Transcript Pain vs. Addiction - Centennial Rehabilitation Associates

Centennial Rehabilitation Associates
Chronic Pain Specialists
When is your pain patient addicted?
Richard L. Stieg, M.D., MHS
www.centen.net
www.richardlstiegmd.com
May 16, 2012
Dr. Richard Stieg, MD MHS and
Centennial Rehabilitation Associates
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One of the founders of the field of Pain Medicine and instrumental in training fellows
President of the American Academy of Pain Medicine (1990-present)
President of the Colorado Society of Clinical Neurologists (1979-1980)
President Western USA Pain Society (1983-1984)
Board certified in Neurology and Pain Medicine, holds a Specialty Certificate in Addiction
Medicine
Level II physician with the Colorado Division of Workers' Compensation
Medical Director, Pinnacol Assurance (1994-2001)
Associate Medical Director of Centennial Rehabilitation Associates since 2002
Centennial Rehabilitation Associates provides a multidisciplinary approach to chronic
pain treatment that is unique to Colorado and the surrounding area. Based on the “gold
standard” set by the Colorado Division of Workers’ Compensation, our program is designed
to address both the physical and behavioral components of chronic pain.
Outline
Part I
Definitions and incidence of chronic pain and addiction in America
Dual diagnosis patients: introduction to problems in evaluation and
treatment
Part II
Treatment options
Use of prescription drugs
Standards of care
Buprenorphine and Methadone
Solutions
Chronic Pain
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Any pain which is unremitting or lasts beyond expected
healing time, when associated with disease or injury. May
defy easy explanation.
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The patient usually expresses the problem in terms of an
injured or diseased body part.
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There is now evidence that for some people it is a
chronic disease characterized by physiological changes
in the central nervous system that may be altered by
biological, social and spiritual factors.
Pain Disorder, Chronic (DSM-IV)
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Pain in one or more area, sufficient to need clinical
attention
Pain causes distress or impairment in social, occupational
or other functional areas
Psychological factors playing an important role in the
severity, exacerbation or maintenance of pain
The symptoms are not being intentionally produced or
feigned (as in Malingering)
The pain is not better accounted for by a Mood, Anxiety or
Psychotic disorder
The estimated prevalence of chronic pain in the US is ~70 million
Addiction -- ASAM/AAPM/APS
A primary, chronic, neurobiological disease
with genetic, psychosocial and environmental
factors influencing its development and
manifestations. It is characterized by behaviors
that include one or more of the following:
impaired control over use, compulsive use,
continued use despite harm and craving.
Substance Abuse (DSM-IV )
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A maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by one or more of the following,
occurring within a 12 month period:
- A failure to fulfill major role obligations at work, school
or home (e.g. repeated absences, truancy, child neglect)
- Recurrent use in situations in which it is physically
hazardous (e.g. driving while impaired)
- Recurrent substance-related legal problems
- Continued substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance
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The symptoms have never met the criteria for “Substance
Dependence” for this class of substance
Substance Dependence (DSM-IV)
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A syndrome characterized by a maladaptive pattern of
substance abuse, leading to clinically significant
impairment or distress, as manifested by 3 or more of the
following, occurring in the same 12 month period:
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Withdrawal
Tolerance
Substance is taken in larger amounts or for longer than Rx
Persistent desire or unsuccessful efforts to cut down or
control
A great deal of time spent in activities to obtain substance
Important social, occupational or recreational activities are
given up or reduced because of substance use
Use continues despite the user’s knowledge that he/she has a
persistent or recurrent problem that is caused by or
exacerbated by the substance
Incidence of illicit drug use
from DAWN (Drug Abuse Warning Network) from 1990-2001
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Marijuana: 15,706 - 110,512 (up 604%)
Heroin: 33,884 - 94,804 (up 180%)
Cocaine: 80,000 - 180,000 (up 125%)
Methamphetamine/speed varied between
15,000 - 19,000 (n/c)
Prescription drugs: sedative-hypnotics,
benzodiazepines, narcotics, stimulants
Dual Diagnoses----Who Gets Treatment?
(U.S. Government study)
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18 million have Serious Mental Illness/
4 million with associated alcohol and/or
drug problem
34% mental illness rx only
2% addiction rx
12% dual rx
52% no rx
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20 million need alcohol or drug rx
14% received it
Reasons for inadequate care of pain
patients in the United States
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Inadequate training of healthcare
professionals
Poor public and professional knowledge
Public fear of narcotics
Charlatanism in pain treatment
Few outcomes-based practice standards
Roadblocks to access
FROM THE NATIONAL CENTER FOR
HEALTH STATISTICS
MMWR / August 20,2010 / Vol. 59 / No. 32
Published rates of abuse/addiction in
chronic pain population are ~ 10% (3-18%)
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This suggests that known risk factors for
abuse or addiction in the general population
would be good predictors for problematic
prescription opioid use:
> History of early substance use
> Personal/family history of substance abuse
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> Co-morbid psychiatric disorders
Is the pain “real”?
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Physiological Pain
Non-organic factors contributing to pain
Factitious or malingering?
The use of pain medications to manage
emotions
Tolerance
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Need for more drug for same effect
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Diminished effect with same amount of drug
Withdrawal
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Physiological and psychological consequences
of decreased dose
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Use of substance to avoid withdrawal
Behavioral Indicators of Medication
Use Problems
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Runs out of medications early
Has multiple prescribers
Obtains medications from others
Has difficulty functioning due to over-medication
Watches the clock for next dose
Takes medication for other than pain relief
Gradually increasing dose to manage pain
Poor pain control with medication
Appropriate use of narcotics
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Psychological assessment does not suggest
substance abuse problem
Patient has physiological pain
Patient has a pain disorder
Centennial Rehabilitation Associates
Chronic Pain Specialists
Half-Time Q&A
Addiction and Chronic Pain
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Distinct biological entities
May coexist
Pharmacologic treatment is different
Physical treatment is different
Psychosocial treatment shares some common
elements (e.g. learning to cope, 12-step tx.)
Traditional treatment doesn’t address
both pain and addiction – important to
treat both the pain and the addiction
Who is best qualified to evaluate and
treat dual diagnosis patients?
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There are many good addiction programs:
almost all emphasize abstinence as part of
treatment
The literature strongly supports the use of
multidisciplinary pain programs as the gold
standard, but these have largely disappeared
Today’s pain specialists emphasize
interventional strategies: most have no interest
in treating addiction
There are very few dual programs or
practitioners
The use of prescription drugs in dual
diagnosis patients
This is the major public health issue
How has the problem evolved?
What are the solutions?
Treating the dual diagnosis patient
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Non-pharmacological treatment is the ideal
The ideal is rarely accomplished
The reasons: lack of funding, lack of
specialists, persistent disease (e.g. chronic
pain requiring opioid management or opioid
addiction requiring maintenance)
Presence of psychiatric disease confounding
care
Why use opioids for chronic non-malignant
pain before end-of-life care?
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The drugs may adequately control pain
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They may help to maintain physical and
emotional functionality
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They may be the only treatment available
Important questions about usage
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Who are appropriate candidates for chronic
opioid therapy?
When is it time to remove narcotics?
How should “breakthrough pain” be treated?
What is the “downside” of lifetime use?
How will government regulatory agencies
continue to deal with users and dispensers of
these drugs?
Important questions (continued)
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How many problem drug users are we
creating?
How can we best identify the problem drug
user?
How is problem drug use treated/does it
always require opioid withdrawal?
Is Buprenorphine the “dream medication” for
opioid withdrawal/opioid maintenance?
What do we know about standards of
care in evaluating and treating patients
with drugs that can be abused?
1. Numerous published guidelines by state
medical boards and medical specialty
organizations
2. An abundant literature in peer-reviewed
publications, trade journals and the lay press
about the dangers involved
3. Availability of prescription drug monitoring
programs
Common themes in published
guidelines
1. Careful history and physical exam with attention
to risk factors associated with potential substance
abuse
2. Periodic reassessment of risk factors, drug
efficacy, need for continued use of specific drugs
3. Utilization of less risky treatment when available
4. Proper utilization of specialty consultations
5. Attention to drug interactions, signs of
overdosing, abusing, diverting, use of drug
monitoring programs and urine drug testing
6. Written documentation of drugs dispensed and
all of the standards listed above
Drug Testing
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Should be used to manage care---not to punish
Should be consensual with honest explanation to patient
Provides objective evidence of compliance with a mutually
agreed-upon treatment plan
Aids in diagnosis and treatment of all disorders present
Can be an advocate for patient in family and social issues
Assesses only the presence of a drug class or a particular drug
in a specific concentration at a moment in time
It does not diagnose drug abuse, dependency or addiction
Clinical judgment should dictate use
Buprenorphine
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Binds tightly to the opioid receptor (“high
affinity”)
Long half-life (30 hours)
Partial agonist (70 percent activity)
– Produces little or no euphoria
– Generally has fewer untoward reactions
– Requires special DEA license
Buprenorphine plus Naloxone
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Subutex
Buprenorphine 2 mg or 8 mg
Suboxone
Buprenorphine with Naloxone
2.0mgm/0.5mgm
8.0mgm/2.0mgm
Why use Buprenorphine for Chronic pain?
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Crossover from short acting opioids
Presence of suspected or known opioid
dependency/addiction
Safety profile/ “ceiling effect”
Convenience of administration
Withdrawal usually mild
Analgesia less than morphine
Methadone for the treatment of opioid
addiction and chronic pain
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Only licensed clinics can treat addiction
Any provider can write for pain treatment, but
few have the requisite expertise
An excellent drug for central neuropathic
pain with unique pharmacological properties
Extremely dangerous if used
improperly/rising death rate in the U.S. and
modern countries
Very inexpensive ($30-$40/month for pain tx)
References
1.
2.
Savage,S. Long-term Opioid Therapy:Assessment of Consequences
and Risks. J.Pain and Symptom Management:11(5).274-286, 1996.
Webster,L. & Fine,P. Approaches to Improve Pain While MinimizingOpioid Abuse
Liability. The Journal of Pain: 11(7). 602-611,2010
3.
Becker,WC et al. Nonmedical Use of Opioid Analgesics Obtained Directly From
Physicians: Prevalence and Correlates. Arch.Intern.Med. 171(11). 1034-1036, 2011
4.
Radley Balko. The War Over Prescription Painkillers. http://www.huffingtonpost.com/radleybalko/prescription-painkillers_b_1240722.html?ici...
Institute of Medicine 2011 Report. Relieving Pain in America: A Blueprint for
Transforming Prevention, Care, Education and Resear
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Website References
1.American Pain Society :
www.ampainsoc.org
2.AAPM: www.painmed.org
3.American Chronic Pain
Assoc:http://theacpa.org
4. [email protected]
5.http://www.uspainfoundation.org
Centennial Rehabilitation Associates
Chronic Pain Specialists
Next Webinar
Wednesday, June 20th from 12-1pm (MT)
“Behavioral Interventions with Chronic Pain Patients”
 Presented by Beverly Noyes, PhD
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This program has been submitted to The Commission for Case Manager Certification
for approval to provide board-certified case managers with 1 clock hour.
To register, go to www.centen.net