Transcript Chronic Pain and Prescription Drug Abuse: Intersecting Epidemics

The Linked Epidemics of Prescription
Opioid Abuse and Chronic Pain:
A Call to Action
Marc Fishman MD
Johns Hopkins University Dept of Psychiatry
Maryland Treatment Centers
Baltimore MD
MADC
May 2013
Outline
•
•
•
•
The problem of prescription drug abuse
The problem of chronic pain
The problem of chronic pain management
A more coherent approach to treatment of
chronic pain
• The treatment of co-occurring chronic pain and
addiction
• Speculation about past and future directions in
doctoring
• Therapeutic optimism, and a call to action
The problem of prescription drug
abuse
Trends in Poisoning Deaths
•In 2008, poisoning became the leading cause of injury death in the
United States
•Nearly 9 out of 10 poisoning deaths are caused by drugs
•During the past 30 years, the number of drug poisoning deaths
increased six fold from about 6,100 in 1980 to 36,500 in 2008.
•During the past 10 years, the number of drug poisoning deaths
involving opioid analgesics more than tripled from about 4,000 in
1999 to 14,800 in 2008.
•Opioid analgesics were involved in more than 40% of all drug
poisoning deaths in 2008, up from about 25% in 1999.
Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008.
NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011.
N
Opioid pain reliever supply
The problem of chronic pain
Chronic pain
– Pain has multiple components
• Sensory experience associated with physical injury
• Emotional response of distress and anxiety related to
the sensory information
• Loss of functional capacity related to these experiences
– Chronic pain may
• Be provoked by ongoing chronic injury such as
malignancy, tissue destruction or chronic infection
• Continue when the original injury that provoked the
initial pain has resolved or improved
– Noxious stimuli and pain have an inconsistent
relationship
Psychological
Anxiety/
Depression
• Diminished
function, ADLs
• Deconditioning
• Impaired sleep
Physical
Anger/
Fear
• Impaired
relationships
• Isolation
• Invalid status
Social
Abnormal Illness Behavior
• The patient expects and pursues a sick role
beyond what is reasonable
• The patient continues his expectation despite
being told it is inappropriate
• The patient’s sick role is reinforced
– Issy Pilowsky
Examples of reinforcers in abnormal
illness behavior
• Positive reinforcers
– Attention from spouses, family, doctors, lawyers
– Disability income
– Possibility of tort payments
– Ability to express prohibited feelings
– Access to reinforcing medications
• Negative reinforcers
– Relief from stress, expectations and criticism
– Relief from pain and discomfort
• The sick role is very powerful
Opioids not effective as treatment for
chronic pain
• Tolerance to analgesic properties
• Opioid-induced hyperalgesia
• Marked inconsistency with fantasy
expectations of persistence of peak pain relief
• Inevitability of dependence as confound
– Withdrawal hyperalgesia
– Withdrawal as new negative reinforcer
• Substantial side effect profile
Can opiates worsen chronic pain
disorders?
• Extremely powerful reinforcers
– Positive reinforcement for use, negative reinforcement for
discontinuation
•
•
•
•
•
Opioid-induced hyperalgesia
Positive reinforcement for illness role
Set up an unreasonable standard for pain control
Allows for ongoing injury during peaks of pain relief
Intoxication allows for psychological comfort with
worsening disability
• Iatrogenic addiction can be disordering
• Side effects that typically exacerbate abnormal illness
behavior
The problem of pain
management
Percentage of visits during which controlled medications were prescribed to adolescents (A)
and young adults (B)
Fortuna, R. J. et al. Pediatrics
2010;126:1108-1116
Aberrant Medication Behaviors
•
•
•
•
•
•
•
•
•
•
•
•
requests for higher medication doses
early refills
requests specific drugs
extra medication because of travel or inability to attend
more frequent visits
lost medication
unsanctioned dose escalations
unexpected urine tests showing no opiates
deterioration in work or social functioning
resistance to change or to discontinuation of opiates
despite adverse effects
refusal to comply with drug screens
concurrent abuse of alcohol or illicit drugs
use of multiple physicians and pharmacies
The failure of pain management
• The narrow focus on pain as an isolated symptom
out of context, without broader doctoring
• The view of chronic pain patients as opioid
receptors with legs
• The consideration of aberrant medication
behaviors as a risk management inconvenience
and grounds for dismissal rather than a core
feature of illness and grounds for aggressive
treatment
• The hopeless view of patient care as palliative,
(analogous to hospice), but for non-terminal
illness
• Deconditioning
The failure of pain management
• There aren’t enough opioids in the world…
A more coherent approach to the
treatment of chronic pain
Reframe the goals of treatment
• Function is primary
• Happiness is important
• The fantasy holy grail of complete analgesia is
unrealistic
• In fact, pain relief is not high on the list at at all
• “You’re taking all the pain meds known to man,
still in pain, with miserable side effects; we can’t
possibly do worse
• This isn’t working; let’s try something different
• Not necessarily helpful to use the term
“addiction”
Essential components of chronic pain
treatment
• Re-evaluation and broad medical treatment
• Evaluation of psychiatric co-morbidity
–
–
–
–
•
•
•
•
•
Depression
Personality
Life circumstances
Addiction
Taper opioids and other impairing medications
Substitute serial trials of non-narcotic pain medications
Reconditioning
Purposeful activity, structure, reconnection
Motivational contingencies and realignment of positive
and negative reinforcers
Non-narcotic medications for chronic
pain
•
•
•
•
•
•
•
Nortriptyline (pamelor)
Duloxetine (cymbalta)
Gabapentin (neurontin)
Carbamazepine (tegretol)
Valproate (depakote)
Pregabalin (lyrica)
Maxelitine (mexitil)
Non-pharmacologic treatment
modalities
•
•
•
•
•
Physical therapy
Cognitive behavioral therapy
Biofeedback
Relaxation training and guided imagery
Meditation and self hypnotic techniques
Rehabilitation
• Patients intuitively believe they have to feel
well before they can do things
• In fact the counterintuitive reality is that they
have to do things before they can feel well
Cognitive behavioral interpretations
Can’t means won’t. Need means want. Think means feel.
“I can’t get out of bed today”
“What if the bed was on fire?”
“Well, then I guess I could.”
“Then you don’t mean can’t, you mean won’t.”
“Oh, fine, trick me.”
“I always go to group”
“You have missed 7 of the last 12 groups”
“That’s practically always”
“I needed to take a mental health day yesterday”
“No, you took a mental illness day yesterday”
-Glenn Treisman
The treatment of co-occurring
chronic pain and addiction
Evidence of co-morbid addiction
• Pre-existing history of substance problems
• Concurrent use of other substances
• Progression of aberrant medication behaviors
– lying, stealing, “street” supplies, etc
Treatment of co-morbid addiction
•
•
•
•
•
Role induction
Clarity of treatment goals re addiction
Consider buprenorphine
Consider extended release naltrexone
Support recovery (in the broad sense) as a
pain treatment strategy
Speculation about past and
future directions in doctoring
Is medical care just another consumer
product?
• Are patients just another variety of customer?
• Is our goal to sell more widgets?
• Is our goal to create markets?
– You didn’t know you needed an iPad until you saw
one
– You didn’t know you needed oxycontin until you
took it
Who’s the grown up?
• What should doctors do when patients are
sure what they “need”
• Is it sufficient grounds for delivering a
treatment that patients are sure they “need”
it
It’s hard to say no
• Patients insist on antibiotics when they have a
viral illness
• Patients ask for benzodiazepines when they
have anxiety
• Patients ask for cosmetic surgery in pursuit of
fashion
• Patients ask for opioids when they have pain
Reciprocal conditioning
• The patients condition us as much as we
condition them
• Reinforcers of abnormal doctoring behavior
– Pain as a vital sign
– Emphasis on speed, efficiency, cost reduction
– Emphasis on patient satisfaction
Meet the patients where they are?
• “I’d like a year’s supply of percocet please”
• “I agree I’m using too much oxycontin. Can you
help me cut down, how about weekends only…
• “Sure I’ll come to group occasionally, when I can
make it”
• “I agree I’ve been using too much heroin, but
cocaine is no big deal”
• “Why can’t I take xanax for my anxiety. Nothing
else works…”
• “I’d like a year’s supply of suboxone please”
Treatment misadventures
We’ve been here before
Is everything
on the menu?
What have we learned?
• Doctors have been part of the problem; but
we can be part of the solution
• Parentalism is not a dirty word
• Beneficence sometimes trumps autonomy
• These are complicated cases
• Treatment requires thoughtfulness, patience,
flexibility, optimism
Therapeutic Optimism
• Palliative care has a role, but it is nihilistic in
non-terminal disease
• Recovery is a process
• Expect mischief and monkey business, and
address it
• Firing the patients usually does not cure them
• Learn to convert “no” into “yes, but…”
Who has the necessary expertise?
• These patients are:
– Psychiatrically ill
– Medically compromised
– Embedded in chaotic lives
– Trapped in a role defined by their suffering
– Poisoned by but still dependent on intoxicating
substances
• Remind you of any other kinds of patients you
know?
The role of counseling
•
•
•
•
•
•
Learn to engage these patients
Do not be afraid of their medical problems
Appreciate their burdens
Be a missionary for rehabilitation
Teach salience of behaviors over feelings
Coach them to improved function
A call to action
• These patients need a multi-disciplinary
approach
– We are the appropriate lead discipline
• These patients need a new therapeutic home
– It should be in our house!
If only it were that easy
Treatment Works!