemical Dependency

Pain and
Chemical Dependency
Russell K. Portenoy, MD
Chairman
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center, New York
Professor of Neurology and Anesthesiology
Albert Einstein College of Medicine
Pain and
Chemical Dependency

The interface between pain and
chemical dependency

Definitions and phenomenology

Focus on opioid pharmacotherapy
Pain and
Chemical Dependency
Neurobiology
Clinical Issues
Translational
research
Craving
vs.
analgesia
vs.
other
effects
Opioid
systems
Genetics
Stigma
and
Undertreatment
Use and
abuse of
controlled
prescription
drugs
Impact of
laws and
regulations
Pain and
Chemical Dependency

Key Terms and Concepts
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Physical Dependence
Tolerance
Aberrant drug-related behavior
Pseudoaddiction
Abuse
Addiction
Pain and
Chemical Dependency
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Physical Dependence
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Potential for abstinence on abrupt discontinuation
or dose reduction, or administration of an
antagonist
Highly variable phenomenology
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Tachycardia, tachypnea
Nausea/vomiting, diarrhea, abdominal cramps
Sweating, rhinorrhea, piloerection
Myalgias and arthralgias
Anxiety, insomnia
Pain and
Chemical Dependency
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Physical Dependence
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–
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Not a problem if abstinence is avoided
Theoretical connection to the genesis of
addiction/relapse, but neither necessary
nor sufficient
Should never be labeled “addiction”
Pain and
Chemical Dependency
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Tolerance
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Declining effect with drug exposure
Tolerance to side effects is desirable;
tolerance to analgesia may be a problem
Large clinical experience is reassuring
Theoretical connection to the genesis of
addiction/relapse, but neither necessary
nor sufficient
Should never be labeled “addiction”
Pain and
Chemical Dependency

Aberrant Drug-Related Behavior
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–
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Problematic behaviors or “red flags” for
clinicians
Culture-bound, but defined by conventional
practice, and by laws and regulations
Should be viewed as “data,” which must be
interpreted in a differential diagnosis of
addiction
Pain and
Chemical Dependency

Aberrant Drug-Related Behavior
(cont’d)
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Aggressive complaining
Drug hoarding when symptoms milder
Requesting specific drugs
Acquisition of drugs from other medical sources
Unsanctioned dose escalation once or twice
Use of the drug to treat another symptom
Reporting unintended psychic effects
Occasional impairment
Pain and
Chemical Dependency

Aberrant Drug-Related Behavior
(cont’d)
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Selling prescription drugs
Prescription forgery
Stealing or “borrowing” drug from another person
Injecting oral formulation
Obtaining prescriptions from non-medical source
Multiple episodes of prescription “loss”
Concurrent abuse of related illicit drugs
Multiple dose escalations despite warnings
Repeated gross impairment or dishevelment
Survey of Aberrant DrugRelated Behaviors (n = 388)
(n = 215)
60
55.4
50
40
(n = 98)
30
20
10
% of Patients
exhibiting behs.
25.3
(n = 33) (n = 26)
8.5
6.7
(n = 16)
4.1
0
0
2 to 3 3 to 4 5 to 7
8+
Number of Behaviors Reported
Passik et al, Clin Ther, 2004
Pain and
Chemical Dependency
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Abuse
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Drug use outside of socially accepted
norms
Includes any use of an illicit drug and
some degree of aberrant use of
prescription drugs
DSM IV: Psychoactive Substance Abuse
 A maladaptive
pattern of drug use that results
in harm or places the individual at risk
Pain and
Chemical Dependency

Addiction
–
Chronic disease with genetic, psychosocial,
and environmental/situational influences,
which can be induced in vulnerable people
exposed to potentially abusable drugs
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DSM IV definition of “substance
dependence” refers to addiction, but
problematic in patients with chronic pain
Pain and
Chemical Dependency

Task Force of APS, AAPM, and ASAM: New
definition of 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
 craving

Savage et al, JPSM, 2003
Pain and
Chemical Dependency
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Pseudoaddiction
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Aberrant drug-related behavior in patients
reacting to undertreatment of pain
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Diagnostic challenge: May co-exist with
addiction or other psychiatric disorders
Pain and
Chemical Dependency
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Diagnosis of Addiction
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Suggested by the occurrence of aberrant drugrelated behavior
Distinguish from other phenomena in the DDx
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Addiction
Pseudoaddiction
Other psychiatric disorders, including personality
disorders, confusional states, and family disturbances
Criminal intent
Diagnoses are not mutually exclusive
Opioid Therapy:
Standard of Care
Populations with
advanced illness
•Cancer
•HIV/AIDS
•Others
Moderate to severe
pain
Populations with acute
illness, injury, or
surgery
Short-term
or long-term
opioid therapy
Opioids for Chronic Pain:
Unresolved Issues
Unresolved
Clinical Issues
Role of opioid
therapy for
chronic
nonmalignant
pain
Treatment of pain
in patients with
chemical dependency
Opioids for Chronic Pain:
Historical Context
War on
drugs
Tragedy of
needless
pain
Risk of Abuse and Addiction:
Evolving View

Acute pain: very unlikely
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Cancer pain and pain at EOL: very
unlikely

Chronic nonmalignant pain:
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Surveys and studies of patients without abuse or
psychopathology show rare addiction
Surveys of populations referred to pain treatment
programs show mixed results
Opioids for Chronic Pain:
Historical Context
War on
drugs
Tragedy of
needless
pain
Increasing Prescription
Drug Abuse
3000
120000
2500
100000
2000
80000
number of 1500
initiates (in
thousands) 1000
number 60000
500
20000
0
0
40000
1985 1991 1993 1995 1997 1999 2001
National Household Survey
On Drug Use and Health
1995 1996 1997 1998 1999 2000 2001 2002
Drug Abuse Warning
Network
Opioids for Chronic Pain:
The Need for Balance
Opioids are
essential drugs.
Patients with pain,
including those with
addiction, must have
access to treatment
Opioids are abusable,
particularly by those
with addiction.
Regulators and law
enforcement must stem
diversion and abuse
What Is the Potential Need
for Opioid Therapy?
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Starting point: epidemiology of pain
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Acute severe pain extremely prevalent
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Chronic pain reported by
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30-80% of cancer patients depending on stage
2-40% of general population (Gureje et al, JAMA, 1998; Verhaak et al,
Pain, 1998)
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Recent study: 30-40% overall, at least partially disabling in
about 30% (Portenoy et al, J Pain, 2004)
Little known about pain in patients with addiction, but
one survey noted “chronic severe pain” in 24-37% of
addicts in treatment (Rosenblum et al, JAMA, 2003)
What Is the Potential Need
for Opioid Therapy?
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Millions of patients with acute pain
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Millions of patients with cancer pain or pain
related to some other life-threatening
medical illness
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Millions more, if even if a small proportion
of patients with chronic noncancer pain are
candidates
Need for Therapy and Need
for “Balance”: Implications

Clinicians must determine
– Who can I treat without help?
– Who can I treat with consultative help?
– Who should I refer?

Clinicians must appreciate that opioid
therapy for chronic pain requires
– Knowledge of the principles of prescribing
– Knowledge of an approach to the assessment and
management of issues related to chemical dependency
Need for Therapy and Need
for “Balance”: Implications

Safe and effective therapy requires
– Comprehensive assessment
– Appropriate positioning of therapy
– Risk assessment and appropriate
structuring of treatment
– Optimal administration over time
– Risk management over time
– Monitoring and documentation
Positioning Opioid Therapy

Assessment is the first step
– Characterize the pain
– Define etiology, syndrome and pathophysiology
– Clarify impact and prior therapies
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Evaluate relevant comorbidities
– Physical/medical
– Psychosocial and psychiatric, including personal
and family history of substance use
Positioning Opioid Therapy
 Consider a multimodality approach
targeting pain and disability
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Pharmacotherapy
Rehabilitative
approaches
Psychological
approaches
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Interventional
approaches
Complementary
and alternative
approaches
Lifestyle changes
Positioning Opioid Therapy
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Analgesic pharmacotherapy
– Opioids
– Nonopioid analgesics
– Adjuvant analgesics
Positioning Opioid Therapy
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Consider opioids for all patients with
moderate or severe chronic pain but
weigh the influences
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What is conventional practice?
Are there alternatives with equal or better
therapeutic ratio?
Is the patient at relatively high risk of toxicity?
Are drug-related behaviors likely to be
responsible?
Risk Assessment
and Management
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Know the laws and regulations
Assess initial level of risk
“Structure” therapy to match risk
Assess and diagnose behaviors during
therapy
Possess strategies to appropriately respond
to aberrant behaviors
Opioid Therapy:
Laws and Regulations

International laws and treaties
– International Narcotics Control Board
– No direct influence on prescribers
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Federal laws and regulations
– FDA assesses safety and efficacy
– DEA monitors and addresses abuse/diversion
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State laws and regulations
– Medical boards and law enforcement
– Variable from state to state
Opioid Therapy:
Judging Initial Risk

Numerous validated measures, none
yet in widespread use
– CAGE-AID (Brown and Rounds, Wisc Med J, 1995)
– Screening Instrument for Substance Abuse
Potential (SISAP) (Coambs et al, Pain Res Manage, 1996)
– Substance Abuse Subtle Screening Inventory
(SASSI) (www.sassi.com)
Opioid Therapy:
Judging Initial Risk

Numerous validated measures, none
yet in widespread use
– Screening tool for Addiction Risk (STAR)
(Friedman et al,
Pain Med, 2003)
– Screener and Opioid Assessment for Patients with
Pain (SOAPP) (Butler et al, Pain, 2004)
– Pain Medicine Questionnaire
Manage, 2004)
(Adams et al, J Pain Symptom
Opioid Therapy:
Judging Initial Risk

Other studies suggest specific
predictors of problematic use
– Prior history of substance abuse (Michna et al, J Pain Symptom
Manage, 2004)
– Need to increase the dose, considering oneself
addicted, and preference for a specific route
(Compton et al, J Pain Symptom Manage, 1998)
– Focus on opioids during visits, need for early refills
or dose escalation, multiple calls or early visits,
other prescription problems, and obtaining opioids
from other sources (Chabal et al, Clin J Pain, 1997)
Opioid Therapy:
Judging Initial Risk

Clinical experience suggests other
factors:
Family history of substance abuse
– Any major psychiatric pathology
– Heavy tobacco or alcohol use
– History of criminal activity
– History of physical/sexual abuse
– Contact with high risk people or environments
– Chaotic home situation
– Family history of major psychiatric pathology
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Opioid Therapy:
Judging Initial Risk
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Most important factors:
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Prior history of substance abuse
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Family history of substance abuse
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Major psychiatric pathology
Initial “Structuring” of
Therapy to Reduce Risk
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Based on assessment, categorize
patient into low or high perceived risk
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Structure the therapy to match the
perceived risk
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Improves the ability to monitor
May help the vulnerable patient maintain
control
Initial “Structuring” of
Therapy to Reduce Risk
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May initiate therapy with:
– Requirement of all prior records and permission to
contact other health care professionals
– Requirement of consultation with addiction medicine
specialist or other mental health professional
– Written agreement, perhaps a formal “contract”
– Prescription of long-acting drug only
– Frequent visits
– Small prescription (one-week or two-week supply)
Initial “Structuring” of
Therapy to Reduce Risk

May initiate therapy with:
– Urine drug screen
– Requirement that only one pharmacy be used (with
contact)
– Requirement that pill bottle be returned for count
– Instruction that there will be no early refills or
replacement of loss drug without police report
– Requirement of concurrent nonpharmacologic
therapy
– Requirement that others (e.g., spouse) be allowed to
comment periodically on progress
Initial “Structuring” of
Therapy to Reduce Risk
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Written “contract” or treatment agreement
– Use remains controversial
– Advantages
Explicit instructions
 Educational tool
 Can clarify the roles of PCP and specialist
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– Potential disadvantages
Can be perceived as capricious or punitive
 Can be stigmatizing
 Can limit clinical flexibility and add liability
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Initial “Structuring” of
Therapy to Reduce Risk
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Opioid “contract”: common elements
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Avoid improper use
Terms of disciplinary termination
Limitations for replacing or changing prescriptions
Inform physician (e.g., side effects, other meds)
Random drug screens
Terms regarding appointments
Requirement for consultation
Limits on drug refills (e.g., phone allowances or in
person)
– Side effects education (including withdrawal)
– Terms of nondisciplinary termination
Fishman et al, J Pain Symptom Manage, 1999
Initial “Structuring” of
Therapy to Reduce Risk

Role of urine drug screen
– Advantages
Can confirm that prescribed drug is taken and
that other drugs are not
 Makes a strong statement potentially useful in
monitoring (“trust but verify”)
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– Disadvantages
Cannot confirm that the proper dose is taken
 Can be misinterpreted
 Can be stigmatizing
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Opioid Therapy:
Principles of Prescribing
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Selection of the drug
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Selection of the route
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Optimal dosing
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Side effect management
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Monitoring outcomes
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Managing the poorly responsive patient
Opioid Therapy:
Monitoring Outcomes
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Assess the “Four A’s” over time
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Analgesia (pain relief)
Activities of daily living (physical and
psychosocial functioning)
Adverse effects (side effects)
Aberrant drug-related behavior
Opioid Therapy:
Monitoring Outcomes
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Monitoring drug-related behaviors:
– Step 1: Are there aberrant drug-related
behaviors?
– Step 2: If yes, assess (consider
consultations)
– Step 3: How should they be interpreted?
 What
are the diagnoses?
 What factors are driving the behaviors?
Opioid Therapy:
Monitoring Outcomes
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DDx of aberrant drug-related behavior
– Addiction
Pseudoaddiction
– Other psychiatric disorders
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Personality disorders
Encephalopathy
Family disturbances
Criminal intent
Responding to Aberrant
Drug-Related Behaviors
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Depends on diagnoses
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May or may not continue opioid therapy
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May or may not refer to specialist in
addiction medicine, pain medicine, or
other
Responding to Aberrant
Drug-Related Behaviors
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If opioid continues, restructure therapy
with one or more of the following
–Required
ongoing treatment by addiction medicine
specialist, mental health care professional or others
–Ongoing coordination with sponsor or program, if
addiction therapy is ongoing
–Written agreement, perhaps a formal “contract”
–Prescription of long-acting drug only
–Frequent visits
–Small prescription (one-week or two-week supply)
Responding to Aberrant
Drug-Related Behaviors

If opioid continues, restructure therapy
with one or more of the following
–Urine drug screens
–Requirement that only one pharmacy be used (with
contact)
–Requirement that pill bottle be returned for count
–Instruction that there will be no early refills or
replacement of loss drug without police report
–Requirement of concurrent nonpharmacologic therapy
–Requirement that others (e.g., spouse) be allowed to
comment periodically on progress
Responding to Aberrant
Drug-Related Behaviors
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Patients whose behavior is out of control, or
cannot be brought quickly under control,
should not be treated
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Patients who cannot accept structure should
not be treated
Responding to Aberrant
Drug-Related Behaviors
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Documentation is essential
Suggested elements
– History and physical examination
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Diagnostic, therapeutic and laboratory results
Evaluations and consultations
Treatment objectives
Discussion of risks and benefits
Informed consent
Treatments
Medications (including date, type, dose and quantity)
Instructions and agreements
Periodic reviews
Federation of State Med. Boards of the U.S., 2004
Responding to Aberrant
Drug-Related Behaviors
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Communicate effectively
To other professionals
– To third party payors
– To the patient
–
Pain and Chemical
Dependency: Conclusions

The complex interface between pain and
chemical dependency extends from
molecular biology to public policy

From the clinical perspective, the issues
surrounding long-term opioid therapy are
most significant

Opioid therapy has both extraordinary
promise and important risks
Pain and Chemical
Dependency: Conclusions

With appropriate risk assessment and
management
– Opioid therapy can be considered in all
populations, including those with addictive
disease
– Ability to treat problematic patients is seen
as a continuum of skills

PCP’s may accept the role in some cases and refer
others
Pain and Chemical
Dependency: Conclusions

Safe and effective opioid therapy requires
– Assessment and reassessment
– Skillful drug administration
– Knowledge of addiction medicine principles
– Documentation and communication