Transcript McPherson Substance Abuse and Pain Management

Pain Management and
Substance Abuse
Mary Lynn McPherson, Pharm.D., BCPS, CPE
Professor and Vice Chair,
University of Maryland School of Pharmacy
Hospice Consultant Pharmacist
[email protected]
Objectives
• Define abuse and addiction, and describe the
prevalence of each in patients with and without
a history of substance abuse.
• Identify predictors of aberrant drug-related
behavior and addiction in hospice patients.
• Identify strategies to limit drug abuse and
diversion in the home environment, and a plan
for the management of pain in the terminally
ill patient with a history of substance abuse.
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YOU
Are
Here
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www.nancydoran.com/2.html
HCPs are
obligated to provide
optimal palliative
care for their
patients
HCPs – health care providers
HCPs are
obligated not to
prescribe, dispense,
or administer fradulent
prescriptions
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Pain and Chemical Dependency
Definitions
Key Terms and Concepts
• Physical Dependence
• Tolerance
• Aberrant drug-related behavior
• Pseudoaddiction
• Abuse
• Addiction
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Physical Dependence
• Pharmacologic property of some drugs
• Defined solely by the occurrence of an
abstinence syndrome on abrupt dose reduction,
continuation of dosing, or administration of an
antagonist drug.
• NOT a problem if abstinence is avoided
• Should NEVER be labeled “addiction”
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Tolerance
• Declining effect with drug exposure
• Tolerance to side effects is desirable; tolerance
to analgesia may be a problem
• Should NEVER be labeled “addiction”
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Abuse
• Defined as the intentional misuse of a
medication
– For nonprescribed effects such as mood alteration
• Drug use outside of socially accepted norms
– Illicit drugs and aberrant use of prescription drugs
• DMS IV: Psychoactive Substance Abuse
– A maladaptive pattern of drug use that results in
harm or places the individual at risk
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Substance Abuse
• Use of a substance in a manner outside of
sociocultural conventions; according to this
definition, all use of illicit drugs is abuse, as is
use of a licit drug in a manner not dictated by
convention (i.e., according to a physician’s
order).
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Substance Abuse
• Actively using drugs or alcohol
• Actively using drugs or alcohol and on
methadone or buprenorphine
• An ex-user on methadone or buprenoprhine
maintenance
• An ex-user who is drug and alcohol-free
• A recreational or social user (occasional pot or
alcohol)
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Addiction
• Task Force of APS, AAPM and ASAM – new
definition of addiction
– A primary, chronic, neurobiologic disease, with
genetic, psychosocial, and environmental factors,
influencing its development and manifestations.
– It is characterized by behaviors that include onr or
more of the following:
•
•
•
•
Impaired control over drug use
Compulsive use
Continued use despite harm
Craving
J Pain Symptom Management 2003;26:655-667.
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Pseudoaddiction
• “…individuals who have severe, unrelieved
pain may become intensely focused on finding
relief for their pain. Sometimes, such patients
may appear to observers to be preoccupied
with obtaining opioids, but the preoccupation
is with finding relief of pain, rather than using
opioids, per se.”
American Society of Addiction Medicine
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Pseudoaddiction
• Drug-seeking behavior resulting from
inadequate pain management
– Patient may become angry, hostile, mistrustful
– Can be differentiated from abuse when an
increased dose stops the behavior
– Increase dose by 50% and assess behavior
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Other Definitions
• Drug-seeking behaviors
– Directed or concerted efforts on the part of the
patient to obtain opioid medication or to ensure an
adequate medication supply; may be an
appropriate response to inadequately treated pain.
• Therapeutic dependence
– Patients with adequate pain relief may demonstrate
drug-seeking behaviors because they fear not only
the re-emergency of pain but perhaps the
emergence of withdrawal symptoms.
Alford DP et al. Ann Intern Med 2006;144:127-134.
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Differential Diagnosis of Aberrant
Drug-Taking Behavior
• Pseudoaddiction (unrelieved pain)
• Addiction (substance-abuse disorder)
• Other psychiatric disorders
– depression, anxiety
– borderline personality diorder
– organic mental syndrome
• Criminal intent
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Results from the 2008
National Survey on Drug Use
and Health:
National Findings
http://www.oas.samhsa.gov
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Past Month Illicit Drug Use among
Persons Aged 12 or Older: 2008
http://www.oas.samhsa.gov
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Past Month Nonmedical Use of Types of
Psychotherapeutic Drugs among Persons Aged
12 or Older: 2002-2008
http://www.oas.samhsa.gov
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Past Month Nonmedical Use of Types of
Psychotherapeutic Drugs among Persons Aged
12 or Older: 2002-2008
http://www.oas.samhsa.gov
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Past Year Initiates for Specific Illicit Drugs
among Persons Aged 12 or Older: 2008
http://www.oas.samhsa.gov
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NSDUH 2008 Survey Highlights
• Acquisition of pain relievers used
nonmedically in past 12 months:
– 55.9% - from a friend or relative for free
– 18.0% - from one doctor
– 8.9% - bought from a friend
or relative
– 4.3% - drug dealer or stranger
– 0.4% - bought from Internet
http://www.oas.samhsa.gov
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The Devil Made Me Do It!
• 48 year old TV sportscaster
in Baltimore charged with
two counts first degree
burglary
• Victim was a 64 year old
neighbor with cancer
• Caught on video – entering
residence, taking opioid, and
returning to wipe fingerprints
away
• BUSTED!
1-26-06: http://wjz.com/topstories/local_story_025165138.html
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I’ve Got My Eye On You!
Nanny
Cam!
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http://DAWNinfo.samhsa.gov
http://www.samhsa.gov
http://www.oas.samhsa.gov
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Opioid Analgesics – DAWN Data
Drug
Methadone
Hydrocodone/combinations
Oxycodone/combinations
https://dawninfo.samhsa.gov/files/ED2006/DAWN2k6ED.pdf
2004
31,874
41,491
36,559
2006
45,130
57,500
64,888
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Physical dependence
Drug-seeking behavior
Addiction
Tolerance
Pseudoaddiction
Abuse
Therapeutic dependence
Pain and the Addiction Continuum
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Ten Steps of Universal Precautions in
Pain Medicine
1. Make a diagnosis with appropriate
differential
2. Psychological assessment including risk of
addictive disorders
3. Informed consent
4. Treatment agreement
5. Pre- and post-intervention assessment of pain
level and function
Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.
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Ten Steps of Universal Precautions in
Pain Medicine
6. Appropriate trial of opioid therapy +/- adjunctive
medication
7. Reassessment of pain score and level of function
8. Regularly assess the four “A’s” of pain medicine
9. Periodically review pain diagnosis and comorbid
conditions, including addictive disorders
10. Documentation
Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.
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Patient Triage – 3 Groups
•
Group I
–
–
–
–
No past or current history of substance abuse
disorders
Noncontributory family history with respect to
substance use disorders
Lack major or untreated psychopathology
Represents the majority of patients seen in
palliative care
Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.
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Management of Group I
• Apply good principles of pain management
• Use common sense and prudently monitor
patient; recognize lower addiction risk
• Remain alert for substance abuse in the home
(not the patient necessarily)
• Differentiate physical dependence from
addiction
• Don’t mistake pain relief seeking
(pseudoaddiction) for drug-seeking
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Patient Triage – 3 Groups
•
Group II
–
–
–
–
May be a past history of treated substance use
disorder, or a significant family history of
problematic drug use
May have a past or concurrent psychiatric
disorder
Not actively addicted, but are at increased risk
May include patients in recovery (opioid
maintenance)
Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.
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Patient Triage – 3 Groups
•
Group III
–
–
Complex cases due to active substance abuse or
major, untreated psychopathology
Patient are actively addicted and pose significant
risk to both themselves and to practitioners
Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.
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Group IV??
• Drug abuse or diversion in the home (or
workplace)
– Patient suffering consequences of undertreated
pain
– We are obligated to care for the patient, but
analgesics are being diverted
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Aberrant Behavior Less
Suggestive of Addiction
• Aggressive complaining about the need for
more drugs
• Drug hoarding during periods of reduced
symptoms
• Requesting specific drugs
• Opening acquiring similar drugs from other
medical sources
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Aberrant Behavior Less
Suggestive of Addiction
• Unsanctioned dose escalation or other
noncompliance with therapy on one or two
occasions
• Unapproved use of the drug to treat another
symptom
• Reporting psychic effects not intended by the
clinician
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Aberrant Behavior Less
Suggestive of Addiction
• Resistance to a change in therapy associated
with tolerable adverse effects accompanied by
expressions of anxiety related to the return of
severe symptoms.
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Aberrant Behavior More
Suggestive of Addiction
•
•
•
•
•
Selling prescription drugs
Prescription forgery
Stealing or borrowing drugs from others
Injecting oral formulations (or transdermal)
Obtaining prescription drugs from nonmedical
sources
• Concurrent abuse of alcohol or illicit drugs
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Aberrant Behavior More
Suggestive of Addiction
• Multiple dose escalations or other
noncompliance with therapy despite warnings
• Repeatedly seeking prescriptions from other
clinicians or from emergency rooms without
informing prescriber
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Aberrant Behavior More
Suggestive of Addiction
• Evidence of a deterioration in the ability to
function at work, in the family, or socially that
appears to be related to drug use
• Repeated resistance to changes in therapy
despite clear evidence of drug-related diverse
physical or psychological effects
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CAGE-AID
C – have you felt you ought to CUT DOWN on
your drinking or drug use?
A – have people ANNOYED you by criticizing
your drinking or drug use?
G – have you felt bad or GUILTY about your
drinking or drug use?
E – have you ever had a drink or used drugs first
thing in the morning to steady your nerves or
get rid of a hangover (EYE-OPENER)?
AMA. Assessing and treating pain in patients with substance abuse concerns.
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CAGE-AID
# positive responses
Probability of substance
abuse
2
50%
3
75%
4
90%
AMA. Assessing and treating pain in patients with substance abuse concerns.
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Assessment Cues to
Medication Diversion
•
•
•
•
Is the patient specific or vague regarding the pain?
Is there a history of chronic pain?
Is there a condition resulting in chronic pain?
Is the reported pain congruent with the expected
presentation of the condition?
• Are there any accommodations for pain level in daily
life (physical, emotional, spiritual, relationships,
interactions)?
• Can the pain be attributed to something else?
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Assessment Cues to
Medication Diversion
• Does the patient or caregiver appear more interested
in obtaining a specific medication than in alleviating
pain?
• Does the patient or caregiver create barriers to
changing drugs or routes of administration?
• Are the patient or caregiver resistant to adjuvants?
• Has the patient or caregiver ever presented as
overmedicated, sedated, or physically or cognitively
impaired?
• Is there a pattern of weekend or evening calls for
more medication?
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Red Flags - Medications
•
•
•
•
Patient/family unable to find
Dropped on floor (in toilet)
Pharmacy did not dispense enough
Dog/cat/canary (insert animal of choice) ate
medication
• Run out at night/weekends when nurse not
available
• Medications present that team or physician did
not order
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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For all those health care professionals who question whether
patients actually dropped their narcotics down the drain, here is
the first scientific proof that it can happen (all by itself).
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Red Flags – Family/Patient Behavior
• Multiple physicians/pharmacies
• Family members under influence
• Patient/family members have extensive drug
knowledge
• PDR in home
• Patient hoards medication
• Patient protects medications from family
members
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Red Flags – Family/Patient Behavior
• Estranged family members
• Family cannot go to establishments because of
history (e.g., shoplifting at the pharmacy)
• Vague regarding sources of income
• Calls nurse the “narcotics police”
• Uncomfortable with nurse counting
medications
• Requests nurse count medications every visit
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Red Flags - Environment
• Drug paraphernalia present
• Requests to get out of court hearing, jail,
probation/parole requirements
• Camera on doorstep or extensive security
measures
• Bare cupboards, empty refrigerator
• Weapons readily accessible/visible
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Red Flags - Environment
• Aggressive animals (rottweilers or pit bulls) in
house “for protection”
• Large amounts of cash around house
• Minimal furniture, new entertainment
equipment, many pagers/answering machines
• Many roommates, people coming and going
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Red Flags - System
• Physician will not prescribe, or only prescribe
in limited amount, not early, or only if he/she
sees patient
• Copy company calls – “We found a
prescription on a copier with your clinic’s
name on it”
• Patient not allowed in or welcome at the ED
• Other hospices expelled/will not accept patient
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Red Flag – Signs and Symptoms of
Withdrawal
First 24 Hours
• Flu-like syndrome
– Sweating, aches,
chills, runny nose,
tearing, weakness
•
•
•
•
Restless sleep
Restlessness/anxiety
Repetitive yawning
Preoccupation with
drug of choice
24-72 hours
• Increased intensity of previous
symptoms
• Hot and cold flushes
• Severe N, V, D
• Uncontrollable kicking movements
• Fluid and electrolyte imbalances
• Delirium tremens (DTs)
• Seizures
• Twitching and spasms
• Paranoia
• Drug-seeking behavior
Smith-DiJulio K. Care of the chemically impaired. In: EM Varcarolis, ed. Foundations of
Psychiatric and Mental Health Nursing: A Clinical Approach, 2002, 4th ed, pp. 745-782.
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Basic Principles for Prescribing Controlled
Substances to Patients with Advanced Illness and
Issues of Addiction
• Choose an opioid based on around-the-clock dosing
• Choose long-acting agents when possible
• As much as possible, limit or eliminate the use of shortacting or “breakthrough” doses
• Use on-opioid adjuvants when possible and monitor for
compliance with those medications
Kirsh KL, Passik SD. Cancer Investigation 2006;24:425-431.
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Basic Principles for Prescribing Controlled
Substances to Patients with Advanced Illness and
Issues of Addiction
• Use nondrug adjuvants whenever possible (e.g.,
relaxation techniques, distraction, biofeedback, TNS,
communication about thoughts and feelings of pain)
• If necessary, limit the amount of medication given at any
one time (e.g., write prescriptions for a few days’ worth
or a weeks’ worth of medication at a time)
Kirsh KL, Passik SD. Cancer Investigation 2006;24:425-431.
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Basic Principles for Prescribing Controlled
Substances to Patients with Advanced Illness and
Issues of Addiction
• Utilize pill counts and urine toxicology screens as
necessary
• If compliance is suspect or poor, refer to an addictions
specialist
Kirsh KL, Passik SD. Cancer Investigation 2006;24:425-431.
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The 4 “A’s”
• Analgesia
• Activities of daily
living
• Adverse events
• Aberrant
drug-taking
behaviors
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Monitoring Analgesic Therapy
• Subjective Therapeutic
– Pain rating
– Perceived well-being
– Decreased associated
symptoms (e.g., sadness)
• Objective Therapeutic
– Increased sleep time
– Ability to walk 50 feet
– Minimal use of
breakthrough analgesic
• Subjective Toxicity
–
–
–
–
c/o constipation
c/o sleepiness
c/o nausea
c/o itching
• Objective Toxicity
–
–
–
–
BM frequency
# hours sleeping/24 hrs
# episodes of emesis
Excoriation
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Step 1: Problem Identification
• Once the problem is identified, it’s up to the team to
determine:
– Whose problem is it? It is important for the hospice to
understand it may very well be an organizational problem if
the patient and/or family are selling medications the
hospice is providing on the street.
– How is it a problem? Is this a safety, legal, ethical, medical,
or financial problem?
– Who is involved? Is it only the patient, or are the family,
paid caregivers, extended family, friends or even staff also
involved?
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Step 2: Goals and Intervention
Formulation
• Goals and interventions are important for all the team
to formulate. The team should analyze 5 questions to
develop their plan:
–
–
–
–
What are we trying to achieve?
What are all the options?
What are all the limitations or obstacles?
What are the consequences of doing nothing? It may be
more appropriate to leave the situation alone, such as if the
patient is actively dying.
– What are the consequences of possible choices?
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Step 3: Building Interdisciplinary
Coalition
• Communication of the plan with all members of the
interdisciplinary team, especially the patient’s physician,
is crucial to assuring the goals are met and interventions
followed.
• A point person or team leader for plan implementation
should be appointed to assure adequate communication is
maintained among team members.
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Step 4: Offering the Choices
• After goals and interventions have been agreed upon
by all team members, the next step is communicating
the choices to patient/family.
• Do during a family meeting .
• Communicate choices in a nonjudgmental fashion, set
clear limits for how the situation will be handled.
• Negotiation should be minimized; only choices and
consequences offered.
• Four choices should be offered.
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Step 4: Offering the Choices
• Four choices should be offered:
– Managing medication, as prescribed. The patient and
family will adhere to the prescribed regimen, and
medications will be closely monitored by the case manager.
– Use of alternate medications and/or routes.
– Being home without medications and/or hospice.
– Out of home placement with medication and hospice.
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Step 5: Implementing the Choices
and their Consequences
• All hospice staff should be informed of patient/family
decision (including on-call staff and volunteers).
• All relevant external supports or referrals (e.g., PT,
medical supply companies) should also be notified of
the plan to ensure implementation across all
disciplines.
• Anticipate attempts at manipulation and have plan in
place (e.g., no medications will be ordered at night or
on weekends when different staff may be working).
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Step 6: Evaluating the Effects
• Once the plan is in place, it will be possible for the
team to evaluate the effects. There will be certain
outcomes to expect such as:
– Improved accountability for medications
– No further seeking of medications within the system
– Involved parties report satisfaction or decreased concern
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Step 7: Doing it all again if the
choice cannot be maintained
• If patient/family do not comply with the plan, such a lack
of progress must be confronted promptly.
• Consequence to noncompliance would be the next choice
on the list, assuring that:
– No second chances are given
– Original expectations are not altered
– Deadlines are not extended
Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO
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Time of Death
• Destroy remaining
opioids and other drugs
in the home.
– Who OWNS the
medication?
– What if the family
refuses to destroy
remaining medication?
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Bereavement Issues
• Patient had a history of SA
– Bereaved may experience ambivalent feelings
during grief process
– Relief that patient’s behavior will no longer be a
stressor to the family
– Guilt for feeling relief the patient has died
• Bereaved has a history of SA
– Risk for return to destructive behaviors
Dy at al. Caring for patients in an inner-city home hospice: challenges and rewards.
Home Health Care Management and Practice 2003:15(4):291-299.
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http://www.mayohealthcare.com.au/products/homecare_mms_mds.htm
http://www.safehomeproducts.com/shp2/hh/medication_dispenser.asp
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Opioid Count Log
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Opioid Safe Count
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