Transcript Pain and Addiction: More Than a Feeling

Pain and Addiction:
More Than a Feeling
Walter Ling, MD
Integrated Substance Abuse Programs (ISAP)
UCLA Dept. of Psychiatry
Pacific Southwest ATTC
Tenth Annual Training and Educational Symposium
September 18, 2013
[email protected]
www.uclaisap.org
Pain and Addiction:
Role of the Opioids
• Scope of the talk:
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Addiction: a brain disease
On becoming and staying addicted
Defining pain: acute and chronic pain
Addiction in pain patients: how to tell
Opioids: the two faces of Janus
Opioids in chronic pain
Overcoming addiction and chronic pain
Addiction: A Brain Disease
What, Where, and How
• Our Three Brains
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Reptilian brain: Survival--feeding, fighting, fleeing, reproducing
• Limbic brain: memory and emotion—love, attachment, consideration for
others, foundation for community and civilization
• Cortical brain: CEO and operating system--intelligence, intuition, insight
flexibility, speed, efficiency, creativity, morality, free will, meaningful life, uniquely
human, under construction
Addiction: Why Do People Take Drugs?
People Take Drugs To:
Dopamine
Feel Good (Sensation seeking)
Feel Better (Self medication)
One way or the other they like what
drugs do to their brain
DA
DOPAC
HVA
200
100
0
250
150
Accumbens200
Caudate
150
100
100
200
0
0 1 2 3 4 5 hr
Time After Cocaine
250Accumbens
0 1 2 3 hr
Time After Nicotine
0
Dose
(mg/k
0.5
g)1.0
2.5
10
0 1 2 3 4 5hr
Time After Morphine
AMPHETAMINE
1100
1000
900
800
700
600
500
400
300
200
100
0
% of Basal Release
300
NICOTINE
% of Basal Release
% of Basal Release
400 Accumbens
MORPHINE
% of Basal Release
COCAINE
0
1
2
3
4 5 hr
Time After Amphetamine
Dopamine
Dopamine: the brain’s motivational or “feel good”
chemical. It makes us want to do it again—to repeat what
activates its release
Dopamine is also involved in reward-driven learning and
memory: conditioning
Conditioned Response: Reward Driven
Learning, Memory and Behavior
1849-1936
Pavlov’s Dog
Conditioned learning incorporates the
drug use environment into drug use
memories and adds weight –salience—to
these memories, giving them higher
priority in driving drug use behavior
until it takes over everything.
How the Brain Got Its Addiction
• You begin with a normal brain and subject it to repeated
exposures to drugs: dopamine spikes
• Repeated reward-driven, salient, learning experiences
became encoded as enduring conscious and
unconscious memories.
• The reward-driven salient drug use memories gain
higher and higher priority in driving drug use behaviors
until they take over everything—extreme take over.
• This is how the brain got its disease of addiction.
Disconnection between the limbic
and cortical brain, an extreme
take over brain disease
“First the man takes a drink,
then the drink takes a drink,
then the drinks takes the man”.
Japanese proverb
Becoming and Staying Addicted:
A Matter of Drugs and Memory
• Becoming addicted is a matter of drugs
• Staying addicted is a matter of memory
• The problem of addiction is not getting off drugs; it’s
staying off drugs.
• Detoxification may be good for a lot of things, but
staying off drugs is not one of them
• To stay off drugs—relapse prevention—you have to
deal with drug memories: no memory, no relapse
• Relapse prevention means substituting drug
memories with non-drug memories.
Defining Pain
• Pain: An unpleasant sensory and emotional experience
arising from actual or potential tissue damage or described
in terms of such damage.
• It is always subjective. Each individual learns the
application of the word through experiences related to
injury in early life.—IASP
IASP = International Association for the Study of Pain
Early life -- historical
Subjective--private
Experience--learned
Individual--unique
Acute vs Chronic Pain:
Acute Pain
• Physiological; protective
• Causes external; obvious
• Tissue damage; resolution
expected within days/wks
• Symptom of illness
• Happens TO you
• Key issue: what pain?
• Meds/big role vs self
Chronic Pain
• Pathological; non-protective
• Causes internal; obscured
• CNS changes; resolution depends
on mastery/control
• Disease & way of life
• Happens IN you
• Key issue: what patient?
• Meds/limited role vs self
The Acute pain patient is afflicted; the Chronic patient is
transformed. Chronic pain sufferer suffers for nothing
When Pain Becomes Chronic
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The one certain thing: treatment didn’t work
Patient frustrated and lost faith in doctors
Patient blamed for not getting better
Lost “role”; becomes dependent on others
Others must pick up slack and provide support
Patient feels neglected when
others can’t do all
• Patient becomes anxious,
angry and depressed
• Patient assumes life style of chronic pain
Defining Addiction in Pain Patients
• Addiction….is characterized by behavior that includes
one or more of the following: impaired Control over
drug use, Compulsive use, Continued use despite harm,
and Craving AAPM/APS/ASAM
• Addiction is not taking lots of drugs; it’s taking drugs
and acting like an addict.
• Addicts are addicts not for who they are, but for what
they do.
Who’s at Risk and How to Tell?
• 4 Ways to identify patients at risk
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History—personal history and family history
Screening instruments
Behavioral checklists
Therapeutic maneuver
History
• What predicts addiction?
– Personal history of drug use
– Family history of drug use
– Current addiction to alcohol or cigarettes
– History of problems with prescriptions
– Co-morbid psychiatric disorders
– Same predictors as in non-pain patients
Screening Instruments
• Several clinical tools are available that estimate risk of
noncompliant opioid use1,2,3
• The results determine how closely a patient should be
monitored during the course of opioid therapy3
– Scores implying a high risk of misuse are not reasons to
deny pain relief3
1 Webster, et alr. Pain Med. 2005;6:432.
2 Coambs, et al. Pain Res Manage. 1996;1:155.
3 Butler, et al. Pain. 2004;112:65.
Opioid Risk Tool (ORT)
Mark each box that applies:
1.
2.
Female
Male
Family history of substance abuse
Alcohol
1
3
Illegal drugs
2
3
Prescription drugs
4
4
Alcohol
3
3
Illegal drugs
4
4
Prescription drugs
5
5
Personal history of substance abuse
Administration
• On initial visit
• Prior to opioid therapy
Scoring
3.
Age (mark box if between 16-45 years)
1
1
4.
History of preadolescent sexual abuse
3
0
• 0-3: low risk (6%)
5.
Psychological disease
ADO, OCD, bipolar, schizophrenia
2
2
• 4-7: moderate risk (28%)
Depression
1
1
Scoring totals:
Webster, et al. Pain Med. 2005;6:432.
• > 8: high risk (> 90%)
Screener and Opioid Assessment for
Patients in Pain (SOAPP)
• 14-item, self-administered form, capturing the primary
determinants of aberrant drug-related behavior
– Validated over a 6-month period in 175 chronic pain patients
– Adequate sensitivity and selectivity
– May not be representative of all patient groups
• A score of ≥ 7 identifies 91% of patients who are high
risk
Butler, et al. Pain. 2004;112:65.
SOAPP® V.1 – 24Q
Butler S et al, Pain, 2005
Aberrant Drug-Taking 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 dose
– 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
Patients Exhibiting Behaviors
(%)
Aberrant Behaviors in
Cancer and AIDS
70
60
50
40
Cancer
AIDS
30
20
10
0
0
1 to 2
3 to 4
5 or more
Number of Behaviors Reported
Passik et al. 2003
Probability of positive urine toxicology by
number of aberrant behaviors
Higher prevalence of SUD among pts on opioids for chronic pain than
general population (8.1% current users)
45
40
35
30
25
%
20
15
10
5
0
0
1
2 or more Overall
No. of aberrant behaviors
Katz N et al, Clin J Pain, 2002
Therapeutic Maneuver:
Is the Pain Patient Addicted?
Drug-seeking or increased requests for pain medication
 Pathology/pain of new source
Detailed pain work-up
No new pain pathology
 Opioid dose
Unimproved functioning
Improved functioning
Presence of toxicity
Absence of toxicity
Addictive disease
Pseudoaddiction
Therapeutic
dependence
Opioids in Chronic Pain:
The Two Faces of Janus
Opioids:
• Relieve pain
• Relieve suffering
• Relieve misery
• Make you feel better
• Make you feel good
• Make you “high”
Use of Opioids for Chronic Pain
Treating Pain with Opioids:
What Can We Expect to Achieve?
• Reduction in pain and suffering
– Meaningful pain reduction (Analgesia; Pain)
– Acceptable side effects (Adverse effects; Price)
• Improved functionality
– Meaningful functional improvement (Activities;
Performance)
– No unacceptable aberrant behavior (Aberrant behavior;
“Pees”
The 4 A’s (Passik); the 4 “P’s”
Meaningful Pain Reduction
• Using a VAS or Numeric scale of 0-10
– (4-6= mod pain; 7-10= severe pain)
• For Moderate pain ( mean=6)
– Meaningful reduction=2.4 (40%)
– Very much better=3.5 (45%)
• For Severe pain (mean=8)
– Meaningful reduction=4.0 (50%)
– Very much better=5.2 (56%)
M. Soledad Cepeda et al.
Proc 10th world Cong on Pain vol 24; pp 601-609 IASP
press 2003
Meaningful Functional Improvement:
My Favorites
• Patient perspective of “improvement”
– Used to do, can’t do now, would like to do again
– Could be physical, social, recreational
– With friends, family, church
• Achievable, enjoyable, and meaningful
– Hobbies
– Volunteer work
Chronic Pain and
Suffering: Some Basics
• Chronic pain hurts, but seldom harms
• Chronic pain patients are not bothered by pain; they are plagued by
suffering.
• Pain happens to you, suffering happens in you.
• Pain is the enemy outside; suffering is the demon within.
• Pain is inevitable and universal, suffering is optional and individual
• Pain can be likened to how much money you owe; suffering is how
poor you feel.
• Suffering cannot be cured, it can only be conquered and mastered.
Chronic Pain and Addiction:
Memory Matters
• Characterized by aberrant behaviors that persist despite their
being destructive and detrimental to one’s best interest.
• Behaviors are based on a distorted belief system rooted in deeply
ingrained learning and memory of past experiences.
• Both involve brain changes that result in the hyperexcitability of a
lower brain and loss of control from a higher rational brain
• Neither can be gotten rid of but must be overcome with new and
different reward-driven learning life experiences creating a new
memory bank and a new belief system and new behaviors.
• We are all created equal, but we don’t sit down at the table with
the same hand; hence, different clinical expressions.
Chronic Pain and Addiction:
Common Overlapping Features
• Chronic pain
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Early trauma
Loss of mastery
Loss of control
Loss of sense of self
Cognitive error
“Personalization”
Over interpretation
“Catastrophization”
• Addiction
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Early trauma
Loss of mastery
Loss of control
Loss of self-efficacy
Cognitive error
“Nirvana”
Denial
Overcoming Chronic Pain
• The sufferer of chronic pain is permanently
preoccupied by it and suffers as a result.
• Overcoming chronic pain means learning to
overcome suffering, no matter what happens.
• Be prepared physically and emotionally
• Actually engage in the act and take charge
• Reconnect and become engaged with friends and
family and community
• Regain a meaningful balanced life
How Not to Succeed
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1. Don’t attend
2. Try not to learn anything
3. Don’t do any of the exercises
4. Don’t try any of the techniques
5. Keep a closed mind
6. Resist change
7. Look and act miserable
8. Tell yourself “nothing will help me”
9. Remain very serious and never smile
10. Don’t share anything
(R. N. Jamison)
Relapse: A Three-Character Play
• Drug memories: …everything, seems to bring
memories of you…(Eubie Blake)
• Cues and triggers: external and internal; craving
and desire for love lost—regression & comfort
• Emotional buildup: justification for use—the
internal dialogue making use okay and natural
• Relapse does not happen by accident.
Treating Chronic Pain and
Relapse Prevention: Forget It?
• Addiction is memory; so is chronic pain
• No memory, no relapse; no memory, no suffering
• Both are brains transformed—cannot be gotten rid of, can
only be conquered and controlled
• Both require memory substitution
• Behavior creates experience, experience creates memory,
memory creates belief systems, belief systems determine
new behavior, new behavior determines new outcome.
• Change your memory, change your brain, change your
brain, change your life.
• The only way to have your life turn out different is to act
differently.
Creating Non-Drug Memories:
The Old Fashion Way
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Experience–activities—leads to protein synthesis
Protein synthesis activates new gene expressions
Gene expressions create new brain connections
New brain connections produce new memories
New non-drug memories create non-drug belief
systems that determine behaviors that determine
how life turns out.
• The only way to change your life is to do things
differently so they will turn out different.
Preventing Relapse:
Eight Steps to a Drug-Free Life
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Sound physical health
Sound mental health
Stay off drugs and stay busy
Take care of business: out of jail and on the job
Take personal responsibilities
Live in harmony with family and friends
Be a good member of the community
• Search for a meaning in life.
Spirituality, Mindfulness, and a
Meaningful Life
In a Nutshell
• Mindfulness of motivation: Doing good for
someone else is better than feeling good
yourself; it’s the true path to happiness.
• Mindfulness of wisdom: Conventional
reality is an illusion; Inherent reality is
emptiness. All things follow the laws of
impermanence and non-self. Nothing lasts
forever, nothing can be possessed, and you
can’t take anything with you.
What Are We? Unique or Random?
Thank you
Thank you
Thank you