Transcript Slide 1

Pain and Addiction
Steven M. Benecke, M.D.
Academic Pain Physicians of Colorado Springs
April 18, 2008
Crossroads
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:
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With some is to deny opioids
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Others, to provide access to opioids
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Cross roads!
Pain:
• An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage.
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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
Addiction to prescription
medications is a Brain
disease
Chemical Dependency (Addiction)
1. Compulsion
2. Craving
3. Continued use despite adverse
consequences
4. 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
Addiction to prescribed opioids
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
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NIDA
Add suboxone slide
Factors contributing to Addiction:
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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:
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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 Study
Ives, et al., BMC Health Serv Res.2006
Apr 4;6(1):46
• Anna Nicole Smith
• Patrick Kennedy
Elvis Presley
• 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
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1Coambs
et al. Pain Res Manage.1996;1:155
et al. Pain. 2004;112:65
3Rohsenow et al. .Addict Behav.2005;30:629
4Conner et al. Exp Clin Psychopharmacol. 1999;7:64.
2Butler
Smoking and Aberrant Drug-taking
Behaviors
o Pseudo-addiction (inadequate analgesia)
o Smokers may require higher doses of opioids because of
nicotine-opioid interactions
o Substance use disorders
o Smoking may be a more socially acceptable form of substance
use or a proxy for other forms of substance use
o Chemical coping/self-medication of pain
o Smoking may be a means of self-medication for stressors related
to persistent pain
o 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
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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
What about THC use and opioid
misuse?
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Screening tools:
• To screen for those susceptible to prescription misuse:
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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)
ORT
Webster & Webster, Pain Med. 2005;6:432.
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Family history of substance abuse
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Alcohol
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Illegal drugs
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Prescription drugs
Personal history of substance
abuse
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Alcohol
2.
Illegal drugs
3.
Prescription drugs
Age (mark box if between 16-45)
History of preadolescent sexual
abuse
Psychological disease (ADD, OCD,
bipolar, schizophrenia,
depression
Scoring:
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0-3: low risk (6%)
4-7: moderate risk (28%)
≥8: high risk (>90%)
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Female
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Male
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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
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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:
1. Make a diagnosis with differential
1. Note comorbidites; substance use, psych
2. Assess risk of addiction (screening tool)
3. Establish treatment agreement to include
informed consent
1. Establish expectations and obligations each party
2. Establish Boundaries!
Universal Precautions:
4. Assess level of pain and function before
intervention and each visit
5. Ask what expectations are with respect
to pain and function
6. Initiate trial of opioid therapy with/without
adjuvants
Universal Precautions:
7. Assess 4 A’s of Pain with each visit:
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Analgesia
Activity
Adverse effects
Aberrant Behaviors
Universal Precautions:
8. Each visit, review pain diagnosis, co
morbid conditions, look for addictive
disorders
9. Document!
Treatment, Addiction to prescribed
opioids:
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Buprenorphine
Methadone
Naloxone
Naltrexone
Patch
• Behavioral counselling
Crossroads
Pain and Addiction
Steven M. Benecke, M.D.
Academic Pain Physicians of Colorado Springs
April 18, 2008