Transcript Edwin A. Salsitz, MD

NYSAM 2011 Case Presentation
Edwin A. Salsitz, M.D. FASAM
Beth Israel Medical Center
New York City
Physician Clinical
Support System
PCSS…
 answers questions about opioids, including
methadone, for treatment of chronic pain
 answers questions about use of
buprenorphine for treatment of opioid
dependence
Physician Clinical
Support System
PCSS…
 is free, for interested physicians and staff
 is supported by SAMHSA through the Center
for Substance Abuse Treatment (CSAT) and
administered by the American Society of
Addiction Medicine (ASAM)
Physician Clinical
Support System
Ask a clinical question…
• get a response from an expert PCSS mentor
– on line by email [email protected]
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guidance's (like FAQs) on specific questions
ADDICTION/PAIN
TREATMENT
“All Treatments Work For Some
People/Patients”
“No One Treatment Works for All
People/Patients”
Alan I. Leshner, Ph.D
Former Director NIDA
CT 2010 Case Presentation
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54 y.o. ♀ evaluated on 6/19/09
Headaches major medical problem
? Paternal uncle—EtOH
Lives with husband, has 2 adult stepchildren
Upper level executive in marketing, 250K
Through H.S. no drugs or EtOH
CT 2010 Case
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Boyfriend 1st year of college introduced to heroin
IN
1st use may have led to gang rape? Uncontrollable
crying over story
1st “migraine” around this time, frequent & severe
“nervous breakdown” after boyfriend ends
relationship in 2nd year college
Heroin INIV x 2yrsillicit methadoneTC
Abstinent age 25
CT 2010 Case
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Migraines lessened in 30’s and 40’s
 frequency and severity post-menopause
Opioids X 4 years—oxyCR & oxyIR
Nationally known HA clinic—weaned off
opioids 2 yrs ago—severe HAsopioids(1 mo.)
Neuro and Pain Specialist—ran out of meds 1
week early? Inpatient “detox”--?work
Current meds. Oxy CR 30mg tid
OxyIR 5mg qid(NSAID, ondansetron,
prednisone, venlafaxine, topiramate)
CT 2010 Case
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Age 17—appendectomy—1st opioid— “felt
good,” “took away my insecurities”
Subsequent heroin--- “energized”
Sobbing and Crying at mention of mother who
died 9 mos ago at age 93
Felt she was a terrible disappointment to mother
Saw therapist on and off for many years—
currently not in psychotherapy
Diagnosis and Plan After Initial
Consultation
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Opioid Physical Dependence
Pain Paradigm
Husband to Dispense Opioids
Attempt to taper opioids
Rx Oxy CR 30mg—attempt bid
One week later 1.Oxy CR bid 2. D/C
venlafaxine, start duloxetine 3. Oxy IR 5 q6h
prn
3 Weeks later
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Headaches have markedly increased while on
vacation—husband not in agreement on chronic
opioid paradigm
Neurologist adds gabapentin 300mg tid and
topiramate(now 100mg.qd)
Continued attempts to taper opioids not
successful
4 Weeks Later
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Husband no longer coming in with patient
Headaches daily—making work and home
difficult
After long discussion, OXY CR d/c’d and
methadone low dose started and titrated
upwards
After 7 months
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Stable methadone dose 30mg tid
Infrequent short acting opioids
Significant improvement in headache frequency,
severity,
Improved function at work
Stopped therapy, and refuses new therapy
Marital issues difficult to discuss
All urines, pill counts, appts., etc reveal no
problematic behavior
Overall patient rating 93(as of 4/13/10)
April 2010Present
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June 2010—2 Rxs given for methadone
October 2010---Short Acting Opioids D/C’d
October 2010---Methadone  30mg bid
Headaches present, but  intensity/frequency
Stigma issue around methadone continues
Marital issue, no psychosocial
Random urines negative
NEUROLOGY 2004;62:1687-1694
160 enrolled 70 remained on daily scheduled opioids X 4 yrs 74% LA, 26% SA
41(59%) Responders by 50% in SHI—freq x duration severe headache/week
Figure 1. Medical record versus visual analog scale: mean percentage improvement in
year 3 or 4 of daily scheduled opioids (year 4 for patients in program for 4 years or more)
Saper, J. R. et al. Neurology 2004;62:1687-1694
Figure 2. Problem drug-related behavior: patients with any incident of problem opioid
behavior over 4 years of daily scheduled opioids
Saper, J. R. et al. Neurology 2004;62:1687-1694
Dose Violation most common
Most problems not “severe”
Chronic
Pain
S
U
B
S
E
T
Addiction
 Hedonic Tone
Somatic Sxs
OPIOIDS
? Endorphin Deficiency
Pain Medicine
Prescriptions
Pharmacies
Legitimate
Anti-Depressants
Anti-Convulsants
Mood Stabilizers
Addiction Treatment
Methadone Clinics
Regulations
Stigma
Buprenorphine
**
*
*Anterior Cingulate Gyrus
Acc
VTA
GLU
FCX
Amphetamine
Cocaine
Opiates
Cannabinoids
Phencyclidine
Ketamine
HIPP
AMYG
CRF
GLU
5HT
GABA
OPIOID
OPIOID
GABA
GABA
DYN
5HT
ENK
VP
OFT
BNST
Opiates
DA
GABA
NE LC
ABN
HYPOTHAL
ICSS
MesoLimbic Dopaminergic Circuit
Pleasure/Reward Center
H2O, Food, Sex, Parenting, Socializing
NE
LAT-TEG
Opiates
Ethanol
Barbiturates
Benzodiazepines
Nicotine
Cannabinoids
PAG
END
5HT
Raphé
To
dorsal
horn
RETIC
HCC=Healthcare for Communities
1998, 2001
Association of common mental disorders in 1998 with
regular prescription opioid use in 2001: unadjusted odds
ratios with 95% confidence intervals
Sullivan, M. D. et al. Arch Intern Med 2006;166:2087-2093.
Non-Cancer Pain
Copyright restrictions may apply.
Journal of Addictive Diseases, Vol.27(3) 2008
Journal of Addictive Diseases, Vol.27(3) 2008
Problematic (Aberrant) Behaviors
• Probably more predictive
– Selling prescription drugs
– Prescription forgery
– Stealing or borrowing
another patient’s drugs
– Injecting oral formulation
– Obtaining prescription
drugs from non-medical
sources
– Concurrent abuse of
related illicit drugs
– Multiple unsanctioned dose
escalations
– Recurrent prescription
losses
Passik and Portenoy, 1998
• Probably less predictive
– Aggressive complaining
about need for higher
doses
– Drug hoarding during
periods of reduced
symptoms
– Requesting specific drugs
– Acquisition of similar drugs
from other medical sources
– Unsanctioned dose
escalation 1-2 times
– Unapproved use of the
drug to treat another
symptom
– Reporting psychic effects
not intended by the
clinician
The ORT Form-Opioid Risk Tool
Mark each box that applies
1. Family history of substance abuse
Female
Male
Illegal drugs
[ ] 1
[ ] 2
[ ] 3
[ ] 3
Prescription drugs
[ ] 4
[ ] 4
Alcohol
[ ] 3
[ ] 3
Illegal drugs
[ ] 4
[ ] 4
Prescription drugs
[ ] 5
[ ] 5
3. Age (mark box if 16-45)
[ ] 1
[ ] 1
4. History of preadolescent sexual abuse
[ ] 3
[ ] 0
compulsive disorder, bipolar, schizophrenia
[ ] 2
[ ] 2
Depression
[ ] 1
[ ] 1
Alcohol
2. Personal history of substance abuse
5. Psychological disease
Attention deficit disorder, obsessive-
Courtesy of Lynn Webster, M.D.
Total score risk category
Low risk: 0–3
Moderate risk: 4–7
High risk: ≥ 8
Aberrant Behavior Displayed (%)
Validation Study
Results
ORT Total Score Risk Category
100
90.9
80
60
40
28
20
5.6
0
Low
Moderate
High
Webster LR and Webster RM. Predicting aberrant behaviors in opioid-treated patients: validation of
the Opioid Risk Tool. Pain Med. 2005;6:432-442.
Non-Cancer Pain
Russell Portenoy, M.D.
“…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
“MORPHINE IS
GOD’S OWN MEDICINE”
Sir William Osler
ADDICTION/PAIN
TREATMENT
“All Treatments Work For Some
People/Patients”
“No One Treatment Works for All
People/Patients”
Alan I. Leshner, Ph.D
Former Director NIDA
SUPPORT ASAM!!