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Pain Management and Substance Abuse Mary Lynn McPherson, Pharm.D., BCPS, CPE Professor and Vice Chair, University of Maryland School of Pharmacy Hospice Consultant Pharmacist [email protected] Objectives • Define abuse and addiction, and describe the prevalence of each in patients with and without a history of substance abuse. • Identify predictors of aberrant drug-related behavior and addiction in hospice patients. • Identify strategies to limit drug abuse and diversion in the home environment, and a plan for the management of pain in the terminally ill patient with a history of substance abuse. 2 YOU Are Here 3 www.nancydoran.com/2.html HCPs are obligated to provide optimal palliative care for their patients HCPs – health care providers HCPs are obligated not to prescribe, dispense, or administer fradulent prescriptions 4 Pain and Chemical Dependency Definitions Key Terms and Concepts • Physical Dependence • Tolerance • Aberrant drug-related behavior • Pseudoaddiction • Abuse • Addiction 5 Physical Dependence • Pharmacologic property of some drugs • Defined solely by the occurrence of an abstinence syndrome on abrupt dose reduction, continuation of dosing, or administration of an antagonist drug. • NOT a problem if abstinence is avoided • Should NEVER be labeled “addiction” 6 Tolerance • Declining effect with drug exposure • Tolerance to side effects is desirable; tolerance to analgesia may be a problem • Should NEVER be labeled “addiction” 7 Abuse • Defined as the intentional misuse of a medication – For nonprescribed effects such as mood alteration • Drug use outside of socially accepted norms – Illicit drugs and aberrant use of prescription drugs • DMS IV: Psychoactive Substance Abuse – A maladaptive pattern of drug use that results in harm or places the individual at risk 8 Substance Abuse • Use of a substance in a manner outside of sociocultural conventions; according to this definition, all use of illicit drugs is abuse, as is use of a licit drug in a manner not dictated by convention (i.e., according to a physician’s order). 9 Substance Abuse • Actively using drugs or alcohol • Actively using drugs or alcohol and on methadone or buprenorphine • An ex-user on methadone or buprenoprhine maintenance • An ex-user who is drug and alcohol-free • A recreational or social user (occasional pot or alcohol) 10 Addiction • 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 onr or more of the following: • • • • Impaired control over drug use Compulsive use Continued use despite harm Craving J Pain Symptom Management 2003;26:655-667. 11 Pseudoaddiction • “…individuals who have severe, unrelieved pain may become intensely focused on finding relief for their pain. Sometimes, such patients may appear to observers to be preoccupied with obtaining opioids, but the preoccupation is with finding relief of pain, rather than using opioids, per se.” American Society of Addiction Medicine 12 Pseudoaddiction • Drug-seeking behavior resulting from inadequate pain management – Patient may become angry, hostile, mistrustful – Can be differentiated from abuse when an increased dose stops the behavior – Increase dose by 50% and assess behavior 13 Other Definitions • Drug-seeking behaviors – Directed or concerted efforts on the part of the patient to obtain opioid medication or to ensure an adequate medication supply; may be an appropriate response to inadequately treated pain. • Therapeutic dependence – Patients with adequate pain relief may demonstrate drug-seeking behaviors because they fear not only the re-emergency of pain but perhaps the emergence of withdrawal symptoms. Alford DP et al. Ann Intern Med 2006;144:127-134. 14 Differential Diagnosis of Aberrant Drug-Taking Behavior • Pseudoaddiction (unrelieved pain) • Addiction (substance-abuse disorder) • Other psychiatric disorders – depression, anxiety – borderline personality diorder – organic mental syndrome • Criminal intent 15 Results from the 2008 National Survey on Drug Use and Health: National Findings http://www.oas.samhsa.gov 16 Past Month Illicit Drug Use among Persons Aged 12 or Older: 2008 http://www.oas.samhsa.gov 17 Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons Aged 12 or Older: 2002-2008 http://www.oas.samhsa.gov 18 Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons Aged 12 or Older: 2002-2008 http://www.oas.samhsa.gov 19 Past Year Initiates for Specific Illicit Drugs among Persons Aged 12 or Older: 2008 http://www.oas.samhsa.gov 20 NSDUH 2008 Survey Highlights • Acquisition of pain relievers used nonmedically in past 12 months: – 55.9% - from a friend or relative for free – 18.0% - from one doctor – 8.9% - bought from a friend or relative – 4.3% - drug dealer or stranger – 0.4% - bought from Internet http://www.oas.samhsa.gov 21 The Devil Made Me Do It! • 48 year old TV sportscaster in Baltimore charged with two counts first degree burglary • Victim was a 64 year old neighbor with cancer • Caught on video – entering residence, taking opioid, and returning to wipe fingerprints away • BUSTED! 1-26-06: http://wjz.com/topstories/local_story_025165138.html 22 I’ve Got My Eye On You! Nanny Cam! 23 http://DAWNinfo.samhsa.gov http://www.samhsa.gov http://www.oas.samhsa.gov 24 Opioid Analgesics – DAWN Data Drug Methadone Hydrocodone/combinations Oxycodone/combinations https://dawninfo.samhsa.gov/files/ED2006/DAWN2k6ED.pdf 2004 31,874 41,491 36,559 2006 45,130 57,500 64,888 25 Physical dependence Drug-seeking behavior Addiction Tolerance Pseudoaddiction Abuse Therapeutic dependence Pain and the Addiction Continuum 26 Ten Steps of Universal Precautions in Pain Medicine 1. Make a diagnosis with appropriate differential 2. Psychological assessment including risk of addictive disorders 3. Informed consent 4. Treatment agreement 5. Pre- and post-intervention assessment of pain level and function Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112. 27 Ten Steps of Universal Precautions in Pain Medicine 6. Appropriate trial of opioid therapy +/- adjunctive medication 7. Reassessment of pain score and level of function 8. Regularly assess the four “A’s” of pain medicine 9. Periodically review pain diagnosis and comorbid conditions, including addictive disorders 10. Documentation Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112. 28 Patient Triage – 3 Groups • Group I – – – – No past or current history of substance abuse disorders Noncontributory family history with respect to substance use disorders Lack major or untreated psychopathology Represents the majority of patients seen in palliative care Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112. 29 Management of Group I • Apply good principles of pain management • Use common sense and prudently monitor patient; recognize lower addiction risk • Remain alert for substance abuse in the home (not the patient necessarily) • Differentiate physical dependence from addiction • Don’t mistake pain relief seeking (pseudoaddiction) for drug-seeking 30 Patient Triage – 3 Groups • Group II – – – – May be a past history of treated substance use disorder, or a significant family history of problematic drug use May have a past or concurrent psychiatric disorder Not actively addicted, but are at increased risk May include patients in recovery (opioid maintenance) Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112. 31 Patient Triage – 3 Groups • Group III – – Complex cases due to active substance abuse or major, untreated psychopathology Patient are actively addicted and pose significant risk to both themselves and to practitioners Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112. 32 Group IV?? • Drug abuse or diversion in the home (or workplace) – Patient suffering consequences of undertreated pain – We are obligated to care for the patient, but analgesics are being diverted 33 Aberrant Behavior Less Suggestive of Addiction • Aggressive complaining about the need for more drugs • Drug hoarding during periods of reduced symptoms • Requesting specific drugs • Opening acquiring similar drugs from other medical sources 34 Aberrant Behavior Less Suggestive of Addiction • Unsanctioned dose escalation or other noncompliance with therapy on one or two occasions • Unapproved use of the drug to treat another symptom • Reporting psychic effects not intended by the clinician 35 Aberrant Behavior Less Suggestive of Addiction • Resistance to a change in therapy associated with tolerable adverse effects accompanied by expressions of anxiety related to the return of severe symptoms. 36 Aberrant Behavior More Suggestive of Addiction • • • • • Selling prescription drugs Prescription forgery Stealing or borrowing drugs from others Injecting oral formulations (or transdermal) Obtaining prescription drugs from nonmedical sources • Concurrent abuse of alcohol or illicit drugs 37 Aberrant Behavior More Suggestive of Addiction • Multiple dose escalations or other noncompliance with therapy despite warnings • Repeatedly seeking prescriptions from other clinicians or from emergency rooms without informing prescriber 38 Aberrant Behavior More Suggestive of Addiction • Evidence of a deterioration in the ability to function at work, in the family, or socially that appears to be related to drug use • Repeated resistance to changes in therapy despite clear evidence of drug-related diverse physical or psychological effects 39 CAGE-AID C – have you felt you ought to CUT DOWN on your drinking or drug use? A – have people ANNOYED you by criticizing your drinking or drug use? G – have you felt bad or GUILTY about your drinking or drug use? E – have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (EYE-OPENER)? AMA. Assessing and treating pain in patients with substance abuse concerns. 40 CAGE-AID # positive responses Probability of substance abuse 2 50% 3 75% 4 90% AMA. Assessing and treating pain in patients with substance abuse concerns. 41 Assessment Cues to Medication Diversion • • • • Is the patient specific or vague regarding the pain? Is there a history of chronic pain? Is there a condition resulting in chronic pain? Is the reported pain congruent with the expected presentation of the condition? • Are there any accommodations for pain level in daily life (physical, emotional, spiritual, relationships, interactions)? • Can the pain be attributed to something else? Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 42 Assessment Cues to Medication Diversion • Does the patient or caregiver appear more interested in obtaining a specific medication than in alleviating pain? • Does the patient or caregiver create barriers to changing drugs or routes of administration? • Are the patient or caregiver resistant to adjuvants? • Has the patient or caregiver ever presented as overmedicated, sedated, or physically or cognitively impaired? • Is there a pattern of weekend or evening calls for more medication? Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 43 Red Flags - Medications • • • • Patient/family unable to find Dropped on floor (in toilet) Pharmacy did not dispense enough Dog/cat/canary (insert animal of choice) ate medication • Run out at night/weekends when nurse not available • Medications present that team or physician did not order Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 44 For all those health care professionals who question whether patients actually dropped their narcotics down the drain, here is the first scientific proof that it can happen (all by itself). 45 Red Flags – Family/Patient Behavior • Multiple physicians/pharmacies • Family members under influence • Patient/family members have extensive drug knowledge • PDR in home • Patient hoards medication • Patient protects medications from family members Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 46 Red Flags – Family/Patient Behavior • Estranged family members • Family cannot go to establishments because of history (e.g., shoplifting at the pharmacy) • Vague regarding sources of income • Calls nurse the “narcotics police” • Uncomfortable with nurse counting medications • Requests nurse count medications every visit Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 47 Red Flags - Environment • Drug paraphernalia present • Requests to get out of court hearing, jail, probation/parole requirements • Camera on doorstep or extensive security measures • Bare cupboards, empty refrigerator • Weapons readily accessible/visible Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 48 Red Flags - Environment • Aggressive animals (rottweilers or pit bulls) in house “for protection” • Large amounts of cash around house • Minimal furniture, new entertainment equipment, many pagers/answering machines • Many roommates, people coming and going Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 49 Red Flags - System • Physician will not prescribe, or only prescribe in limited amount, not early, or only if he/she sees patient • Copy company calls – “We found a prescription on a copier with your clinic’s name on it” • Patient not allowed in or welcome at the ED • Other hospices expelled/will not accept patient Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 50 Red Flag – Signs and Symptoms of Withdrawal First 24 Hours • Flu-like syndrome – Sweating, aches, chills, runny nose, tearing, weakness • • • • Restless sleep Restlessness/anxiety Repetitive yawning Preoccupation with drug of choice 24-72 hours • Increased intensity of previous symptoms • Hot and cold flushes • Severe N, V, D • Uncontrollable kicking movements • Fluid and electrolyte imbalances • Delirium tremens (DTs) • Seizures • Twitching and spasms • Paranoia • Drug-seeking behavior Smith-DiJulio K. Care of the chemically impaired. In: EM Varcarolis, ed. Foundations of Psychiatric and Mental Health Nursing: A Clinical Approach, 2002, 4th ed, pp. 745-782. 51 Basic Principles for Prescribing Controlled Substances to Patients with Advanced Illness and Issues of Addiction • Choose an opioid based on around-the-clock dosing • Choose long-acting agents when possible • As much as possible, limit or eliminate the use of shortacting or “breakthrough” doses • Use on-opioid adjuvants when possible and monitor for compliance with those medications Kirsh KL, Passik SD. Cancer Investigation 2006;24:425-431. 52 Basic Principles for Prescribing Controlled Substances to Patients with Advanced Illness and Issues of Addiction • Use nondrug adjuvants whenever possible (e.g., relaxation techniques, distraction, biofeedback, TNS, communication about thoughts and feelings of pain) • If necessary, limit the amount of medication given at any one time (e.g., write prescriptions for a few days’ worth or a weeks’ worth of medication at a time) Kirsh KL, Passik SD. Cancer Investigation 2006;24:425-431. 53 Basic Principles for Prescribing Controlled Substances to Patients with Advanced Illness and Issues of Addiction • Utilize pill counts and urine toxicology screens as necessary • If compliance is suspect or poor, refer to an addictions specialist Kirsh KL, Passik SD. Cancer Investigation 2006;24:425-431. 54 The 4 “A’s” • Analgesia • Activities of daily living • Adverse events • Aberrant drug-taking behaviors 55 Monitoring Analgesic Therapy • Subjective Therapeutic – Pain rating – Perceived well-being – Decreased associated symptoms (e.g., sadness) • Objective Therapeutic – Increased sleep time – Ability to walk 50 feet – Minimal use of breakthrough analgesic • Subjective Toxicity – – – – c/o constipation c/o sleepiness c/o nausea c/o itching • Objective Toxicity – – – – BM frequency # hours sleeping/24 hrs # episodes of emesis Excoriation 56 Step 1: Problem Identification • Once the problem is identified, it’s up to the team to determine: – Whose problem is it? It is important for the hospice to understand it may very well be an organizational problem if the patient and/or family are selling medications the hospice is providing on the street. – How is it a problem? Is this a safety, legal, ethical, medical, or financial problem? – Who is involved? Is it only the patient, or are the family, paid caregivers, extended family, friends or even staff also involved? Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 57 Step 2: Goals and Intervention Formulation • Goals and interventions are important for all the team to formulate. The team should analyze 5 questions to develop their plan: – – – – What are we trying to achieve? What are all the options? What are all the limitations or obstacles? What are the consequences of doing nothing? It may be more appropriate to leave the situation alone, such as if the patient is actively dying. – What are the consequences of possible choices? Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 58 Step 3: Building Interdisciplinary Coalition • Communication of the plan with all members of the interdisciplinary team, especially the patient’s physician, is crucial to assuring the goals are met and interventions followed. • A point person or team leader for plan implementation should be appointed to assure adequate communication is maintained among team members. Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 59 Step 4: Offering the Choices • After goals and interventions have been agreed upon by all team members, the next step is communicating the choices to patient/family. • Do during a family meeting . • Communicate choices in a nonjudgmental fashion, set clear limits for how the situation will be handled. • Negotiation should be minimized; only choices and consequences offered. • Four choices should be offered. Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 60 Step 4: Offering the Choices • Four choices should be offered: – Managing medication, as prescribed. The patient and family will adhere to the prescribed regimen, and medications will be closely monitored by the case manager. – Use of alternate medications and/or routes. – Being home without medications and/or hospice. – Out of home placement with medication and hospice. Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 61 Step 5: Implementing the Choices and their Consequences • All hospice staff should be informed of patient/family decision (including on-call staff and volunteers). • All relevant external supports or referrals (e.g., PT, medical supply companies) should also be notified of the plan to ensure implementation across all disciplines. • Anticipate attempts at manipulation and have plan in place (e.g., no medications will be ordered at night or on weekends when different staff may be working). Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 62 Step 6: Evaluating the Effects • Once the plan is in place, it will be possible for the team to evaluate the effects. There will be certain outcomes to expect such as: – Improved accountability for medications – No further seeking of medications within the system – Involved parties report satisfaction or decreased concern Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 63 Step 7: Doing it all again if the choice cannot be maintained • If patient/family do not comply with the plan, such a lack of progress must be confronted promptly. • Consequence to noncompliance would be the next choice on the list, assuring that: – No second chances are given – Original expectations are not altered – Deadlines are not extended Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO 64 Time of Death • Destroy remaining opioids and other drugs in the home. – Who OWNS the medication? – What if the family refuses to destroy remaining medication? 65 Bereavement Issues • Patient had a history of SA – Bereaved may experience ambivalent feelings during grief process – Relief that patient’s behavior will no longer be a stressor to the family – Guilt for feeling relief the patient has died • Bereaved has a history of SA – Risk for return to destructive behaviors Dy at al. Caring for patients in an inner-city home hospice: challenges and rewards. Home Health Care Management and Practice 2003:15(4):291-299. 66 67 http://www.mayohealthcare.com.au/products/homecare_mms_mds.htm http://www.safehomeproducts.com/shp2/hh/medication_dispenser.asp 68 69 Opioid Count Log 70 Opioid Safe Count 71 72