Skills to become abstinent have positive influence on experience of pain management of pain functionality I am always struck by similarities in effective intervention techniques for both addictive disease and Chronic pain Cognitive Tx Behavior Modification Stress management family involvement psychiatric treartment group support
Co-occurring Disorders: Pain, Depression and Substance Abuse Walter Ling MD Integrated Substance Abuse Programs UCLA [email_address] www.uclaisap Fifth Annual Statewide Conference on Co-Occurring Disorders October 3, 2006 Long Beach Convention Center Long Beach, California
Estimates of psychiatric co-morbidity among clinical populations in substance abuse treatment settings range from 20-80%
Estimates of substance use co-morbidity among clinical populations in mental health treatment settings range from 10-35%
Differences in incidence due to: nature of population served (eg: homeless vs. middle class), sophistication of psychiatric diagnostic methods used (psychiatrist or DSM checklist) and severity of diagnoses included (major depression vs. dysthymia ).
ECA DSM-III Diagnoses (rates per 100 people) Regier, et al. (1990) 3.5 0.8 Drug Dependence 7.9 1.7 Alcohol Dependence 22.5 13.0 Any Mental Disorder 32.7 15.7 Any Alcohol, Drug or Mental Health Disorder Lifetime 1 Month
Four times as many US citizens died by suicide during the Viet Nam War period than died as soldiers.
Rates increase with age ( as do other causes of death) CDC web site
Suicide rate among addicts is 5-10 times that of non-addicts Preuss/Schuckit Am J Psych 03
Less than than half of the women with interpersonal trauma and co-morbidity will receive treatment that addresses their trauma history and co-occurring conditions (Timko & Moos, 2002).
Comorbidity of Depression and Anxiety Disorders 49% of social anxiety disorder patients have panic disorder** 50% to 65% of panic disorder patients have depression † 11% of social anxiety disorder patients have OCD** 67% of OCD patients have depression* 70% of social anxiety disorder patients have depression Depression OCD Social Anxiety Disorder Panic Disorder HIGHLY COMMON… HIGHLY COMORBID
The Four Quadrant Framework for Co-Occurring Disorders
A four-quadrant conceptual framework to guide systems integration and resource allocation in treating individuals with co-occurring disorders (NASMHPD,NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002)
Not intended to be used to classify individuals (SAMHSA, 2002), but . . .
Less severe mental disorder/ less severe substance abuse disorder More severe mental disorder/ less severe substance abuse disorder More severe mental disorder/ more severe substance abuse disorder Less severe mental disorder/ more severe substance abuse disorder High severity High severity Low severity
Addiction- primary, chronic, neurobiologic disease characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and/or craving
American Pain Society. Available at: http://www.ampainsoc.org/advocacy/opioids2.htm
“ Addiction is not taking a lot of drugs; it’s taking drugs and acting like an addict.”—Alan Leshner
Aberrant Behaviors in Cancer and AIDS Passik et al. 2003
Therapeutic Maneuver: Is the Pain Patient Addicted? Drug-seeking or increased requests for pain medication Detailed pain work-up Pathology/pain of new source No new pain pathology Opioid dose Improved functioning Absence of toxicity Pseudoaddiction Therapeutic dependence Unimproved functioning Presence of toxicity Addictive disease
Treating Pain with Opioids: What Can We Expect to Achieve?
Reduction in pain and suffering
Meaningful pain reduction ( A nalgesia; Pain )
Acceptable side effects ( A dverse effects; Price )
Meaningful functional improvement ( A ctivities; Performance )
No unacceptable aberrant behavior ( A berrant bahavior; “Pees”