Pain and Addiction Steven M. Benecke, M.D. Academic Pain Physicians of Colorado Springs April 18, 2008
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
Chemical Dependency (Addiction) • Compulsion • Craving • Continued use despite adverse consequences • 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 symptoms • Is progressive • It is primary • It is chronic • It is permanent • It is fatal if not treated
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
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 StudyIves, et al., BMC Health Serv Res.2006 Apr 4;6(1):46
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 • Pseudo-addiction (inadequate analgesia) • Smokers may require higher doses of opioids because of nicotine-opioid interactions • Substance use disorders • Smoking may be a more socially acceptable form of substance use or a proxy for other forms of substance use • Chemical coping/self-medication of pain • Smoking may be a means of self-medication for stressors related to persistent pain • 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
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)
Family history of substance abuse Alcohol Illegal drugs Prescription drugs Personal history of substance abuse Alcohol Illegal drugs Prescription drugs Age (mark box if between 16-45) History of preadolescent sexual abuse 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 ORTWebster & Webster, Pain Med. 2005;6:432.
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 Springs Medication 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: • Make a diagnosis with differential • Note comorbidites; substance use, psych • Assess risk of addiction (screening tool) • Establish treatment agreement to include informed consent • Establish expectations and obligations each party • Establish Boundaries!
Universal Precautions: • Assess level of pain and function before intervention and each visit • Ask what expectations are with respect to pain and function • Initiate trial of opioid therapy with/without adjuvants
Universal Precautions: • Assess 4 A’s of Pain with each visit: • Analgesia • Activity • Adverse effects • Aberrant Behaviors
Universal Precautions: • Each visit, review pain diagnosis, co morbid conditions, look for addictive disorders • Document!
Treatment, Addiction to prescribed opioids: • Buprenorphine • Methadone • Naloxone • Naltrexone • Patch • Behavioral counselling
Pain and Addiction Steven M. Benecke, M.D. Academic Pain Physicians of Colorado Springs April 18, 2008