Chronic Pain and Addiction April 10-12, 2012Walt Disney World Swan Resort
Learning Objectives:1. Distinguish the differences between propermanagement of chronic pain and practicesthat contribute to over-prescribing and drugabuse.2. Describe the effects and consequences ofprescription pain abuse as it progresses overtime.3. Advocate the importance of continuingeducation on addiction for painmanagement providers.
Disclosure Statement• Dr. Barbara Krantz has disclosed no relevant, real or apparent personal or professional financial relationships.• Dr. Lynn R. Webster has disclosed that he has a relationship with AlphaBioCom, American Academy of Pain Management, American Board of Pain Medicine, Cephalon, Inc., Covidien Mallinckrodt, Pfizer, Adolor Corp, Alkermes Inc., Allergan Inc., Astellas, AstraZeneca, Bayer Healthcare, BioDelivery Systems International, Boston Scientific, Cephalon, Collegium Pharmaceuticals, Covidien, Eisai, Elan Pharmaceuticals, Gilead Sciences, GlaxoSmithKline, Identigene (Sorenson), King Pharmaceuticals, Meagan Medical, Medtronic, Merck, Naurex, Nektar Therapeutics, NeurogesX Inc., Novartis, SchaBar, Shionogi USA Inc., St. Renatus, SuCampo Pharma Americas USA, Takeda, TEVA Pharmaceuticals (Sub-1), Theravance Inc., Vanda, Vertex, Xandoyne Pharmaceuticals
Chronic Pain & Addiction Lynn R. Webster, MDMedical Director, Lifetree Clinical Research Salt Lake City, UT (801) 269-8200 LRWebsterMD@gmail.com Twitter: @LynnRWebsterMD
Finanical Disclosure• Consultant/Honoraria/Advisory Board – AlphaBioCom, American Academy of Pain Medicine, American Academy of Pain Management, Boston Scientific, Cephalon, Covidien, Medtronic, Pfizer• Research – Adolor, Alkermes, Allergan, Astellas, AstraZeneca, Bayer Healthcare, BioDelivery Sciences International, Boston Scientific, Cephalon, Collegium, Covidien, Eisai, Elan, F. Hoffman La-Roche, Gilead, GlaxoSmithKline, Identigene (Sorenson), King, Meagan Medical, Medtronic, Merck, Naurex, Nektar, NeurogesX, Novartis, Pfizer, Professional Service Solutions, Inc, SchaBar, Shionogi, Shire, St. Renatus, Sucampo, Takeda, TEVA, Theravance, US WorldMeds, Vanda, Vertex, Xanodyne Pharmaceuticals
The Opioid Pendulum Avoidance Even dying people at risk Widespread Use for addic4on Opiophobia must go Balance Risk stra4ﬁca4on and principles of addic4on medicine applied to opioid prescribing regardless of the pain problem at hand
Definition of Terms Use of a medica4on (for a medical purpose) other than as directed or as Misuse indicated, whether willful or uninten4onal, and whether harm results or not Any use of an illegal drug The inten4onal self administra4on of a medica4on for a non-‐medical Abuse purpose such as altering one’s state of consciousness, e.g. geFng high A primary, chronic, neurobiological disease, with gene4c, psychosocial, and environmental factors inﬂuencing its development and manifesta4ons Addic0on Behavioral characteris4cs include one or more of the following: Impaired control over drug use, compulsive use, con4nued use despite harm, craving The inten4onal removal of a medica4on from legi4mate and dispensing Diversion channels Katz N, et al. Clin J Pain. 2007;23:648-‐660.
Major Opioid Risks• Opioid Use Outcomes – Misuse – Abuse – Addiction – Death• Diversion
Statistics on Substance Use and Chronic Pain in the United States Category StatisticChronic pain patients who may have addictive 32 % (Chelminski et al., 2005)disordersPeople ages 20+ who report pain that lasted 56% (National Center for Health Statistics, 2006)more than 3 monthsPeople experiencing disabling pain in the 36% (Portenoy, Ugarte, Fuller & Haas, 2004)previous yearPeople ages 65+ who experience pain that has 57% (National Center for Health Statistics, 2006)lasted more than 12 monthsCivilian, noninstitutionalized U.S. residents ages 5% (Substance Abuse and Mental Health12+ who report nonmedical use* of pain relievers Services Administration [SAMHSA], 2007)in past yearPeople ages 12+ who report that they initiated 19% (SAMHSA, 2008)illegal drug use with pain relieversPeople with opioid addiction who report chronic 29-60% (Peles, Schreiber, Gordon & Adelson,pain 2005; Potter, Shiffman & Weiss, 2008; Rosenblum*Nonmedical use is use for purposes other than that for which the medica4on was prescribed et al., 2003; Sheu et al., 2008)Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.
Spectrum of Behaviors nal “Self- reatio Treaters” “Adherent” “Chem “Rec ers” ic coper al us s” Nonmedical Users Pain PatientsKirsh, K.L., Passik, S.D. The Interface Between Pain and Drug Abuse and the Evolution of Strategies to Optimize Pain management while Minimizing Drug Abuse. Experimental and Clinical Psychopharmacology 2008, 16 (5): 400-‐404
Prevalence of Opioid Abuse/Addiction Aberrant Behavior: 40% Abuse: 20% Total Pain Addic0on: 2% to 5% Popula0on Webster LR, Webster RM. Pain Med. 2005;6(6):432-‐442.
Lifetime Opioid-Use Disorder Among Outpatients on Opioid Therapy for Non-Cancer Pain Associated With:N = 705 Source: Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients:comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011 Jul-Sep;20(3):185-94.
Patient Risk Factors for Aberrant Behaviors/ Harm Biological Biological Psychiatric Psychiatric Social • Age ≤45 years • Substance use • Prior legal problems • Gender disorder • History of motor • Family history of • Preadolescent vehicle accidents sexual abuse • Poor family support prescription drug or (in women) alcohol abuse • Involvement in a • Cigarette smoking • Major psychiatric problematic disorder • Physical Illnesses subculture (eg, personality • Pain severity disorder, anxiety or • Unemployed depressive disorder, • Isolation • Pain duration bipolar disorder) • Sleep disorders • Depression Katz NP, et al. Clin J Pain. 2007;23:103-118; Manchikanti L, et al. J Opioid Manag. 2007;3:89-100. Webster LR, Webster RM. Pain Med. 2005;6:432-442. Cheatle MD. Depression, Chronic Pain, and Suicide by Overdose: On the Edge. Pain Medicine. 2011;12(s2):S43-S48.Utah Drug Overdose Mortality Report: Findings from interview with family and friends of Utah residents aged 13 and older who died of a drug overdose between October 26, 2008 and October 25, 2009. Prepared by the Utah Department of Health.
Pain, Opioid Use andPsychiatric Co-morbidities Managing a critical interplay… Pain Opioids Psychiatr ic Illness
The Chemical CoperKey Clinical Features *Alexythymic *Soma4zing *Overly drug focused *Unmo4vated for non-‐drug therapies *Make li_le progress towards psychosocial goals
Major Depression & PainBlair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: A literature review. Arch Intern Med 2003; 163(20): 2433-45.
Depression & Pain Comorbid Depression Chronic Pain 35% 21.9%N= 1,179 Miller LR, Cano A. Comorbid chronic pain and depression: Who is at risk? J Pain 2009; 10(6): 619-‐627
Depression • Patients who have CNCP and comorbid depression tend to: – Have high pain scores – Feel less in control of their lives – Use passive-avoidant coping strategies – Adhere less to treatment plans than patients who are not depressed – Have greater interference from pain, including more pain behaviors observed by others – Respond less well to pain treatment, unless depression is addressedSubstance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.
Depression and Pain vs Smoking Status%Hooten WM, Shi Y, Gazelka HM, Warner DO. (2011). The eﬀects of depression and smoking on pain severity and opioid use in pa4ents with chronic pain. Pain 103, 16-‐24.
ORT ValidationMark each box that applies Female Male 1. Family history of substance abuse Alcohol 1 3 Illegal drugs 2 3 Prescrip0on drugs 4 4 2. Personal history of substance abuse Alcohol 3 3 Illegal drugs 4 4 Prescrip0on drugs 5 5 3. Age (mark box if 16-‐45 years) 1 1 4. History of preadolescent sexual abuse 3 0 ADD, attention deﬁcit disorder; 5. Psychological disease N=185 OCD, obsessive-‐compulsive ADD, OCD, bipolar, schizophrenia 2 2 disorder. Depression 1 1 Webster L, Webster R. Pain Med. 2005;6:432-‐442.
Predicting Aberrant Drug Behavior Importance of Abuse HistoryMichna E, Ross EL, Hynes WL, et al. Predic4ng aberrant behavior in pa4ents treated for chronic pain: Importance of abuse history. Journal of Pain & Symptom Management 2004; 28(3)250-‐8.
Genetic Vulnerability to Addiction?Fisher 344 Abs0nence Drug Rejec0ng Lewis Polysubstance Drug Seeking Abuse Sprague-‐Dawley Average Drug Neutral Webster L, Dove B; Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. 1st ed. North Branch, MN: Sunrise River Press; 2007.
Vulnerability to Opioid Addiction Individuals respond diﬀerently to opioid exposure No addic0ve disease with exposure No addic0ve disease due to lack of exposure Addic0ve Disease aRer opioid exposure
Level of Abuse in Stressful Environments Drug-‐Abusing Behavior Low Moderate High Pa0ent Stress Level Webster L, Dove B; Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. 1st ed. North Branch, MN: Sunrise River Press; 2007.
Suicide 20061 19991 2005 – 2007 1Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2005. NCHS Data Brief 2009;22:1-8. 2Substance Abuse and Mental Health Services Administra4on, Oﬃce of Applied Studies. Drug Abuse Warning Network, 2007: Es4mates of Drug-‐Related Emergency Department Visits. Rockville, MD: Author, 2010.
Why Suicide? Non-Pain Patients Escape from severe suﬀering Only option Hopelessness Permanent Solution Krao TL, Jobes DA, Lineberry TW, Conrad A, Kung S. Brief report: Why suicide? Percep4ons of suicidal inpa4ents and reﬂec4ons of clinical researchers. Arch Suicide Res 2010;14(4):375-‐82.
Suicide Ideation in Chronic Pain Patients • Hitchcock1 N=153 – 50% chronic pain pts had suicidal thoughts due to pain • Fishabain2 – Pain severity – Severe comorbidity (depression)1Hitchcock LS, Ferrell BR, McCaffery M. The experience of chronic nonmalignant pain. J Pain Symptom Manage 1994;9(5):213-8.2FishbainDA. The association of chronic pain and suicide. Semin Clin Neuropsychiatry 1999;4)3):221-7.3Smith MT, Edwards RR, Robinson RC, Dworkin RH. Suicidal ideation, plans and attempts in chronic pain patients: Factors associated withincreased risk. Pain 2004;111(1-2):201-8.
Risk for Suicide Pain Patients Family history of History of substance suicide abuse History of childhood Impulsive and abuse aggressive behaviors Previous suicide Losses such as work, attempts family, self-esteem History of mental Isolation disorder, particularly Physical illness depression Hopelessness +1: Access to poten0ally lethal doses of prescrip0on medica0ons (ie opioids) 1Fishbain DA. The association of chronic pain and suicide. Semin Clin Neuropsychiatry 1999;(3):221-7.2TangNK, Crane C. Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. PsycholMed 2006;36(5):575-86.
Mitigate Risk• Prescription monitoring programs• Urine drug test• Opioid agreements• Mental health evaluations• Limit dose where appropriate 32
Mitigate RiskCheatle MD. Depression, Chronic Pain, and Suicide by Overdose: On the Edge. Pain Medicine. 2011;12(s2):S43-‐S48.
Risk Stratification Lower Risk Moderate Risk Higher Risk Primary Care Primary Care Patients with Pain Specialist Patients Specialist Support Patients ORT Score: 0-‐3 ORT Score: 4-‐7 ORT Score: 8+ • No past or current • May be a past history of • Active substance use history of substance use substance use disorders disorders disorders • May be family history of • Major, untreated • No family history of past problematic drug use psychopathology or current substance use • May have past or • Poor social support disorders concurrent • Actively addicted • No major or untreated psychopathology • Inconsistent UDT psychopathology • Not actively addicted • PMP multiple prescribers • Consistent UDT • Usually consistent UDT • Moderate to sever pain • PMP consistent • PMP consistent • Pain mild to moderate • Mild to severe pain Adapted from Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain J Med. 2005;6(2):107–112 and Webster LR Webster RM. Predicting aberrant behaviors in opioid-‐ treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005; 6(6):432-‐442.
8 Prescribing Guidelines 1. Assess risk for opioid abuse 2. Assess and treat co-‐morbid mental health 3. Use conversion tables cau4ously 4. Avoid benzodiazepines with opioids 5. Start opioids low and advance slowly 6. Assess for sleep apnea at > 100 mg/day 7. Reduce opioids with URI’s, ﬂu and asthma 8. Avoid long ac4ng opioids with acute pain http://www.painfoundation.org/painsafe/safety-tools-resources/
8 Ways Pa4ents can Prevent Overdose Deaths 1. Never take prescrip4on pain medica4on that is not prescribed to you 2. Never adjust your own doses 3. Never mix with alcohol 4. Taking sleep aids or an4-‐anxiety medica4ons together with prescrip4on pain medica4on can be dangerous 5. Always tell your healthcare provider about all medica4ons you are taking from any source 6. Keep track of when you take all medica4ons 7. Keep your medica4ons locked in a safe place 8. Dispose of any unused medica4ons http://www.painfoundation.org/painsafe/safety-tools-resources/
Conclusion• Pain is the most common cause of disability in America• Substance abuse is a serious public health issue• Co-occurring pain and substance abuse is common and major challenge for clinicians• Treating pain while minimizing opioid abuse requires vigilances and compassion 37