Pain and Addiction

Steven M. Benecke, M.D.

Academic Pain Physicians of Colorado Springs

April 18, 2008

Crossroads

Crossroads

• Do no harm

• Cannot always correct the condition causing pain.

Paradigm shift in treatment:

Pain has become the “fifth” vital sign

Specialty of pain management

Effects of under treatment of pain

Crossroads:

• Opioids are the best we have for the treatment of pain

Little end organ toxicity

Have no pharmacologic ceiling

affordable

Presently:Worst thing a care giver can do:

• With some is to deny opioids

• Others, to provide access to opioids

• Cross roads!

Pain:

• An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

• IASP

Which Opioids are addicting?

•All of them!

Chemical Dependency(Addiction)

• Is a chronic, primary disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic use. ASAM

Addiction to prescription medications is a Brain

disease

Chemical Dependency (Addiction)

1. Compulsion

2. Craving

3. Continued use despite adverse consequences

4. Loss of Control

Addiction:

• Characterized by behaviors: (one or more)

• 1.impaired control over drug use• 2. continued use despite harm• 3. craving

Addiction:

• The disease lacks a clear cut definition as all addictions involve the brain but only some involve substances, e.g., pedophilia, gambling.

Chemical Dependency is a disease

Has predictable symptomsIs progressiveIt is primaryIt is chronicIt is permanentIt is fatal if not treated

Addiction to prescribed opioids

Statistics:

4.4 million used opioids without Rx

3.1 million (>12) used oxycontin in 2004

495,732 ED visits for misuse of >1 drug

1988-1998 Opioid Rx inc 500k to 1.6 million

NIDA

Add suboxone slide

Factors contributing to Addiction:

• Availability• Job and personal stress• Curiosity• Physical/emotional pain• Being “Invincible”• Can’t talk about feelings, failures,

hopelessness, and pain

Predictors of Opioid Misuse in Patients with chronic Pain: A Prospective Cohort

Study.

• Prospective, cohort study to examine one year prevalence of “opioid misuse” in chronic non-cancer pain pts (n=196)

Opioid misuse defined as:

• Negative urine toxicological screen for prescribed opioids

• UTS positive fo opioids or controlled substances not prescribed by practice

• Evidence of procurement of opioids from multiple providers

• Diversion of opioids• Prescription forgery• Stimulants (cocaine or amphetamines) on UTS

Results:

• Mean patient age was 52 years,, 55% were male, and 75% were Caucasian

• Sixty—two of 196(32%) patients committed opioid misuse– Detection of cocaine or amphetamines on UTS most common (40.3% of

mis-users)– Mis-users more likely than non mis-users:

• Younger• male• Past alcohol abuse• Past cocaine abuse• Previous drug or DUI conviction• Race, income, education, depression score,, disability score, pain score, and

literacy not associated with misuse• No relationship between pain scores and misuse

Predictors of Opioid Misuse in Patients with Chronic Pain:A Prospective Cohort Study

Ives, et al., BMC Health Serv Res.2006 Apr 4;6(1):46

• Anna Nicole Smith

• Patrick Kennedy

Elvis Presley

• The euphoric effect of any opioid is not predictable. Vicodin,Eddy

• Specialty specific (DDS, anesth. Bartender)

• Heroin (Bayer)

Smoking: Predictor of Aberrant Drug Use?

• SISAP and SOAPP include tobacco use as a factor in determining risk. 1,2

• Tobacco use is highly prevalent among substance misusers3

– Smoking increased desire to abuse drugs in an addict population (n=160)3

– Smoking may be used as a form of substance replacement in those trying to abstain3,4

– 1Coambs et al. Pain Res Manage.1996;1:155– 2Butler et al. Pain. 2004;112:65– 3Rohsenow et al. .Addict Behav.2005;30:629– 4Conner et al. Exp Clin Psychopharmacol. 1999;7:64.

Smoking and Aberrant Drug-taking Behaviors

o Pseudo-addiction (inadequate analgesia)o Smokers may require higher doses of opioids because of

nicotine-opioid interactions

o Substance use disorderso Smoking may be a more socially acceptable form of substance

use or a proxy for other forms of substance use

o Chemical coping/self-medication of paino Smoking may be a means of self-medication for stressors

related to persistent pain

o Dhingra and Passik, Practical Pain Management 6(2) p A-D, 2006

Smoking and Persistent Pain

• Chronic pain patients smoke at significantly higher rates than the general population

• Smoking is associated with nonspecific low back pain, firbromyalgia, and headache disorders.1-4

• Strong dose response relationship exists between cigarette consumption and persistent low back pain.5

• 1Jamison et al. Addictive Behaviors. 1991. 16: 103-10• 2Hahn et al. 2006. Submitted• 3Payne et al. Headache. 1991. 31: 329-32• 4Yunus et al. Scand J Reumatol. 2002. 31: 301-5• 5Porter et al. J Am Acad Orthop Surg. 2001. 9: 9-17

What about THC use and opioid misuse?

•?

Screening tools:

• To screen for those susceptible to prescription misuse:

– ORT (opioid risk tool)– CAGE (alcohol)– SMAST-D (short Michigan alcohol screening test)– COM (current opioid misuse measure)– STAR (screener and opioid assessment for patient with pain,

screening tool for addiction risk)– SOAPP (screener and assessment for patients with pain)

ORTWebster & Webster, Pain Med. 2005;6:432.

1. Family history of substance abuse1. Alcohol2. Illegal drugs3. Prescription drugs

2. Personal history of substance abuse1. Alcohol2. Illegal drugs3. Prescription drugs

3. Age (mark box if between 16-45)4. History of preadolescent sexual abuse5. Psychological disease (ADD, OCD, bipolar,

schizophrenia, depression

Scoring:• 0-3: low risk (6%)• 4-7: moderate risk (28%)• ≥8: high risk (>90%)

• Female Male• 1 3• 2 3• 4 4

• 3 3• 4 4• 5 5• 1 1• 3 0

• 2 2• 1 1

How do we avoid becoming a cause of Rx misuse?

∞ Establish opioid agreement∞ Perform random UTS∞ Perform random pill counts∞ Psychological evaluation∞ Functional score with/without opioids∞ Speak with family members∞ DORA (www.coloradopdmp.org)

Academic Pain Physicians of Colorado SpringsMedication Agreement:

Patient Name: __________________________

Dear Patient:This letter serves to confirm that you and Dr. Benecke have come to a mutual agreement that all other modalities

of pain management have been exhausted and because of persistent pain, it has been mutually agreed upon to begin opioids. You and your care giver agree to:

You acknowledge that you have no prior history of substance misuse (alcohol/ recreational drugs).Only Dr. Benecke will prescribe analgesics for you.You will adhere to the medications’ prescribed schedule and not increase the number of pills or their frequency

without being directed to.Only one pharmacy will fill these prescriptions and you will include that pharmacy’s address and number to be

included with this document and will allow this document to be shared with them.Your primary care physician as well as all treating physicians will be made aware of this agreement.Prescriptions or medications that are lost or stolen will not be replaced.You agree to random drug testing and will comply when requested to bring your pills with you for a random pill

count.If the medications are continued for more than six months, you will agree to see a pain psychologist as part of the

therapy for your pain condition.Violation of any of these will lead to a termination of the relationship and an immediate cessation of the

medications with a referral to an appropriate detoxification center.It must be understood that there are risks and uncertainty to the long-term use of these medications. Risks

include psychological dependency (addiction), sedation, slowing of your respirations, nausea, itching, and constipation. Abrupt withdrawal of these medications, will lead to abstinence syndrome (increased heart rate, sweating, diarrhea, nausea, vomiting). Long term effects are not known and these drugs should not be taken when pregnant or if the possibility of pregnancy exists. You are responsible for keeping these medications from children and other adults. Determining if it is safe to drive or work while consuming these medications is your responsibility. Consuming opioids during pregnancy will lead to physical dependence in the new born.

These medications must be refilled in person at your monthly appointment.Your signature recognizes the seriousness of your voluntary decision to participate in the use of opioids for your

pain condition. Honest communication between everyone will ensure your success and continued health.Date:_____________ Signature of Patient:______________________________________Physician:____________________ _________ Witness:____________________________________Pharmacy:________________________ Address:__________________________________________Phone:_______ ________ _____________

Board of Medical Examiners for State of Colorado:

Board Policy 10-14

• Evaluate pain with H&P• State outcome objectives and plans• Risks and benefits of tx with informed consent• Periodic review of course of treatment• Refer as necessary when achievement not met (esp. those with

psychiatric co morbidities• Medical record document eval/tx, indications for use of controlled

substances• Must comply with federal and state regulations regarding use of

controlled substances.

Universal Precautions in Pain Medicine:

• Allows for standardized assessment and ongoing management of all chronic pain patients

• It is impossible to predict which patients will become problematic users of prescription medications

• There is no test or physical sign that will predict which patient will do well on therapeutic trial of opioids for pain

Universal Precautions:

1. Make a diagnosis with differential1. Note comorbidites; substance use, psych

2. Assess risk of addiction (screening tool)

3. Establish treatment agreement to include informed consent

1. Establish expectations and obligations each party

2. Establish Boundaries!

Universal Precautions:

4. Assess level of pain and function before intervention and each visit

5. Ask what expectations are with respect to pain and function

6. Initiate trial of opioid therapy with/without adjuvants

Universal Precautions:

7. Assess 4 A’s of Pain with each visit:1. Analgesia

2. Activity

3. Adverse effects

4. Aberrant Behaviors

Universal Precautions:

8. Each visit, review pain diagnosis, co morbid conditions, look for addictive disorders

9. Document!

Treatment, Addiction to prescribed opioids:

• Buprenorphine• Methadone• Naloxone• Naltrexone• Patch

• Behavioral counselling

Crossroads

Pain and Addiction

Steven M. Benecke, M.D.

Academic Pain Physicians of Colorado Springs

April 18, 2008