addiction issues in chronic pain management
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Addiction Issues in ChronicAddiction Issues in ChronicPain ManagementPain Management
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StatisticsStatistics
Base rate of addictive disease in generalBase rate of addictive disease in generalpopulation:population:
AlcoholAlcohol 15%15%
Cocaine/HeroinCocaine/Heroin ---- 5%5%
10% of adults in US have genetic10% of adults in US have genetic
susceptibility to addictionsusceptibility to addiction
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StatisticsStatistics
In 2003, 4.7 million Americans usedIn 2003, 4.7 million Americans usedprescription drugs nonprescription drugs non--medically:medically:
2.5 million2.5 million analgesicsanalgesics
1.4 million1.4 million sedatives/tranquilizerssedatives/tranquilizers
761 000761 000 stimulantsstimulants
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StatisticsStatistics
Vicodin: Most commonly prescribedVicodin: Most commonly prescribedprescription analgesic in USprescription analgesic in US
Vicodin: Most prescribed medication ofVicodin: Most prescribed medication ofany category (>100 million Rxs)any category (>100 million Rxs)
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StatisticsStatistics
>50 million Americans suffer from chronic pain>50 million Americans suffer from chronic pain
Overall rate of prescription analgesicOverall rate of prescription analgesicabuse/addiction in pain patients = 3.3%abuse/addiction in pain patients = 3.3%
0.19% without a past or current substance0.19% without a past or current substanceabuse disorder experienced problems withabuse disorder experienced problems withopioids for painopioids for pain
Overall rate of concurrent addiction (allOverall rate of concurrent addiction (allsubstances) in chronic pain patients is the samesubstances) in chronic pain patients is the sameas in general population 6as in general population 6--10%10%
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Proper definitions areProper definitions areimportant!important!
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Basic TerminologyBasic Terminology
Abuse = Abnormal use, nonAbuse = Abnormal use, non--therapeutictherapeutic
Addiction is a form of abuseAddiction is a form of abuse
Addiction = Drug AbuseAddiction = Drug Abuse
Drug AbuseDrug Abuse {{ Addiction, but can imply itAddiction, but can imply it
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The 4 Cs of AddictionThe 4 Cs of Addiction
Loss ofLoss ofCControlontrol
CCompulsive Useompulsive Use
CCravingraving
CConsequences (Use Despite Harm)onsequences (Use Despite Harm)
Definitions related to the use of opioids for the treatment of pain. AConsensus Statement on Pain and OpioidsASAM, APS, AAPM, April 2001
http://www.painmed.org/productpub/statements/pdfs/definition.pdf
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In a Patient With Pain onIn a Patient With Pain on
OpioidsOpioids
Physical DependencePhysical Dependence {{ AddictionAddictionToleranceTolerance {{ AddictionAddiction
High doseHigh dose {{ AddictionAddiction
RD Jovey, J Ennis, J Gardner-Nix, B Goldman, H Hays, M Lynch, D Moulin. Use of opioid analgesics for the treatment of chronicnoncancer pain A consenus statement and
guidelines from the Canadian Pain Society, 2002. Pain Res Manage 2003;8(Suppl A):3A-14A.
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DSMDSM--IVIV--TR Substance DependenceTR Substance Dependence
1.1. ToleranceTolerance
2.2. Physical dependence/withdrawalPhysical dependence/withdrawal
3.3. Used in greater amounts or longer than intendedUsed in greater amounts or longer than intended
4.4. Unsuccessful attempts to cut down or discontinueUnsuccessful attempts to cut down or discontinue5.5. Much time spent pursuing or recovering from useMuch time spent pursuing or recovering from use
6.6. Important activities reduced or given upImportant activities reduced or given up
7.7. Continued use despite knowledge of persistentContinued use despite knowledge of persistent
physical or psychological harmphysical or psychological harm
Sees and Clark, J Pafter Savage, 2004
3/7 required for diagnosis
4/7 common in non-addicted pain patients
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DSMDSM--IVIV--TR Substance AbuseTR Substance Abuse
1.1. Recurrent use affecting daily participation inRecurrent use affecting daily participation inmajor obligations at work, school or homemajor obligations at work, school or home
2.2. Recurrent use in physically hazardous settingsRecurrent use in physically hazardous settings(driving)(driving)
3.3. Recurrent substanceRecurrent substance--related legal issuesrelated legal issues
4.4. Continued use despite recurrent or persistentContinued use despite recurrent or persistent
social or interpersonal consequencessocial or interpersonal consequences
Sees and Clark, J Pafter Savage, 2004
1/4 required for diagnosis
Exclusionary for substance dependence
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1313
Addiction:
A Biopsychosocial Illness
*NeurobiologyGeneticsAcquired
Drug
Environment
Reinforcement
Psychology Availability
& Milieu
*Manifestation ofthe disease ofaddiction
Adapted from JD Haddox, DDS, MD.
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Tomkin & Sellers, CMAJ, 2001
Brain Circuits of AddictionBrain Circuits of Addiction
Planning,Judgment
Prefrontalcortex
frontalcortex
Nucleusaccumbens
Medial forebrainbundle
Ventral tegmentalarea
Reward
Amygdala
Emotions,conditioned effects
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Pain Patient vs. Opioid AbuserPain Patient vs. Opioid Abuser
Controls medsControls meds
Meds improve QOLMeds improve QOL
Complains of side effectsComplains of side effects Concerned re: risk ofConcerned re: risk of
addictionaddiction
Follows agreed uponFollows agreed upontreatment plantreatment plan
Left over meds, does notLeft over meds, does notrun out of or lose medsrun out of or lose meds
Cant control medsCant control meds
Meds decrease QOLMeds decrease QOL
Wants meds despite S/EWants meds despite S/E
Denies possibility ofDenies possibility ofaddictionaddiction
Does not follow treatmentDoes not follow treatmentplanplan
Seldom has meds leftSeldom has meds leftoverover excuses for lostexcuses for lostmedsmeds
Schnoll, J Law Med Ethics.1994
Heit, Eur J Pain 2001
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Ambiguous drug behavioursAmbiguous drug behaviours
MoreMore suggestive of addictionsuggestive of addiction Rx drug: selling, stealing, forgeryRx drug: selling, stealing, forgery
Injecting oral formulationsInjecting oral formulations
Obtaining Rx drugs from the streetObtaining Rx drugs from the street Concurrent abuse of ETOH or illicit drugsConcurrent abuse of ETOH or illicit drugs
Repeated nonRepeated non--compliance despite warningscompliance despite warnings
Double doctoringDouble doctoring
DrugDrug--related deterioration in functionrelated deterioration in function
Resistance to change in therapy despite evidence ofResistance to change in therapy despite evidence ofadverse drug effectsadverse drug effects
Passik, Portenoy, 2004
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Ambiguous drug behavioursAmbiguous drug behaviours
LessLess suggestive of addictionsuggestive of addiction
Asking for more pain meds or specific medsAsking for more pain meds or specific meds
Drug hoardingDrug hoarding
Openly getting meds from other MDsOpenly getting meds from other MDs Occasional dose escalation or other nonOccasional dose escalation or other non--compliancecompliance
Treating another symptom with opioidsTreating another symptom with opioids
Unintentional psychic effectsUnintentional psychic effects
Resistance to change in therapy that is workingResistance to change in therapy that is working Intense anxiety about recurrent symptomsIntense anxiety about recurrent symptoms
Passik, Portenoy, 2004
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PseudotolerancePseudotolerance
Occurs when a patient with chronic pain treated withOccurs when a patient with chronic pain treated withopioids increases activity levels resulting in more painopioids increases activity levels resulting in more pain
OROR
there is a worsening of the underlying pain conditionthere is a worsening of the underlying pain condition
This pain is relieved when the dose of opioid is increasedThis pain is relieved when the dose of opioid is increased
Tends to occur during the initial titration phase or at a time thatTends to occur during the initial titration phase or at a time that
the patient undergoes a significant change in activity level orthe patient undergoes a significant change in activity level ordisease activitydisease activity
Jackson KC, 2003
Heit H, 2005
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1919
PseudoaddictionPseudoaddiction
An iatrogenic misinterpretation caused byAn iatrogenic misinterpretation caused byundertreatment of pain that isundertreatment of pain that ismisidentified by the clinician asmisidentified by the clinician asinappropriate druginappropriate drug--seeking behaviourseeking behaviour
Behaviour ceases when adequate painBehaviour ceases when adequate painrelief is providedrelief is provided
Not a diagnosis, rather a description of aNot a diagnosis, rather a description of aclinical interactionclinical interaction
Weissman DE, Haddox JD. Pain. 1989;36:363-6.
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Addiction versusAddiction versus
PseudoaddictionPseudoaddiction AddictionAddiction
Dx made prospectively:Dx made prospectively:
Patients behavior and compliance withPatients behavior and compliance with
treatment agreement becomestreatment agreement becomes aberrantaberrantdespite Rational Pharmacotherapy.despite Rational Pharmacotherapy.
PseudoaddictionPseudoaddiction
Dx made retrorespectivelyDx made retrorespectively Patients behavior and compliance with thePatients behavior and compliance with the
treatment agreementtreatment agreementnormalizesnormalizes withwithRational Pharmacotherapy.Rational Pharmacotherapy.
Gourlay, 2005
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Concurrent Pain & AddictionConcurrent Pain & Addiction
Both pain and addiction can coBoth pain and addiction can co--exist in theexist in thesame patientsame patient
Addiction can be to prescription medications,Addiction can be to prescription medications,illicit narcotics and/or alcoholillicit narcotics and/or alcohol
This does not necessarily preclude the use ofThis does not necessarily preclude the use ofopioid therapy, but does require more attentionopioid therapy, but does require more attention(and time)(and time)
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Treatment of Pain & OpioidTreatment of Pain & OpioidAddictionAddiction
InpatientInpatient
OutpatientOutpatient
SubstitutionSubstitution MethadoneMethadone
Suboxone (buprenorphine/naloxone)Suboxone (buprenorphine/naloxone)
DiscontinuationDiscontinuation
Tapering (Rapid vs Gradual)Tapering (Rapid vs Gradual)
Narcanon/CounsellingNarcanon/Counselling
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Treatment of Pain & OpioidTreatment of Pain & OpioidAddictionAddiction
Methadone: 2 indicationsMethadone: 2 indications
Treating heroin/opioid addictionTreating heroin/opioid addiction
Treating chronic pain with or without addictionTreating chronic pain with or without addiction
Suboxone:Suboxone:
Addiction treatment as a substitute for MethadoneAddiction treatment as a substitute for Methadone
Safer with less substituteSafer with less substitute--addiction potentialaddiction potential
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Underwriting PointsUnderwriting Points
Differentiate between abuse and addiction asDifferentiate between abuse and addiction asthere are different outcome implicationsthere are different outcome implications
Use of cocaine recreationally constitutes abuseUse of cocaine recreationally constitutes abuse
Habitual use of marijuana likely constitutes addictionHabitual use of marijuana likely constitutes addiction
(as with tobacco)(as with tobacco)
Abuse (illicit substances) without addiction hasAbuse (illicit substances) without addiction haslegal/criminal ramificationslegal/criminal ramifications
Addiction has more health related consequencesAddiction has more health related consequences
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Underwriting PointsUnderwriting Points
Consider comorbidities, specificallyConsider comorbidities, specificallypsychiatric/psychological (depression/anxiety)psychiatric/psychological (depression/anxiety)
Watch for unusual health outcomes (CVA, MI,Watch for unusual health outcomes (CVA, MI,COPD) not associated with risk factors andCOPD) not associated with risk factors andoutside ageoutside age--appropriate ranges for occurrenceappropriate ranges for occurrence
Frequent ER visits for unspecified diagnosesFrequent ER visits for unspecified diagnoses(chest pains)(chest pains)
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Underwriting PointsUnderwriting Points
If there is chronic pain with a history ofIf there is chronic pain with a history ofsubstance abuse/addictionsubstance abuse/addiction
Determine past treatment historyDetermine past treatment history
Assess current statusAssess current status
UDTs in APSUDTs in APS
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Underwriting PointsUnderwriting Points
Virtually any prescription drug can beVirtually any prescription drug can bemisused/abused but psychotropic drugs are themisused/abused but psychotropic drugs are thefocus of concern especially with addictionfocus of concern especially with addiction
Trends temporally and geographicallyTrends temporally and geographically
Media biasesMedia biases
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Underwriting PointsUnderwriting Points
Opioids of choice:Opioids of choice: HydrocodoneHydrocodone
OxycodoneOxycodone
MethadoneMethadone
Benzodiazepines of choice:Benzodiazepines of choice:
AlprazolamAlprazolam
ClonazepamClonazepam
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