1.3 salsitz pain addiction - acmt · iatrogenic addiction/complex dependence iatrogenic addiction...
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CHRONIC PAIN, CHRONIC OPIOIDS: IS MY PATIENT ADDICTED? ASAM Unit VII Edwin Salsitz, MD, FASAM
Complex Interactions
Opioids
Pain Addiction
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Pain
“ Pain is viewed as a biopsychosocial phenomenon that includes sensory, emotional, cognitive, developmental, behavioral, spiritual and cultural components. ” (IASP website)
“ Pain is whatever the experiencing person says it is, existing whenever he says it does. ”
(McCaffrey 1968)
“ An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. ” (IASP 1994)
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Addiction Public Policy Statement: Definition of Addiction ASAM 2011 Short Definition of Addiction:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
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Pain and Addiction No Objective Measurements
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Physical Dependence
“Physical dependence is a normal and expected response to continuous opioid therapy. Physical dependence may occur within a few days of dosing with opioids, although it varies among patients. Physical dependence (indicated by withdrawal symptoms) does not mean that the patient is addicted. ”
“Physical dependence is the physiological adaptation of the body to the presence of an opioid. It is defined by the development of withdrawal symptoms when opioids are discontinued, when the dose is reduced abruptly or when an antagonist (e.g., naloxone) or an agonist-antagonist (e.g., pentazocine) is administered. ”
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O'Brien CP. Drug addiction and drug abuse. In: Goodman and Gilman's The pharmacological basis of therapeutics. 9th edition.
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Anterior Cingulate Gyrus
Opioid Sites of Action in the Brain
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Locus Coeruleus Ventral
Tegmental Area
Amygdala
Arcuate Nucleus
Arcuate Nucleus Nucleus Accumbens
Prefrontal Cortex
Periaqueductal Gray Area
Amphetamine Cocaine Opiates Cannabinoids Phencyclidine Ketamine
Opiates Ethanol Barbiturates Benzodiazepines Nicotine Cannabinoids
Acc VTA
FCX AMYG
VP
ABN
Raphé
LC
GLU
GABA
ENK OPIOID GABA
GABA
GABA
DYN
5HT
5HT
5HT
NE
HIPP
PAG
RETIC
To dorsal horn
END
DA
GLU
Opiates
ICSS
OPIOID
HYPOTHAL LAT-TEG
BNST
NE
CRF
OFT
Mesolimbic Dopaminergic Circuit Pleasure/Reward Center H2O, Food, Sex, Parenting, Social
Eliot Gardner
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Hedonic Tone
Human Condition
(abnormal tone in the vulnerable to addiction)
A Delicate Balance
Altered by Psychoactive Activities
Range: Euphoria ß à Dysphoria
“Set” by/in the mesolimbic dopaminergic circuitry(Pleasure/Reward/Survival Center)
Sense of well being, happiness, pleasure, contentment
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Hedonic Tone Demonstration
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Opioid Dependence (DSM-IV) (3 or more within one year)
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• Tolerance
• Physical Dependence/Withdrawal
• Larger amounts/longer period than intended
• Inability to/persistent desire to cut down or control
• Increased amount of time spent in activities necessary to obtain opioids
• Social, occupational and recreational activities given up or reduced
• Opioid use is continued despite adverse consequences
Substance Use Disorder DSM-V
Severity measured by number of symptoms; 2-3 mild, 4-6 moderate, 7-11 severe
Tolerance* Withdrawal*
More use than intended Craving for the substance
Unsuccessful efforts to cut down Spends excessive time in acquisition
Activities given up because of use Uses despite negative effects
Failure to fulfill major role obligations
Continued use despite consistent social or interpersonal problems
Recurrent use in hazardous situations
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* These do not apply if the medication is prescribed
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Robert 48 Year Old Male
Case:
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Case: Robert
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• 48 year-old male—initial evaluation 1997 Social Worker
• HIV + for 15 yrs.----IVDA—1970’s
• F.H. +--EtOH-mother and father
• Age 17- 15 year-old younger brother died-leukemia 4+traumatic event for patient
• Age 22 à TC—Started methadone, MAT for 4 years then weaned off. No drug use since
Case: Robert, cont’d
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• Pain à HIV neuropathy à non-opioid medications not effective
• Rx for Tylenol/Codeine #3—reports inadequate analgesia at 4 tabs per day
• Started to take his wife’s(MS) Rx 5mg Oxycodone/APAP up to 10/day
• Told his MDs he was taking his wife’s opioids for ~ 1 week
• Referred by HIV and PCP for opioid abuse/addiction
• UDS--+oxycodone, -opioids, -all else
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What is your diagnosis?
Case: Robert
Doctor Shopping
Aberrant Behavior
Catastrophizing Pain Relapsed Opioid Addiction
Malingering
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Answer 3 is Correct
Which of the following statements are correct?
Case: Robert
A trial of opioids, with close monitoring, can be started.
If opioids are prescribed, relapse to full blown addiction is likely.
A patient-provider opioid agreement should be obtained.
Opioids are contraindicated due his previous diagnosis of opioid addiction.
Both 2 and 4 are correct.
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Answer 5 is Correct
Robert: Case Summary
Died July 2007---HIV/AIDS complications
No Problematic/Aberrant Behavior 1997—2007 All UDS neg. for non-prescribed/illicit drugs
Rx---MS-Contin 60mg 3Xday à 60mg. 2xday after 1 year
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Pain and Addiction
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Chronic Pain OR
Addiction
Depression and Anxiety
Cognitive Disturbances
Sleep Disturbances
Functional Disability
Family/ Social
Problems
Financial Problems
Secondary Physical Problems
Human Suffering
Ann Quinlan-Colwell, PhD, PCSS-O Webinar 2011
Pain: Psychiatric Co-Morbidity
Depression and Pain Comorbidity-Bair,et al Arch Intern Med. 2003;163:2433-2445
• 56 Articles(14D>P, 42P>D)
• 65% with Depression (Dep.) have significant Pain
• ~50% in Pain Clinic have Dep.
• Pain negatively affects Dep. Outcomes
• Dep. associated with decreased pain mgt.
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Twelve-Month Prevalence of DSM-IV Independent Mood and Anxiety Disorders Among Respondents with DSM-IV Substance Use Disorders Who Sought Treatment in the Past 12 Months
Disorder Respondents, % (SE)
Those With Any Drug Use Disorder (13.10%)* Any mood disorder 60.31 (5.86)
Major Depression 44.26 (6.28) Dysthymia 25.91 (5.19) Mania 20.39 (5.17) Hypomania 2.48 (1.67)
Any anxiety disorder 42.63 (5.97) Panic disorder With agoraphobia 5.92 (2.19) Without agoraphobia 8.64 (3.05) Social phobia 12.09 (3.48) Specific phobia 22.52 (4.99) Generalized anxiety disorder 22.07 (5.18)
Any alcohol use disorder 55.16 (6.29)
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*Data in parentheses are the percentages of respondents with the substance use disorders who sought treatment in the past 12 months.
Grant B, JAMA 2004
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Pain and Addiction-Psychiatric Co-morbidity
Odds Ratios: Major Depression—3.43 Dysthymia—6.51 Panic—5.37 GAD—2.56 Problem Drugs—3.57 Problem Alcohol—.73 Conclusion: Common mental health and drug disorders are associated with initiation and use of prescribed opioids. Attention to psychiatric disorders is important when considering opioid therapy
Association Between Mental Health Disorders, Problem Drug Use, and Regular Prescription Opioid Use Sullivan M.D., Arch Intern Med 2006;166:2087-2093 Healthcare for Communities waves 1998 and 2001 N=6430 telephone survey Association of common mental health disorders in 1998 with regular Opioid Rx. Use in 2001
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Iatrogenic Addiction/Complex Dependence
Iatrogenic addiction occurs when a patient, [with a negative personal or family history for alcohol or drug addiction or abuse]*, is appropriately prescribed a controlled substance & subsequently in the therapeutic course meets the diagnostic criteria for addiction to that substance.
* There is controversy about the validity of this modifier
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Heit HA, Gourlay DL. Treatment of Pain in Substance Abuse Disordered Population. Ballantyne JC, Rathmell JP, Fishman SM (eds). Bonica’s Management of Pain. 4th ed. Lippincott Williams & Wilkins. In Press.
Opioid Treatment for Pain: Risk of Addiction
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Voluminous literature including multiple systematic reviews
Rates vary widely 0%-50%-- higher in those with addiction hx
Often not clear how the diagnosis of addiction is confirmed
Aberrant and Problematic Behaviors often considered to make a diagnosis of addiction
Diagnosis is often not clear when opioids are prescribed for pain by HCP—lack of education in addictive disease
Clinical expertise and individualization required. ASAM members uniquely qualified
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Opioid Treatment for Pain: Risk of Addiction Development of dependence following treatment with opioids for pain (Minozzi S, et al. Addiction 2012) Minozzi S, et al. Addiction 2012;
“The most impressive finding of the present review is the deficiency of good-quality studies.”
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Systematic review of 17 studies (N=88,235) including 3 systematic reviews, 1 RCT, and 12 observational studies
Results: Incidence = 0-24% (median 0.5%); prevalence = 0-31% (median 4.5%)
Conclusion: Opioids for chronic pain are not associated with a major risk for developing an OUD
Opioids and Pain: Risk of Addiction A Critique of Minozzi et al.’s Pain Relief and Dependence Systematic Review Mcauliffe, W. Addiction, 108. 1162-1171 2013
• “This critique concurs with authors who have concluded that existing research is inadequate for estimating the rate of iatrogenic addiction in patients treated for non-cancer pain.”
• “Systematic reviews of many irrelevant, inadequate, and incomparable studies cannot substitute for properly designed studies”
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Opioid Treatment for Pain: Risk of Addiction What Percentage of CNCP Patients Exposed to COT develop Addiction and/or Aberrant drug-Related Behaviors? A Structured Evidence-Based Review. Fishbain et al Pain Med 2008
• 24 studies COT, 26.2 mos. (n=2,507), average % addiction= 3.27% • 17% of studies pre-selected for no current/past hx. of addiction/abuse
addiction in pre-selected 0.19% vs. 5.0% in non-selected • Average % ADRBs =11.5% , pre-selected= 0.59% • UDS, 5 studies n=15,442, ADRBs = 20% no opioid/other non-Rx opioid • UDS, illicit drugs non-opioid, 14.5%
Conclusions: The results of this evidence-based structured review indicate that COT exposure will lead to abuse/addiction in a very small % of patients. This % can be dramatically decreased by preselecting CPPs for no previous/ current hx of drug/alcohol abuse/addiction
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Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Addiction Martell, B. Ann Intern Med. 2007;146:116-127 Conclusion: Opioids are commonly prescribed for chronic back pain and may be efficacious for short-term pain relief. Long-term efficacy (>16 weeks) is unclear. Substance use disorders are common in patients taking opioids for back pain, and aberrant medication-taking behaviors occur in up to 24%. Concept of “Adverse Selection”
Opioids and Pain: Evidence Assessment ASIPP Evidence Assessment/Guidelines Manchikanti L, et al, Pain Physician 2012;15:S1-S66
Selected Conclusions:
• Limited evidence that screening for opioid abuse using an instrument reduces abuse à Recommended
• Good Evidence that UDS reduces abuse of Rx opioids
• Good to Fair evidence that Prescription Monitoring Programs reduce drug abuse of doctor shopping
• Fair evidence that Prescription Monitoring Programs reduce ED visits, overdoses, or deaths
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Treating Pain in the Addicted Patient
• “Pain Patients with a coexisting SUD are among the most challenging patients in medicine.”
• Awareness of potential deception in pt’s history
• Universal Precautions
• ?? “Real Pain” may make opioids less rewarding/euphorogenic
• Screening Tests: ORT, SOAPP, others
• Untreated Pain is a trigger for relapse
• Address both pain and addiction
• Significant other to secure and dispense opioid meds
• Active recovery program
• UDS, pill counts, agreements, etc.
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Bailey, et al. Pain Medicine 2010; 11: 1803-1818
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Treating Pain in the Addicted Patient, cont’d
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UDS—consider using opioids without confusing metabolic conversions to other non-prescribed opioid analgesics: oxycodone à oxymorphone (hydromorphone, methadone)
No poppy seeds
Opioid agreement
Avoid other potentially abusable medications: benzos, hypnotics, muscle relaxants, etc
Identify and treat psychiatric co-morbidity— common in both
This review does not discuss the management of pain, requiring chronic opioids, in the context of active or ongoing addiction.
Bailey, et al. Pain Medicine 2010; 11: 1803-1818
Treating Pain in the Addicted Patient, cont’d
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Methadone—FDA approved for both pain and addiction
Addiction dosing q 24 hours: Analgesic dosing q 6-8 hours
MMTPs/OTPs not authorized to treat pain
MMTPs not able to provide 3-4 doses per day for pain/addiction
MMTPs “take homes” take time
Prescribing methadone for addiction not legal—CSA
Buprenorphine pharmacotherapy: formulations approved for addiction and for pain. OBOT waivered physicians
Judicious use of non-opioid medications
Psychosocial modalities: MI, CBT, Acupuncture, Meditation, etc.
Wachholtz, et al. Substance Abuse and Rehabilitation 2011:2 145--162
Pain and Addiction
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Pain and Addiction – ASAM REMS
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e.g. (1) caffeine (2) nicotine (3) alcohol (4) opiates (5) cocaine (6) methadone
Does Not
Necessarily Equal
Physical Dependence
Addiction
Definitions: Complex Physical Dependence
“Dependence on opioid pain treatment is not, as we once believed, easily reversible; it is a complex physical and psychological state that may require therapy similar to addiction treatment, consisting of structure, monitoring, and counseling, and possibly continued prescription of opioid agonists. Whether or not it is called addiction, complex persistent opioid dependence is a serious consequence of long term pain treatment that requires consideration when deciding whether to embark on long term opioid pain therapy as well as during the course of such therapy.
Opioid Dependence vs Addiction A Distinction Without a Difference? Ballantyne J, Sullivan M, Kolodny A, Arch Intern Med, 2012
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Pain and Addiction – ASAM REMS
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Does Not
Necessarily Equal
Aberrant/ Problematic Behavior
Addiction
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Pain and Addiction – ASAM REMS
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Does Not
Necessarily Equal
Chronic Pain Suffering
Treatment of Opioid Addiction
Drug Free Recovery-Initially or Post-Medication
Medication Plus Psychosocial
Opioid Antagonist Therapy: Naltrexone Tablets and Depot I.M.
Opioid Full/Partial Agonist Therapy: Methadone, Buprenorphine
Medication Assisted: Therapy, Treatment, Recovery
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“ …as we know, there are known knowns, there are things we
know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones
we don’t know we don’t know.”
– Donald Rumsfeld
The Clinical Conundrum
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Conclusions: Known Knowns & Unknowns
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• De Novo Iatrogenic addiction 0 – 50%
• Aberrant/Problematic Behaviors are common ~ 20%
• Risks are highest in those with current/past history of addiction – Multidisciplinary Team
• Monitoring patients, using Universal Precautions is helpful
• Follow the FSMBs guidelines to avoid any regulatory problems
• Is it a “Pain Case Gone Bad” or Addiction—often Grey Zone
• *Suffering is common: “Terribly Sad Life Syndrome”
• Challenging Clinical Cases—Requires Individualization Tx
• **Buprenorphine: Therapeutic Option – Pain and Addiction
**Roux,et al. Pain, 154 (2013) 1442-1448
*Sullivan,M JAMA Int Med 172(2012)
Opioid Therapy for Chronic Pain in the United States: Promises and Perils
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• 12 week studies: pain reduced 30% vs placebo
• Functional Improvement ±
• Majority of patients stop opioids: -efficacy + Aes
• COT : Less likely to return to work
• Patients with SUD or Mental Health Disorders are More likely to receive Long Term COT
• >90 days COT> long term: >120mgME> misuse
• “Adverse Selection” - The likelihood of a patient receiving COT increases as the associated risks increase
Sullivan, Howe: Pain, 154 (2013) S94-S100
Principle of Balance Dual obligation of governments and HCPs:
Establish system of controls to prevent abuse, misuse, &
diversion of CS--opioids Ensure medical availability
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Pain & Policy Studies Group. Achieving Balance in State Pain Policy: A Progress Report Card. 3rd ed. 2007.
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