Problem Patient or Problem Prescription? Ken Roy, MD Tulane Department of Psychiatry Addiction...
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Transcript of Problem Patient or Problem Prescription? Ken Roy, MD Tulane Department of Psychiatry Addiction...
Problem Patient or Problem Prescription?
Ken Roy, MD
Tulane Department of Psychiatry
Addiction Recovery Resources of New Orleans
504-780-2766
www.arrno.org
Scope
Problem patients
Problem prescriptions
Classes of addicting drugs
Recognition of addiction
What to do about problem patients
Potential Problem Patients
Family history of alcoholism
External locus of control
Pain persistent or out of proportion
Litigation
Multiple meds
Problem Prescriptions
Soma, Fiorinal, Valium, Xanax
Ritalin, Adderall
Vicodin, Percodan, Ultram, OxyContin
Classes of Addicting Drugs
Related to the reinforcing pathway
Three main classes
Sedative hypnotics and opioids contain the vast
majority of problem prescriptions
Sedative Hypnotics
Active in the GABA system Alcohol Benzodiazepines (Rohypnol) Barbiturates (Fiorinal) Anxiolytics & Hypnotics (Ambien, Soma,
Sonata)
Opiates
Active in the endorphin systems
Vicodin, other oxy & hydro codones Especially ES formulations & OxyContin
Ultram
Methadone
Stimulants
Active in the dopamine system
Amphetamines (Adderall)
Others (Ritalin, Cylert)
*Decongestants
The Case AgainstChronic Sedative Hypnotics
Short term anxiolytic in non-recovering patients No controversy
Effects on the GABA system
Effects on mood, anxiety and insomnia
Alternatives
The GABA System
Cause tolerance (40,42,43)
Down regulate receptors (36,37,38) And receptor function (39,40)
Decrease effect of endogenous anxiolytics
(41)
Cause physical dependence (59)
Mood, Anxiety and Insomnia
Paradoxical anxiety with long term use (45)
Cause depression (54,55,56,57)
Not effective long term for sleep (44)
Make opiates less effective (58)
No evidence of long term efficacy for PTSD (60)
Alternatives to Sedative Hypnotics (Benzo’s)
SSRI’s and TCA’s Better for GAD (46,47,48,49)
Better for panic (49,50,51,52)
Better for agoraphobia (53)
Better for “stress” (61)
Quetiapine, Trazodone, Doxepin, etc.
The Case Against Chronic Opiates in Chronic Pain
Acute vs. chronic pain
The effects on the endogenous opiate system
The effects on the perception of pain
The effects on activity and behavior
Alternatives to chronic opiate analgesia
Acute vs.Chronic Pain
Acute - perioperative, traumatic, infectious No controversy (except monitoring for relapse)
Chronic Malignant or progressive
No controversy
Non malignant Huge controversy (1)
Chronic Non-Malignant Pain
Subjective pain relief Few studies
Urban - 5 patients (2)
Taub & Tennant - both anecdotal (3,4)
Portnoy - reduced perception of pain in 1/3 (5)
Improvement in function Not demonstrated (1,6)
It Doesn’t Work
“Overall, the use of opioids in chronic pain of non malignant origin will achieve analgesic benefit in some patients, while improved function has not yet been adequately demonstrated.”(1)
“Until opioid therapy can be shown to yield long term outcomes that are superior, we cannot endorse it as a treatment of choice for chronic non cancer pain.” (7)
Even in Non Addicts
“In patients with treatment resistant chronic
regional pain of soft tissue or musculoskeletal
origin, nine weeks of oral morphine in doses of up
to 120 mg daily may confer analgesic benefit with
a low risk of addiction, but is unlikely to yield
psychological or functional benefit.” (6)
The Endogenous Opiate System
Tolerance B-Endorphin neurons become tolerant after chronic
morphine administration (8)
Release of Pro-opiomelanocortin-derived peptides
decreased in tolerance (9)
Pro-opiomelanocortin synthesis and B-Endorphin
utilization down-regulated in morphine tolerance
(10,11)
The Perception of Pain
Chronic opiates cause sensitization Hyperalgesia caused by noxious stimulation is
similar to hyperalgesia caused by chronic
opiates (15)
Thermal hyperalgesia develops in morphine
tolerance (16)
Activity and Behavior
Depression Opiates and opiate system implicated in
model of learned helplessness (17,18)
Opiates cause depression (19,20)
Potential for relapse Opiate use increases potential for relapse
(21,22,23)
Alternatives
Multidisciplinary chronic pain treatment
programs Nerve Blocks (24)
Psychotherapy (25,26,27,28,29)
Acupuncture (30)
Exercise (25,31,32)
Spiritual growth and recovery (33)
Criteria for Substance Abuse
Recurrent use affecting role obligations Recurrent use where hazardous Recurrent use causing legal problems Recurrent use causing social or
interpersonal problems
Prevalence
Almost 50% of persons age 21 abuse alcohol 70% drink
22% of persons 18 – 22 years of age use illicit drugs 76% are employed Rate in college students 21%
Treatment Harm reduction strategies
Designated Driver Education and conversation
Response to behavior Don’t excuse behavior Don’t remove consequences
Most people discontinue SUBSTANCE ABUSE unless they develop SUBSTANCE DEPENDENCE
Criteria for Substance Dependence
Criteria for Substance Dependence
A maladaptive pattern of use, causing significant impairment or distress as manifested by three (or more) of the following seven criteria, occurring at any time in the same twelve months Tolerance, as defined by:
a need for increased amounts to achieve effect markedly diminished effect from using the same
amount
Substance Dependence continued
Substance Dependence continued
withdrawal, as manifested by: characteristic withdrawal syndrome the same substance is used to avoid or relieve
withdrawal symptoms the substance is taken in larger amounts or over
a longer period than was intended there is a persistent desire or unsuccessful
efforts to cut down or control use
Substance Dependence continued
Substance Dependence continued
a great deal of time is spent in activities necessary to obtain or use the substance or recover from it’s effects
important social, occupational, or recreational activities are given up or reduced because of substance use
Substance Dependence continued
Substance Dependence continued
the substance use is continued despite knowledge of having a persistent or recurring physical or psychological problem that is likely to have been caused or exacerbated by the substance (ulcer, depression, etc.)
Incidence of Substance Dependence
Incidence of Substance Dependence
14.1% National Comorbidity Study 1994 Other drug dependencies in 7.5% of these
5% to 15% is the range in previous studies
Substance Dependence Shorthand
Substance Dependence Shorthand
Compulsion Loss of Control Continued use in the face of adverse
consequences
The Disease of Addiction
Criteria for a disease Recognizable symptoms Predictable Course Common Cause
The Course of Addictive Disease Progressive Affects all organ systems Associated with the cause of death A disease of relationships
Disturbance in the relationship with self and others
Based on dishonesty in the form of denial
The Cause of Addictive Disease
Genetic Experience - Family History Family Studies Twin Studies Adoption Studies
Importance of Disease Orientation
Cause - not Effect of Something Else Therefore a primary illness
Helps to understand Denial Providers don’t blame their patients Patients Have a Healthy Target to Work on
Impact on Treatment
Abstinence is the Only Reasonable Goal Use Alters Neurotransmitters
Denial is the Primary and Universal Symptom Preserves the Right to Drink or Use
Identification With Others Possible OK Not to Have Coping Skills
Treatment Takes Time Levels of Care can provide time
Contribution of EnvironmentContribution of Environment
Similarity to TB Impact of Using on Emotional
Development
AbstinenceAbstinence
Similarity to Diabetes AA/NA/GA/RR not MM
Common Experiences Fellowship Impact on Emotional Development
Getting Help
Public Sector Overcrowded, under funded, restrictive 32 Detox beds – 900 waiting for treatment
Private Sector Effective, welcoming, shame reducing Requires Parity (Non-discrimination) for
maximal effectiveness Current insurance coverage inadequate and
often inappropriate
So, what do I do? Call it like you see it Don’t shame the patient
May point out consequences Be realistic, don’t try to “scare” the patient
Refer to appropriate addiction specific practices JPSAC
Public ARRNO
Private – Insurance, etc