Transcript Pain and Prescription Drug Abuse

COMPETING EPIDEMICS:
PAIN AND PRESCRIPTION DRUG ABUSE
Brian A. Rosenberg, MD
Interventional Pain Mgmt
Bone & Joint – Wausau, WI
DISCLOSURES
“We must all die. But
that I can save a
person from days of
torture that is what I
feel is my great and
ever-new privilege.
Pain is a more terrible
lord of mankind than
even death itself.”
Albert Schweitzer,
Theologian/Medical Missionary
AGENDA
• Definitions
• Epidemiology of Rx Abuse
• Impact of Rx Abuse
• Contributing Factors to Rx Abuse
• Reducing Rx Abuse
Pain
Words Can Hurt
DEFINITIONS
PAIN
• “Pain is whatever the patient says it is,
existing whenever he says it does.”
- (McCaffery, 1979)
!!!PAIN!!!
www.chucknorrisfacts.com
PAIN
• “An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.”
- IASP
PAIN
• Consistent pain assessment tools (VAS, 5 th vital sign)
• Include patient report
MEASURING PAIN
=
THE FACE OF PAIN
ADDICTION
ADDICTION?
“I know an addict when I
see one…”
• A maladaptive pattern of drug use marked
by tolerance and a drug class-specific
withdrawal syndrome that can be produced
by abrupt cessation, rapid dose reduction,
decreasing blood levels of drug, or
administration of an antagonist.
DEPENDENCE
DEPENDENCE
DEPENDENCE
DEPENDENCE
• A state of adaptation in which exposure to
a drug induces changes that result in
diminution of one or more of the drug’s
effects over time.
TOLERANCE
TOLERANCE
ADDICTION
• A chronic biopsychosocial disease
characterized by impaired control over drug
use, compulsive use, continued use
despite harm and craving.
ADDICTION
PSEUDOADDICTION
• A drug-seeking behavior that simulates true addiction, which
occurs in patients with pain who are receiving inadequate pain
control.
PSEUDOADDICTION
• Undertreated pain condition
• Patient exhibits seeking behavior
• These behaviors extinguish with therapeutic doses
OLIGOANALGESIA
• Inadequate pain management
• “There is oligo-evidence for
oligoanalgesia.”
• Green SM, Ann Emerg Med.
2013;
PLACEBO
• Latin for “I shall please.”
• Any therapy that is intentionally or
knowingly used for its nonspecific,
psychological or psychophysiological,
therapeutic effect, or that is used for
a presumed specific therapeutic
effect on a patient, symptom, or
illness but is without specific activity
for the condition being treated.
NOCEBO
• Latin for "I shall harm”
• A harmless substance that creates harmful effects in a patient
who takes it.
PSYCHOGENIC VS.
PSYCHOSOMATIC
Psychogenic
• Pain not due to an
identifiable, somatic origin
and that may reflect
psychologic factors.
Psychosomatic
• Of or pertaining to a
physical disorder that is
caused by or notably
influenced by emotional
factors.
C.O.A.T.
Chronic Opioid Analgesic Therapy
Diversion
• Medications prescribed
end up out of the
patient’s possession
• Lost
• Stolen
• Shared
• Sold
USER VS ABUSER
User
•
Takes to treat illness
• Improved quality of life
• Control – Cooperates with
prescriber, abuser controls
his own regimen
• Pattern –stable and does
not include nonmedical
drugs
Abuser
• Uses for recreation (often in
conjunction with other
nonmedical drugs)
• Consequences,
deteriorated quality of life
• Controls own regimen
• Unstable, typically with
polydrug abuse and
excessive alcohol
IDENTIFYING THE ABUSER
CONSEQUENCES OF INADEQUATE
ANALGESIA
• Unnecessary suffering
• Delayed healing
• Functional disability
• Increased length of hospitalization
• Increased medical cost to patient and society
• Inadequate pain management as a “medical error.”
McNeill et al., J of Pain and Symptoms Management. 2004;
PROBLEMS WITH C.O.A.T.
• Cognitive effects
• Sleep/Resp Disorders
• Gastrointestinal Effects
• Endocrine Effects
• Cardiac Effects
• Opioid hyperalgesia and
pronociceptive effects
COGNITIVE EFFECTS
• Memory Deficits/Poor concentration
• Sleep Disturbance
• Fatigue
• Delirium
• Decreased alertness/Coma
• Emotional distress/Mood disturbance
GASTROINTESTINAL EFFECTS
• Nausea/Vomiting
• Anorexia and Weight Loss
• Opioid Induced Constipation
• Not responsive to conventional laxatives in half of patients
• Can lead to bowel obstruction
ENDOCRINE EFFECTS
• Decreased testosterone, progesterone, estradiol – decreased
libido
• Amenorrhea
• Reduced cortisol response to stress
• Breast pain/gynecomastia
• Hair loss
• Infertility
• Low bone density
• Hot flushes/sweating
• Reduced muscle mass
CARDIAC EFFECTS
• Bradycardia
• Vasodilation
• Edema
• Hypotension
• Syncope
• Some (methadone and buprenorphine) prolong QTc causing
arrhythmia
• Above effects are magnified when combined with other
medications (benzos)
• Same nature as dependence and tolerance
• Increase in pain receptor/Opioid receptor desensitization
• Increased spinal dynorphin, descending central facilitation, and
activation of pronociceptive glutamate
Rx Drug Abuse
EPIDEMIOLOGY
EPIDEMIOLOGY
• Prescriptions for opioid medications have increased
annually since 1990
• Evolving attitudes toward opioids for chronic pain
• Increasing prevalence of chronic pain in aging
population
• Prevalence of prescription abuse increasing faster
than medical use
EPIDEMIOLOGY
• Decline in use of some illicit drugs in US while
Rx abuse increases
• Misconception that prescription drugs are
safe
• Relatively cheap
• Widely available
EPIDEMIOLOGY
• Street value of controlled drugs comparable to cocaine,
greater than heroin and MJ
• Increasing demand
• Increase production of counterfeit drugs
• Internet has expanded global market
• Over 300 sites on web search for “no prescription” sites
EPIDEMIOLOGY
• 1992 – 7.8 million persons in US used prescription
medication for nonmedical reasons
• 2003 – 15.1 million
• 2006 – More Americans used Rx drugs nonmedically than
used cocaine, heroin, hallucinogens, ecstasy and inhalants
combined
• Rx drugs second only to cannabis in frequency of use
EPIDEMIOLOGY
• Lifetime incidence of nonmedical use of Rx meds:
• Pain Relievers = 13%
• Tranquilizers = 9%
• Sedatives = 4%
EPIDEMIOLOGY
• 2005 student survey (compared to 1995)
• Much less illicit drug use (33% lower in 8 th, 10% lower in
12th)
• Nonmedical Rx use much higher
• 7.2% high school seniors used sedatives
• 5.5% used oxycodone products
• Obtained from friends and parents, often from physicians
EPIDEMIOLOGY
• 2004 physician survey
• Found 43% physicians don’t
routinely ask about drug
abuse (except alcohol)
• 1/3 did not obtain patient’s
previous records before
Rxing controlled meds
IMPACT
IMPACT
• Dramatic increase in number of
ED visits for accidental overdose
• Increase in admissions to
addiction programs for Rx
opiates
• Most pronounced in rural states
IMPACT
• Increased scrutiny of prescriptions
for controlled drugs
• Increasing public health attention
• Laws internationally have now been
written restricting certain agents to
“appropriate diagnoses” and within
the context of “appropriate medical
care”
• Regulations in place to identify
shoppers
• Produces new barriers to clinicians
IMPACT
• Clinicians now undertreating anxiety disorders,
attention deficit/hyperactivity disorder and
chronic pain
• Substantial amount of controlled meds are
prescribed appropriately, but used
inappropriately, given away or sold
• Now exists an “imbalance in controlled drug
prescribing”
• Simultaneous over- and under-prescribing
• Debate between expanding or limiting
access
CONTRIBUTING FACTORS
TO ABUSE
CONTRIBUTING FACTORS TO ABUSE
• Drug
• Patient
• Clinician
BLAME THE DRUG
• Brain rewarding (Not “Brain affecting”)
• Formerly withdrawal suspected to be correlated
BLAME THE DRUG
Four major classes:
Stimulants
Cocaine, methamphetamine, nicotine, caffeine, Rx’d stimulants
Sedative-hypnotics
EtOH, Benzos, Barbiturates, other hypnotics
Opioids
Heroin, Rx Opioids
“Other”
Psychedelics, dissociative anesthetics, cannabinoids, hallucinogens
BLAME THE DRUG
• Drugs in 4 classes provoke acute dopamine release from
ventral tegmental area and nucleus accumbens (midbrain) to
the forebrain
• Dopamine surge = brain reward
• Higher dopamine surge, greater addiction risk
• Street value determined by:
• Rapid onset
• Magnitude of dopamine surge
• Route of administration
• Purity
• Trade name
BLAME THE DRUG
• Availability also yields higher abuse potential
• Clinicians more willing to prescribe Sch.III (Now
Tramadol, formerly Hydrocodone)
• Oxycodone Rx’s increased dramatically in late
90’s
• Internet sales contribute to abuse
• Law enforcement closing US internet pharmacies,
sanctioning MD’s
• Offshore pharmacies have increased delivering
substandard manufacture, inconsistent potency
and even counterfeit drugs
BLAME THE PATIENT
• Quantitative and qualitative variation of dopamine surge with
drug use between patients
• Individuals susceptible to addiction have ‘abnormal’ brain
response/reward creating persistent craving
• Leads to escalation in dose/frequency despite consequences
• Global dysfunction develops due to inability to prioritize
pathologic relationship with drug vs. interpersonal
relationships
BLAME THE PATIENT
• Patients vulnerable to addiction usually have succumbed to
addiction to EtOH, tobacco or marijuana in late
adolescence/early adulthood
• Prescription for a drug does not CAUSE addiction, but it can
complicate a pre-existing addiction
BLAME THE PATIENT
• Risk factors for addiction:
• Current addiction or history of substance abuse
• Nonmedical use of controlled substances (non-Rx’d routes)
• Use of controlled substances for wrong reasons (e.g. sleep)
• Younger age
• Patients who work in health care
• When they lose control, supply runs short:
• Pressure the clinician for more
• Pressure the clinician/pharmacist for early refills
• Seek additional sources
• DISHONESTY is a hallmark of addiction
BLAME THE PATIENT
• Those not vulnerable to addiction
will not experience brain reward and
will not misuse Rx’d meds
• Patients and caretakers have
disproportionate fear of addiction,
however, leading to under-treatment
• When prescribed ‘addictive’ drugs
on long-term basis, physical
dependence develops, but
behavioral criteria for addiction are
not met
BLAME THE CLINICIAN
• One of principal reasons for adverse action
against physicians is “inappropriate or
excessive prescribing of controlled drugs”
• Most lack formal training in diagnosis and
treatment of acute, chronic and malignant
pain as well as anxiety, depression,
insomnia and addiction
• Clinicians report discomfort in managing
these conditions
• Clinicians fail to recognize aberrant
behavior in their patients
BLAME THE CLINICIAN
• The Six D’s
• Dated – lack up-to-date knowledge
• Deceived – Misled by patients
• Distracted – Time pressured
• Defiant – Overestimate their expertise
• Disabled – Have personal problems (Psych, medical,
substance)
• Dishonest – Prescribe for other than legitimate purposes
($$$)
• Add’l factors are pathological enabling and confrontation
phobia
BLAME THE CLINICIAN
• Prescribing prior to obtaining complete record
• Concomitantly prescribing multiple controlled
drugs
• Prescribing for extended periods of time
without reevaluating indications
• Lack of monitoring to detect other substance
abuse
• Failure to communicate with colleagues
• Continued prescribing despite aberrant
behaviors
RISE OF THE RX
• Rx opiate deaths surpass heroin and
cocaine combined
- CDC, 2011;
RISE OF THE RX
• Among oxycontin addicts, 78% had never been prescribed the
drug, and 78% had been treated for prior addiction.
• 86% used the drug to get “high or buzzed.”
- Carise D, Am J Psychiatry. 2007;
REDUCING ABUSE
REDUCING ABUSE
The US government is:
•
Tracking prescription drug overdose trends to better understand the epidemic.
•
Educating health care providers and the public about prescription drug abuse and overdose.
•
Developing, evaluating and promoting programs and policies shown to prevent and treat prescription
drug abuse and overdose, while making sure patients have access to safe, effective pain treatment.
STATES CAN:
•
Start or improve prescription drug monitoring programs (PDMPs), which are electronic databases that
track all prescriptions for painkillers in the state.
•
Use PDMP, Medicaid, and workers’ compensation data to identify improper prescribing of painkillers.
•
Set up programs for Medicaid, workers’ compensation programs, and state-run health plans that
identify and address improper patient use of painkillers.
•
Pass, enforce and evaluate pill mill, doctor shopping and other laws to reduce prescription painkiller
abuse.
•
Encourage professional licensing boards to take action against inappropriate prescribing.
•
Increase access to substance abuse treatment.
REDUCING ABUSE
REDUCING ABUSE – BETTER
DRUGS
• Lower risk of addiction
• Pain relief without dopamine
surge
• Lower risk of abuse
• Abuse deterrents
• Lower risk of diversion
• Lower quantity
• Injectables
REDUCING ABUSE – BETTER DRUGS
• Controlled-release slows entry into
brain, reduces abuse
• Prodrugs produce slower onset of
action, less activated if not taken orally
• Compounding drug with antagonist
activated by quantity (atropine) or
nonmedical route (naloxone)
REDUCING ABUSE - BETTER PATIENTS
• Education
• Reasonable goals
• Alternatives
• Accountability
REDUCING ABUSE – BETTER PATIENTS
• Education of staff in their
role as patient advocates
• Educate PATIENT in role
as patient advocate
• Educate
FAMILIES/FRIENDS in
role as patient advocate
PATIENT WITH HISTORY OF ADDICTION
• Risk of relapse depends on class of drug to be
used, patient’s drug of choice
• Former alcoholics have moderate risk for
opioid or stimulant addiction, but high risk for
sedative/hypnotic abuse
• Former opiate addicts are at high risk for
opioid analgesics, especially if used for long
periods of time
• In absence of urgency, pain/addiction consultation
is warranted
DRUG SEEKING
• Early requests for refills- urgent unscheduled visits late in the
day, lost/stolen Rx’s and pills, pharmacist shorted count
• Multisourcing – Recruiting surrogates, multiple
physicians/pharmacies, internet or illicit dealers
• Intoxicated behavior – Slurred or disinhibited calls,
presenting under the influence, frequent ER visits for falls,
trauma or accidental overdose
• Pressuring behaviors – begging, excessive compliments,
breaching boundaries, solicitous implications, vague or overt
threats to harm self or others
DEALING WITH DRUG ABUSING PATIENT
• Working with the patient and family
• Referral to an addiction expert
• Placement in a formal addiction treatment program
• Long term participation in a 12 step mutual help program
• Follow up of medical and psychiatric problems
DEALING WITH DRUG ABUSING PATIENT
• Immediate cessation of prescription if:
• Unsafe, out of control behaviors
• Altering or selling
• Overdose (Accidental or otherwise)
• Bingeing
• Doctor shopping
• Threatening staff
CESSATION OF TREATMENT
• Cease prescribing
• Indicate that continued prescribing is not clinically
supportable
• Urge the patient to accept referral for medically supervised
withdrawal
• Educate patient about signs and symptoms of withdrawal
• Urge patient to report to ED if symptoms occur
CESSATION OF TREATMENT - CONTROVERSY
• Supplying an abusing patient with a supply of drugs
• Illegal?
• Medically inadvisable?
• May actually defer patient’s acceptance of need for
treatment
• Believing your patient
• Desire to quit may be genuine
• Patient’s expression of intent to quit may be ruse
• Should nevertheless be referred to an addiction specialist
ETHICAL CONSIDERATIONS
• Clinician/patient relationship – TRUST
• Patient autonomy vs. Clinician Beneficence
• Informed consent and patient’s right to know
• Obligations to relieve suffering when possible
• “Do No Harm” (non-malfeasance)
• Patient abandonment and obligation to treat
BETTER CLINICIANS
BETTER CLINICIANS
ALTERNATIVE THERAPIES
Medications
Alternatives
• TCA’s
• Acupuncture
• Na Channel Blockers
• Injections (Facet, ESI, etc…)
• Ca Channel Blockers
• Muscle Relaxers
• Physical/Occupational
Therapy
• NSAIDS
• Hypnosis
• Antidepressants
• Counseling
• Anticonvulsants
• Guided Imagery
• Topicals (Lidocaine, Menthol,
Capsaicin)
• TENS unit
• Potentiation
• Neuromodulation (SCS)
RESPONSIBLE PRESCRIBING
REDUCING ABUSE – BETTER CLINICIANS
• Opiate agreements
• Urine drug screens
• Pill counts
• Board of Pharmacy Prescription Monitoring Program (BOP/PMP)
OPIATE AGREEMENT: “PAIN CONTRACT”
• Rx to be obtained from a single clinician and
single pharmacy when possible (Identify each in
the agreement)
• Take only as prescribed with limited latitude
• Patients are responsible for arranging refills
during regular office hours
• Patient will stop all other controlled medications
unless instructed to continue
• Terms for violations indicating that prescribing
may be stopped leading to gradual or abrupt
discontinuation of therapy if it is deemed unsafe
to continue
THE NEW PATIENT
• Patient assessment
• Careful drug selection
• Clear communication of treatment plan
• Minimizing potential for Rx alteration
• Monitoring response to treatment
• Maintain clear/accurate records
• Be knowledgeable about legal/regulatory requirements
• In past 6 months have you taken any medications to help you
calm down, keep from getting nervous/upset, raise your
spirits or make you feel better?
• Have you been taking any med to help you sleep? Have you
used EtOH for this purpose?
• Have you ever taken a med to help you with a drug/EtOH
problem?
• Have you ever taken a medication for a nervous stomach?
• Have you taken a medication to give you more energy or to
cut down your appetite?
• Have you ever taken OTC cold preparations other than when
you have a cold? Have you taken OTC diet pills?
THE NEW PATIENT
THE NEW PATIENT
• Also determine who has been providing medical care in past,
what drugs have been prescribed for what indications
• Patient Consent/Agreement should be obtained and
submitted to the record
• In emergency situation, physician should Rx no more than
one day’s supply and arrange for return visit (Photo ID should
be obtained at minimum)
• Limit quantities – only enough to meet patient’s needs until
next appt.
DRUG SELECTION
• Efficacy and Safety come first
• Prior response
• Metabolism and excretion
• Comorbidities
• Likelihood of compliance
• Potential for interaction
• Cost
• Formulary availability
DRUG SELECTION
• Dependence-producing potential of drug
• Is there an alternative?
• Are there effective adjuvants reducing requirement?
• Determination of endpoint
• Relief of symptoms is goal
• Patients differ in tolerance/threshold
• Drug abusers exaggerate/enhance symptoms
• Using multiple psychoactive drugs to achieve complete
relief can be risky
DRUG SELECTION
• Dose
• Based on age, weight, severity of disease, loading dose
and potential interaction
• Timing of Administration
• Bedtime dose to minimize sedative effects
• Formulation and Route
• Patch vs. tablet
• Extended release vs. immediate
COMMUNICATING TREATMENT
PLAN
• Stress that EVERY medication is part of plan
• Monitor for efficacy, safety, compliance, and development of
tolerance and communicate this to patient
• NO treatment program should be left open-ended
• Planned termination minimizes exposure and contains
cost
COMMUNICATING THE TREATMENT PLAN
• Pain Consent
• Risks vs. Benefits
• Ethical and legal obligations
• Potential for dependence and cognitive impairment
• Possible adverse effects from interaction, including EtOH
• Implications of opioids in pregnancy (dependent newborn)
• Informs patient and encourages adherence
• Limits potential for inadvertent or intentional misuse
• Improves efficacy (at least enhances comfort among staff)
PRESCRIPTIONS
• Date
• Name and address of patient
• Name, address and DEA registration of physician
• Number of clinician
• Signature
• Name and quantity of drug
• Directions
• Refill information
PRESCRIPTIONS
• DEA number should not be preprinted
• Forms should be tamper-resistant
• Spelling out quantity limits tampering
• Electronic prescribing with direct transmission to pharmacy
may prevent transcription errors, avert tampering
• Forged Rx’s
• often begins with a legitimate Rx form
• Seekers are on the lookout for blank forms
• May utilize names of retired, departed or deceased
physicians
• Lock Rx pads up, don’t leave them in exam rooms
• Immediately report lost/stolen forms
• Altered Rx’s
• Pen with same color ink
• Numerals easily altered, including refills
• Spelled out can be altered as well
PRESCRIPTIONS
MONITORING THE PATIENT
• Subjective
• Symptom response – Patient log
• Side effects
• Objective
• Signs of intoxication/abuse
• Body weight
• Pulse
• Temp
• BP
• Urine/Serum levels
DOCUMENTATION
• Accurate and up-to-date records
• H&P including history of all controlled drugs, illicit drugs,
allergies, personal/family history of alcoholism/addiction,
major depression or other psych disorder
• Caution with records supplied by patient
• Clearly outline individualized treatment plan and response
• Use of Consultants with written report of consultation
DOCUMENTATION
• Prescription orders, whether written or telephone, should be
charted including explicit instructions
• Informed consent form
• Evidence of monitoring visits (nurse visits)
• Report of outcomes, regardless whether favorable
GOLDEN RULES OF
PRESCRIBING
• Screen for history of abuse before and
during treatment
• Do not provide early refills
• Do not prescribe on chronic basis in face
of diagnostic insecurity – saying no early
is better than later
• Stay within your area of expertise, seek
second opinions
• Discontinue or revise regimen if patient
shows “out-of-control” behavior
GOLDEN RULES OF PRESCRIBING
• Do not prescribe to self, family, friends or colleagues
• Never prescribe without a medical record of doctor/patient
relationship and legitimate medical purpose
• Perform periodic toxicology
• Become familiar with opioid, benzo and stimulant
pharmacology and withdrawal management
• Follow a structured monitoring strategy (Like DM, Anticoag)
• Beware the “heart-sink” patient – screen and screen, refer
CONCLUSION
• Rx abuse is a major and increasing problem
• Stems from 3P’s: Patients, Pills and Providers
• Improving the problem means improving all 3
• Adhere to the golden rules to limit use and abuse
• Educate
Questions?