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Lynn Webster


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Chronic Pain and Addiction
National Rx Drug Abuse Summit 4-10-12

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Lynn Webster

  1. 1. Chronic Pain and Addiction April 10-12, 2012Walt Disney World Swan Resort
  2. 2. 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.
  3. 3. 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
  4. 4. Chronic Pain & Addiction Lynn R. Webster, MDMedical Director, Lifetree Clinical Research Salt Lake City, UT (801) 269-8200 Twitter: @LynnRWebsterMD
  5. 5. 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
  6. 6. 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  
  7. 7. 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.  
  8. 8. Major Opioid Risks•  Opioid Use Outcomes – Misuse – Abuse – Addiction – Death•  Diversion
  9. 9. 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.
  10. 10. 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  
  11. 11. 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.    
  12. 12. Significant Risk Factors for Abuse and Overdose•  Pharmacologic substance –  Potency –  Tmax –  Cmax –  Availability•  Patient risk factors –  Individual risk factors –  Environmental risk factors•  Prescriber behavior –  Improper patient selection, dosing, and titration –  Improper patient counseling and management
  13. 13. 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.
  14. 14. 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.
  15. 15. Pain, Opioid Use andPsychiatric Co-morbidities Managing a critical interplay… Pain Opioids Psychiatr ic Illness
  16. 16. The Chemical CoperKey  Clinical  Features  *Alexythymic  *Soma4zing  *Overly  drug  focused  *Unmo4vated  for  non-­‐drug  therapies  *Make  li_le  progress  towards  psychosocial  goals  
  17. 17. 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.
  18. 18. 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  
  19. 19. 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.
  20. 20. 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.  
  21. 21. 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.  
  22. 22. 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.  
  23. 23. Opioid Use in High vs Low Risk Patients%
  24. 24. 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.  
  25. 25. 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  
  26. 26. 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.  
  27. 27. 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.  
  28. 28. 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.  
  29. 29. 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.
  30. 30. 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.
  31. 31. Mitigate Risk•  Prescription monitoring programs•  Urine drug test•  Opioid agreements•  Mental health evaluations•  Limit dose where appropriate 32  
  32. 32. Mitigate RiskCheatle  MD.    Depression,  Chronic  Pain,  and  Suicide  by  Overdose:  On  the  Edge.    Pain  Medicine.    2011;12(s2):S43-­‐S48.  
  33. 33. 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.  
  34. 34. 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
  35. 35. 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
  36. 36. 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  
  37. 37. Thank you!