Pain and Chemical Dependency

Not an “Either – Or” Not an “Either – Or” propositionproposition

Douglas Gourlay, MD, FRCPC, FASAMWasser Pain Centre, Toronto ON

DL Gourlay, MD, FRCPC, FASAM 2

The Problem

• Pain and Addiction CAN coexist• Addiction in General Population

– Varies 3 – 16% prevalence– Varies with the drug, gender, economic status,

race, age…

• Addiction in the Chronic Pain Population– We really have no idea– We use the same terms, with different

meaning

• Lack of precision in definitions around abuse/dependency/addiction

DL Gourlay, MD, FRCPC, FASAM 3

Definitions

•Addiction: Addiction is 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, and craving. (LCPA)

DL Gourlay, MD, FRCPC, FASAM 4

Definitions

• Physical Dependence: Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (LCPA)

DL Gourlay, MD, FRCPC, FASAM 5

Definitions

• Tolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

• Tolerance develops at different rates, in different people, to different effects

DL Gourlay, MD, FRCPC, FASAM 6

Definitions

• Pseudoaddiction: Iatrogenic, maladaptive behavior resulting from inadequate pain control

• Not to be used “instead of” addiction• Unwise to diagnose in patient with

history of addictive disorder, even in other substance

DL Gourlay, MD, FRCPC, FASAM 7

Addiction *

Biology

Environment

Drug

*

DL Gourlay, MD, FRCPC, FASAM 8

Diagnosis• DSM-IV criteria - dependence

– Maladaptive behavior having at least three of the following in a 12 month period• Withdrawal• Tolerance• Use in larger amounts or over longer period than

intended• Persistent use, or unsuccessful attempts to cut-

down or control use• XS time spent using or recovering from use• Narrowing of focus due to substance use• Continued use despite harm

DL Gourlay, MD, FRCPC, FASAM 9

Pain and Addictionas Co-morbid Conditions

• Pain often complicate the Dx of Addiction

• Pain and Addiction can coexist– Pain plus

• Alcoholism• Cocaine • Cannabis

– Relatively simple to use current tools to assess addiction i.e. DSM-IV

DL Gourlay, MD, FRCPC, FASAM 10

Pain and Opioid Addiction

• What happens when the ‘drug of choice’ is both the problem AND the solution, depending on point of view?– Addiction Specialist

• Aberrant behavior is due to opioid abuse/addiction

– Pain Specialist• Aberrant behavior is due to inadequate

treatment of pain (pseudoaddiction)

DL Gourlay, MD, FRCPC, FASAM 11

Pain-Addiction Continuum

PainPainAddictionAddiction PatientPatient

PatientPatient

PatienPatientt

DL Gourlay, MD, FRCPC, FASAM 12

Boundary Setting

• 90%+ of patients don’t need strict boundary setting– Most patients have their own internal

set

• For remaining ~10%, strict boundary setting is essential

• Treatment Agreements, Urine Testing, interval / contingency dispensing

DL Gourlay, MD, FRCPC, FASAM 13

Boundaries – Identification and Enforcement

Discharge Patient

DL Gourlay, MD, FRCPC, FASAM 14

Boundaries – Identification and Enforcement

Consultation with Addiction Medicine

DL Gourlay, MD, FRCPC, FASAM 15

Aberrant Drug-Related Behaviors

• Selling prescription drugs• Prescription forgery• Stealing or “borrowing”

drugs from another patient• Injecting oral formulations• Obtaining prescription drugs

from non-medical sources• Concurrent abuse of related

illicit drugs• Multiple unsanctioned dose

escalations• Repeated episodes of lost

prescriptions

• Aggressive complaining about the need for higher doses

• Drug hoarding during periods of reduced symptoms

• Requesting specific drugs• Prescriptions from other

physicians• Unsanctioned dose

escalation• Unapproved use of the drug• Reporting psychic effects

not intended by the physician

More PredictiveMore Predictive Less PredictiveLess Predictive

Jaffee, 1996Jaffee, 1996

DL Gourlay, MD, FRCPC, FASAM 16

Assessing Aberrant Behavior

• What does it mean?– Aberrant behavior is a late and often

unreliable sign of an addictive disorder– When used to trigger UDT, more often

used in punitive fashion

• Aberrant behavior does NOT equal inadequate pain management in all patients

DL Gourlay, MD, FRCPC, FASAM 17

Assessment Strategies

• 1st address pain complaints– Explore AM pain and role of IR opioids

• Carefully document medication use– Dosing intervals, what worked, what didn’t– Lost/stolen, early refills, double doctoring,

problems with control, withdrawal symptoms

• Family history of drug/EtOH problems• Personal psychiatric history

DL Gourlay, MD, FRCPC, FASAM 18

Assessment Strategies

• Personal Substance Use History– Alcohol, tobacco, street drugs– Time of last use

• Drug Treatment History• Legal Issues• Social• Physical Examination• Lab Tests: Liver, Hepatitis, HIV, CBC, UDS

DL Gourlay, MD, FRCPC, FASAM 19

Pain and Chemical Dependency

Program• Pain and CD Clinic CAMH

– Initially at the AMC– Problems with stigma (many “no show’s”)

• Pain and CD division at the Wasser– Easier for patients to comfortably attend

• Very few patients fail to attend appointments• But difficult to manage dominant SUD pts

– “Easier to teach pain docs about addiction”

DL Gourlay, MD, FRCPC, FASAM 20

Pain and Chemical Dependency

Program• Strong bridge between the Wasser Pain

Centre and CAMH was needed– Currently fellows and residents from CAMH

spend time at the Wasser Clinic on Thursday

– Queen Street Lab does UDT for Wasser– Stabilized Pain and CD pts are seen at

Wasser• But we don’t have a place to manage

complex pharmacotherapy problems; we’re not integrated

DL Gourlay, MD, FRCPC, FASAM 21

Pain and Chemical Dependency

Program• 2004, Purdue Canada donated $300,000

over 3 yrs for a Pain and CD division at the Wasser Pain Management Centre– We are now discussing possibilities of

having a “Rationalization of Pharmacotherapy Unit” at the Donwood Site

– Pts will be assessed and medically stabilized before deciding what services might next be offered

DL Gourlay, MD, FRCPC, FASAM 22

Conclusions

• Pain and Addiction can coexist• Successful treatment of either often

requires assessment and management of both

• The Pain and CD Division of the Wasser Pain Centre will do what neither CAMH nor Wasser could do alone