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Co-Occurring Disorders: Pain, Depression and Substance Abuse


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Co-Occurring Disorders: Pain, Depression and Substance Abuse

  1. 1. 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
  2. 2. Scope of the Talk <ul><li>“What’s the big deal”? “Why bother with it”? </li></ul><ul><li>How big a problem is it? </li></ul><ul><li>How do we go about it? </li></ul><ul><li>What can we do? </li></ul><ul><li>A few specific tricks? </li></ul>
  3. 3. What’s the Big Deal? <ul><li>Common clinical problems </li></ul><ul><li>Overlaps in neurobiology </li></ul><ul><li>Confusing diagnosis </li></ul><ul><li>Complicates treatment , presence of one predicts poor treatment outcome of the other </li></ul><ul><li>Strain on treatment systems and resources </li></ul>
  4. 4. What’s the Problem? <ul><li>Estimates of psychiatric co-morbidity among clinical populations in substance abuse treatment settings range from 20-80% </li></ul><ul><li>Estimates of substance use co-morbidity among clinical populations in mental health treatment settings range from 10-35% </li></ul><ul><li>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 ). </li></ul>
  5. 5. 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
  6. 6. Lifetime Prevalence and Odds Ratios ECA Study
  7. 7. Chronic pain, Depression and Anxiety <ul><li>National Co-morbidity Study (8098 15-54 y.o. chronic pain arthritic patients vs general population control) </li></ul><ul><li>Mood disorder: 27% patients vs 10% controls </li></ul><ul><li>Anxiety disorder: 35% vs 9% </li></ul><ul><li>Depression: 20% vs 9% </li></ul><ul><li>Generalized anxiety disorder: 7% vs3% </li></ul><ul><li>Panic disorder: 7% vs 2% </li></ul><ul><li>PTSD: 11% vs 3% </li></ul><ul><li>Odds of disability from chronic pain increase: anxiety (2.86); depression (2.8);panic disorder ( 4.27) </li></ul>
  8. 8. The “ideal, but infrequent” patients for the separated service delivery systems <ul><li>The mental health service system </li></ul><ul><li>The uncomplicated schizophrenic </li></ul><ul><li>The “simple” affective disordered individual </li></ul><ul><li>The “pure” bi-polar patient </li></ul><ul><li>The substance abuse service system </li></ul><ul><li>The “plain” alcoholic </li></ul><ul><li>The addict who uses only heroin </li></ul><ul><li>The stimulant dependent individual w/o other psych diagnoses </li></ul>
  9. 9. Drug Induced Psychopathology <ul><li>Drug States </li></ul><ul><li>Withdrawal </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><li>Protracted </li></ul></ul><ul><li>Intoxication </li></ul><ul><li>Chronic Use </li></ul><ul><li>Symptom Groups </li></ul><ul><li>Depression </li></ul><ul><li>Anxiety </li></ul><ul><li>Psychosis </li></ul><ul><li>Mania </li></ul><ul><li>Rounsaville ‘90 </li></ul>
  10. 10. Likelihood of a Suicide Attempt <ul><li>Risk Factor </li></ul><ul><li>Cocaine use </li></ul><ul><li>Major Depression </li></ul><ul><li>Alcohol use </li></ul><ul><li>Separation or Divorce </li></ul><ul><ul><ul><ul><ul><li>NIMH/NIDA </li></ul></ul></ul></ul></ul><ul><li>Increased Odds Of Attempting Suicide </li></ul><ul><li>62 times more likely </li></ul><ul><li>41 times more likely </li></ul><ul><li>8 times more likely </li></ul><ul><li>11 times more likely </li></ul><ul><li>ECA EVALUATION </li></ul>
  11. 11. Facts about Suicide: <ul><li>500,000 ER visits for attempts in 1997 </li></ul><ul><li>Four times as many US citizens died by suicide during the Viet Nam War period than died as soldiers. </li></ul><ul><li>Rates increase with age ( as do other causes of death) CDC web site </li></ul><ul><li>Suicide rate among addicts is 5-10 times that of non-addicts Preuss/Schuckit Am J Psych 03 </li></ul>
  12. 12. 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).
  13. 13. 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
  14. 14. The Four Quadrant Framework for Co-Occurring Disorders <ul><li>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) </li></ul><ul><li>Not intended to be used to classify individuals (SAMHSA, 2002), but  . . .  </li></ul>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
  15. 15. DSM and ICD: The “Bibles”
  16. 16. Assessing for addiction in pain patients <ul><li>Substance Abuse </li></ul><ul><li>One or more within a 12 month period </li></ul><ul><ul><li>Failure to fulfill major role obligation </li></ul></ul><ul><ul><li>Recurrent use in hazardous situations </li></ul></ul><ul><ul><li>Recurrent legal problems </li></ul></ul><ul><ul><li>Recurrent social or interpersonal problems </li></ul></ul><ul><li>Substance Dependence </li></ul><ul><li>Three or more within a 12 month period </li></ul><ul><ul><li>Abuse criteria , plus: </li></ul></ul><ul><ul><li>Tolerance </li></ul></ul><ul><ul><li>Withdrawal </li></ul></ul><ul><ul><li>Larger amount/longer time than intended </li></ul></ul><ul><ul><li>Persistent desire to control use </li></ul></ul><ul><ul><li>Great deal of time spent in activities related to use </li></ul></ul>Diagnostic and Statistical Manual of Mental Disorders* *4 th ed, APA, 1994
  17. 17. Pain and Depression <ul><li>What comes first? </li></ul><ul><ul><li>The antecedent hypothesis </li></ul></ul><ul><ul><li>The consequence hypothesis </li></ul></ul><ul><ul><li>The “scar” hypothesis </li></ul></ul><ul><ul><li>“ Pain-prone personality” </li></ul></ul><ul><ul><li>Life experience and personal mastery </li></ul></ul><ul><li>Does it really matter? </li></ul><ul><ul><li>Pain and depression make each other worse </li></ul></ul>
  18. 18. Pain and Depression <ul><li>Between 30% and 60% of depressed patients have chronic pain </li></ul><ul><li>Chronic pain patients who are depressed are 9 times more likely to be disabled </li></ul><ul><ul><li>This depression is responsive to treatment </li></ul></ul><ul><ul><li>Treatment lowers pain intensity and improves function and quality of life </li></ul></ul><ul><li>Treatment needs to be adequate and sustained; combined pharmacotherapy with behavioral therapy, aim to improve self management, beware of increased suicide risks </li></ul>
  19. 19. Depression IS Pain <ul><li>Pain is second most common somatic symptom in depression, second only to insomnia. </li></ul><ul><li>Pain occurs in over 50% of depressed patients </li></ul><ul><li>Common pain in depressed patients: headaches, facial pain, neck and back pain, chest and abdominal pain and extremity pain </li></ul><ul><li>Pain often dominate clinical picture overshadowing other depressive symptoms </li></ul>
  20. 20. Pain and Depression <ul><li>Pain is depressive equivalent </li></ul><ul><li>Chronic pain leads to depression </li></ul><ul><li>Circular relationship, vicious circle </li></ul><ul><li>Common association and overlapping </li></ul><ul><li>Common neurobiological substrate </li></ul><ul><li>Psychological determinants critical </li></ul><ul><li>Responsive to antidepressants </li></ul><ul><li>Non-pharmacological strategies critical </li></ul>
  21. 21. Pain and Depression <ul><li>Two thirds of new neurological patients have pain. </li></ul><ul><li>One third are depressed; 75% of them have pain. </li></ul><ul><li>One quarter have both pain and depression. </li></ul><ul><li>Neuropathy, neuromuscular disease, headaches. </li></ul><ul><li>Sx persist at 3 & 12 mo. follow up </li></ul><ul><li>Pain predicts depression at f/u and vice versa </li></ul><ul><li>Odds of pain increase: female, depressed, NMD </li></ul><ul><li>Odds of depression increase: CVD, Cognitive dis </li></ul>Williams LS et al J Neuro Neurosurg Psych. 2003
  22. 22. Pain IS Depression <ul><li>Somatic cyclothymia </li></ul><ul><li>Periodic melancholy </li></ul><ul><li>Vegetative depression </li></ul><ul><li>Masked depression </li></ul><ul><li>Affective equivalents </li></ul><ul><li>Depressive equivalents </li></ul><ul><li>Variant of depressive disease </li></ul>
  23. 24. Pain and Depression <ul><li>Co-occurrence makes diagnosis difficult </li></ul><ul><li>Pain patients tend to show more irritability, anhedonia, loss of interest, reduced capacity to experience pleasure. </li></ul><ul><li>Depressed patients tend to exhibit more dysphoria, early morning awakening, indecisiveness, despair and suicidal ideations </li></ul>
  24. 25. Treating Co-morbid Pain and Depression <ul><li>Tricylclic antidepressants </li></ul><ul><ul><li>Efficacy in neuropathic pain </li></ul></ul><ul><li>SSRI’s </li></ul><ul><ul><li>Safety profile </li></ul></ul><ul><li>Dual-acting agents </li></ul><ul><ul><li>Effective for depression and pain </li></ul></ul><ul><ul><ul><ul><li>Detke MJ 2002 </li></ul></ul></ul></ul>
  25. 26. Treating Co-morbid Pain and Depression <ul><li>Non-pharmacological treatment </li></ul><ul><ul><li>Cognitive behavioral treatment </li></ul></ul><ul><ul><li>Operant behavioral treatment </li></ul></ul><ul><ul><li>Biofeedback training </li></ul></ul><ul><ul><li>Motivational interviewing </li></ul></ul><ul><ul><li>Private emotional disclosure </li></ul></ul><ul><li>Integrating pharmacotherapy and behavioral treatment </li></ul>
  26. 27. What happen when pain becomes chronic <ul><li>The one certain thing: treatment didn’t work </li></ul><ul><li>Patient frustrated and lost faith in doctors </li></ul><ul><li>Patient blamed for not getting better </li></ul><ul><li>Lost “role”; becomes dependent on others </li></ul><ul><li>Others must pick up slack and must provide support </li></ul><ul><li>Patient feels neglected when others can’t do all </li></ul><ul><li>Patient becomes anxious, angry and depressed </li></ul><ul><li>Patient assumes life style of chronic pain </li></ul>
  27. 28. Chronic pain: identifying early risk factors <ul><li>Attitude and belief of pain </li></ul><ul><li>Whose fault? </li></ul><ul><li>Behavior and compensation issues </li></ul><ul><li>Dx and Tx issues </li></ul><ul><li>Emotions </li></ul><ul><li>Family </li></ul><ul><li>Work </li></ul>
  28. 29. Early signs of chronic pain <ul><li>Not healing as expected </li></ul><ul><li>Perceived neglect or ill treatment </li></ul><ul><li>Perceived management abandonment </li></ul><ul><li>Not adequately treated </li></ul><ul><li>Accident was some one’s fault </li></ul><ul><li>Expanding Sx </li></ul><ul><li>Sleep disturbance, anger fear </li></ul>
  29. 30. Opioid, Pain and Addiction: Confluence of Events <ul><li>Under treatment of pain: </li></ul><ul><li>Increasing availability of opioids: </li></ul><ul><li>Rise in abuse of prescription opioids </li></ul>New Demand: Core competency in pain and in addiction
  30. 31. From Pain Relief to Addiction: Opioids and the Faces of Janus <ul><li>Relieve pain </li></ul><ul><li>Relieve pain and suffering </li></ul><ul><li>Relieve suffering and misery </li></ul><ul><li>Make you feel better </li></ul><ul><li>Make you feel good </li></ul><ul><li>Make you “high” </li></ul>
  31. 32. The Clinician’s Dilemma <ul><li>What God hath joined together, can man put asunder? </li></ul><ul><li>What to do in the meantime to maximize pain relief while minimizing abuse ? </li></ul>
  32. 33. Definitions: Addiction <ul><li>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 </li></ul><ul><li>American Pain Society. Available at: </li></ul><ul><li>“ Addiction is not taking a lot of drugs; it’s taking drugs and acting like an addict.”—Alan Leshner </li></ul>
  33. 34. Characterizing Pain <ul><li>Pain: An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage </li></ul><ul><li>It is always subjective; each individual learns the application of the word ( pain ) through experiences related to injury in early life—IASP </li></ul>IASP = International Association for the Study of Pain.
  34. 35. Acute Versus Chronic Pain <ul><li>Acute pain: </li></ul><ul><li>Related to a particular event (eg fall) </li></ul><ul><li>Resolution expected within days/weeks </li></ul><ul><li>Chronic pain: </li></ul><ul><li>Cause not often easily identified </li></ul><ul><li>CNS changes </li></ul><ul><li>Not repeated acute pain episodes </li></ul>Acute pain: a sensation; what pain does the patient have? Chronic pain: a life style: what patient does the pain have?
  35. 36. Pain in Addiction: “More Than a Feeling” <ul><li>Feeling (sensory experience): pain </li></ul><ul><li>Meaning (emotional and cognitive): suffering </li></ul><ul><ul><li>Historical—early life </li></ul></ul><ul><ul><li>Learned—experience </li></ul></ul><ul><ul><li>Private—subjective </li></ul></ul><ul><ul><li>Unique—individual </li></ul></ul><ul><li>Action—expression of the “word”: behavior </li></ul><ul><li>Chronic pain is not having lots of pain; it is having pain and behaving like a chronic pain patient </li></ul>
  36. 38. The Martyrdom of St. Sebastian by Hans Holbein (1516)
  37. 39. Chronic Pain and Addiction: Common Overlapping Features <ul><li>Chronic pain </li></ul><ul><ul><li>Early trauma </li></ul></ul><ul><ul><li>Loss of mastery </li></ul></ul><ul><ul><li>Loss of control </li></ul></ul><ul><ul><li>Loss of sense of self </li></ul></ul><ul><ul><li>Cognitive error </li></ul></ul><ul><ul><li>“ Personalization” </li></ul></ul><ul><ul><li>Overinterpretation </li></ul></ul><ul><ul><li>“ Catastrophizing” </li></ul></ul><ul><li>Addiction </li></ul><ul><ul><li>Early trauma </li></ul></ul><ul><ul><li>Loss of mastery </li></ul></ul><ul><ul><li>Loss of control </li></ul></ul><ul><ul><li>Loss of self-efficacy </li></ul></ul><ul><ul><li>Cognitive error </li></ul></ul><ul><ul><li>“ Nirvana” </li></ul></ul><ul><ul><li>Denial </li></ul></ul>
  38. 40. Chronic Pain Common in Methadone Clinics <ul><li>Over 60% of methadone clinics patients experience chronic pain </li></ul><ul><li>Less employed; more disabilities </li></ul><ul><li>More medically and psychiatrically ill </li></ul><ul><li>Take more prescribed and non-prescribed drugs </li></ul><ul><li>Most feel under treated </li></ul><ul><li>Most believe prescribed opiates led to addiction </li></ul><ul><li>Most believe methadone is very helpful </li></ul><ul><li>Most have “problems most of their lives” </li></ul><ul><li>Most believe “always need something to feel good” </li></ul><ul><li>Ref: Jamison et al. (2000) </li></ul>
  39. 41. With respect to chronic opioid therapy and the patient with chronic non-malignant pain, <ul><li>How does one identify addiction in the patient on chronic opioid therapy? </li></ul><ul><li>How does one identify the patient at risk for becoming addicted to chronic opioid therapy? </li></ul>
  40. 42. Published rates of abuse and/or addiction in chronic pain populations are ~ 10% (3-18%)* <ul><li>Suggests that known risk factors for abuse or addiction in the general population would be good predictors for problematic prescription opioid use </li></ul><ul><ul><li>History of early substance use </li></ul></ul><ul><ul><li>Personal/family history of substance abuse </li></ul></ul><ul><ul><li>Co-morbid psychiatric disorders </li></ul></ul>*Adams et al., 2001; Brown, 1996; Fishbain, 1986, 1992; Kouyanou et al., 1997
  41. 43. Who’s at Risk for Addiction and How to Tell? <ul><li>4 Ways to identify patients at risk </li></ul><ul><ul><li>History — personal history and family history </li></ul></ul><ul><ul><li>Screening instruments </li></ul></ul><ul><ul><li>Behavioral checklists </li></ul></ul><ul><ul><li>Therapeutic maneuver </li></ul></ul>
  42. 44. Screening Instruments <ul><li>Several clinical tools are available that estimate risk of noncompliant opioid use 1,2,3 </li></ul><ul><li>The results determine how closely a patient should be monitored during the course of opioid therapy 3 </li></ul><ul><ul><li>Scores implying a high risk of abuse are not reasons to deny pain relief 3 </li></ul></ul><ul><ul><li>1 Webster, et alr. Pain Med. 2005;6:432. </li></ul></ul><ul><ul><li>2 Coambs, et al. Pain Res Manage. 1996;1:155. </li></ul></ul><ul><ul><li>3 Butler, et al. Pain. 2004;112:65. </li></ul></ul>
  43. 45. Opioid Risk Tool (ORT) <ul><li>Scoring </li></ul><ul><li>0-3: low risk (6%) </li></ul><ul><li>4-7: moderate risk (28%) </li></ul><ul><li>> 8: high risk (> 90%) </li></ul><ul><li>Administration </li></ul><ul><li>On initial visit </li></ul><ul><li>Prior to opioid therapy </li></ul>Webster, et al. Pain Med. 2005;6:432. <ul><li>Mark each box that applies: Female Male </li></ul><ul><li>Family history of substance abuse </li></ul><ul><li>Alcohol 1 3 </li></ul><ul><li>Illegal drugs 2 3 </li></ul><ul><li>Prescription drugs 4 4 </li></ul><ul><li>Personal history of substance abuse </li></ul><ul><li>Alcohol 3 3 </li></ul><ul><li>Illegal drugs 4 4 </li></ul><ul><li>Prescription drugs 5 5 </li></ul><ul><li>Age (mark box if between 16-45 years) 1 1 </li></ul><ul><li>History of preadolescent sexual abuse 3 0 </li></ul><ul><li>Psychological disease </li></ul><ul><li>ADO, OCD, bipolar, schizophrenia 2 2 </li></ul><ul><li>Depression 1 1 </li></ul><ul><li>Scoring totals: </li></ul>
  44. 46. Screener and Opioid Assessment for Patients in Pain (SOAPP) <ul><li>14-item, self-administered form, capturing the primary determinants of aberrant drug-related behavior </li></ul><ul><ul><li>Validated over a 6-month period in 175 chronic pain patients </li></ul></ul><ul><ul><li>Adequate sensitivity and selectivity </li></ul></ul><ul><ul><li>May not be representative of all patient groups </li></ul></ul><ul><li>A score of ≥ 7 identifies 91% of patients who are high risk </li></ul>Butler, et al. Pain. 2004;112:65.
  45. 47. Aberrant Drug-Taking Behaviors: The Model <ul><li>Probably more predictive </li></ul><ul><ul><li>Selling prescription drugs </li></ul></ul><ul><ul><li>Prescription forgery </li></ul></ul><ul><ul><li>Stealing or borrowing another patient’s drugs </li></ul></ul><ul><ul><li>Injecting oral formulation </li></ul></ul><ul><ul><li>Obtaining prescription drugs from non-medical sources </li></ul></ul><ul><ul><li>Concurrent abuse of related illicit drugs </li></ul></ul><ul><ul><li>Multiple unsanctioned dose escalations </li></ul></ul><ul><ul><li>Recurrent prescription losses </li></ul></ul><ul><li>Probably less predictive </li></ul><ul><ul><li>Aggressive complaining about need for higher dose </li></ul></ul><ul><ul><li>Drug hoarding during periods of reduced symptoms </li></ul></ul><ul><ul><li>Requesting specific drugs </li></ul></ul><ul><ul><li>Acquisition of similar drugs from other medical sources </li></ul></ul><ul><ul><li>Unsanctioned dose escalation 1 – 2 times </li></ul></ul><ul><ul><li>Unapproved use of the drug to treat another symptom </li></ul></ul><ul><ul><li>Reporting psychic effects not intended by the clinician </li></ul></ul>Passik and Portenoy, 1998
  46. 48. Aberrant Behaviors N=388 Passik et al. 2003
  47. 49. Aberrant Behaviors in Cancer and AIDS Passik et al. 2003
  48. 50. 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
  49. 51. Treating Pain with Opioids: What Can We Expect to Achieve? <ul><li>Reduction in pain and suffering </li></ul><ul><ul><li>Meaningful pain reduction ( A nalgesia; Pain ) </li></ul></ul><ul><ul><li>Acceptable side effects ( A dverse effects; Price ) </li></ul></ul><ul><li>Improved functionality </li></ul><ul><ul><li>Meaningful functional improvement ( A ctivities; Performance ) </li></ul></ul><ul><ul><li>No unacceptable aberrant behavior ( A berrant bahavior; “Pees” </li></ul></ul><ul><li>The 4 A’s (Passik); the 4 “P’s” </li></ul>
  50. 52. Meaningful Pain Reduction: How Much? <ul><li>Using a VAS or numeric scale of 0–10 (4–6 = moderate pain; 7–10 = severe pain) </li></ul><ul><li>For moderate pain (mean = 6) </li></ul><ul><ul><li>Meaningful reduction = 2.4 (40%) </li></ul></ul><ul><ul><li>Very much better = 3.5 (45%) </li></ul></ul><ul><li>For severe pain (mean = 8) </li></ul><ul><ul><li>Meaningful reduction = 4.0 (50%) </li></ul></ul><ul><ul><li>Very much better = 5.2 (56%) </li></ul></ul><ul><ul><li>VAS = visual analogue scale. </li></ul></ul><ul><ul><li>Cepeda MS. Pain . 2003;105:151–157. [Evidence Level B] </li></ul></ul>
  51. 53. Analogue Pain Scale
  52. 54. Evaluation of Functional Restoration <ul><li>physical capabilities </li></ul><ul><li>psychological intactness </li></ul><ul><li>family and social interactions </li></ul><ul><li>Relationships with healthcare professionals and therapeutic outcomes </li></ul><ul><li>degree of health care utilization </li></ul><ul><li>drug use for symptom control </li></ul>
  53. 55. Remission of Addictive Disease Improves Pain and Functionality <ul><li>Increased ability to comply with regimes </li></ul><ul><li>Enhanced cognitive skills </li></ul><ul><li>Able to use behavior modification techniques </li></ul><ul><li>Improved social support </li></ul><ul><li>Better management of neuropsychiatric problems </li></ul><ul><li>Improved stress control </li></ul>
  54. 56. Meaningful Functional Improvement: My Favorites <ul><li>Patient perspective of “improvement” </li></ul><ul><ul><li>Used to do, can’t do now, would like to do again </li></ul></ul><ul><ul><li>Could be physical, social, recreational </li></ul></ul><ul><ul><li>With friends, family, church, neighborhood </li></ul></ul><ul><li>Achievable, enjoyable, and meaningful </li></ul><ul><ul><li>Hobbies </li></ul></ul><ul><ul><li>Volunteer work </li></ul></ul>
  55. 57. Pain Behavior <ul><li>Pt behavior is total out put of </li></ul><ul><ul><li>Belief </li></ul></ul><ul><ul><li>Emotional reaction to perceived “pain” </li></ul></ul><ul><ul><li>Modulation by internal neural mechanism </li></ul></ul><ul><ul><li>Modulation by external social mechanism (family) </li></ul></ul>
  56. 58. Belief, Expectation, & Outcome <ul><li>What you believe and expect and do as a result are far more important than what situation you’re in. </li></ul><ul><li>Prayers and hope are useless if you don’t recognize the answers. </li></ul><ul><li>Behavior are largely self-fulfilling prophesies; if the sky falls, it will fall on those who believe the sky is falling </li></ul><ul><li>Pain is part of life, so is uncertainty </li></ul>
  57. 59. Dr. to Patients <ul><li>What are your concerns, worries, and goals for this visit? </li></ul><ul><li>What condition you have, what will happen, what we can expect, and why we recommend what we recommend </li></ul><ul><li>Here are some specific strategies for Sx relief and for high risk situations </li></ul><ul><li>Let’s develop a plan for your future </li></ul>
  58. 60. Treating Neuropathic Pain <ul><li>Five first-line drugs: </li></ul><ul><ul><li>Gabapentin </li></ul></ul><ul><ul><li>5 % lidocaine patch </li></ul></ul><ul><ul><li>Opioid analgesics </li></ul></ul><ul><ul><li>Tramadol </li></ul></ul><ul><ul><li>Tricyclic antidepressants </li></ul></ul><ul><ul><ul><li>NIH consensus panel Arch Neurology 2003; 60:1537-1540 </li></ul></ul></ul>
  59. 61. Opioids for Neuropathic Pain <ul><li>Postherpetic neuralgia </li></ul><ul><ul><li>Neurology 1998; 50: 1837-41(60 mg/d ) </li></ul></ul><ul><ul><li>Neurology 2002; 59:1015-21 (controlled release ms 240 mg/d </li></ul></ul><ul><li>Diabetic neuropathy </li></ul><ul><ul><li>Neurology 2003; 60:927-34 (120 mg Oxycontin) </li></ul></ul><ul><li>Phantom limb pain </li></ul><ul><ul><li>Pain 2001; 90:47-55 (300mg/d) </li></ul></ul><ul><li>Peripheral and central neuropathic pain </li></ul><ul><ul><li>NEJM 2003; 348: 1223-1232 </li></ul></ul>
  60. 62. Documentation <ul><li>Why opioids are prescribed in this case </li></ul><ul><li>What reduction in pain has been achieved </li></ul><ul><li>What functional improvement has occurred </li></ul><ul><li>Document acceptable side effects </li></ul><ul><li>Document responsible medication use and absence of aberrant behaviour </li></ul>Remember: 1.What is not written down didn't happen. 2.Your record will testify in public not what patients you have but what doctor they have
  61. 63. Summary <ul><li>Pain and addiction: public health problems </li></ul><ul><li>Opioids critical in both </li></ul><ul><li>Demarcation is not always clear </li></ul><ul><li>Pathophysiological and clinical overlaps </li></ul><ul><li>Identifying risks: challenging, not hopeless </li></ul><ul><li>Core competency in both pain and addiction </li></ul>
  62. 64. Treatment of Co-occurring Disorders <ul><li>Treatment System Paradigms </li></ul><ul><ul><li>Independent , disconnected </li></ul></ul><ul><ul><li>Sequential, disconnected </li></ul></ul><ul><ul><li>Parallel, connected </li></ul></ul><ul><ul><li>Integrated </li></ul></ul>
  63. 65. Treatment of Co-occurring Disorders <ul><li>Independent, disconnected “model” </li></ul><ul><li>Result of very different and somewhat antagonistic systems </li></ul><ul><ul><li>Contributed to by different funding streams </li></ul></ul><ul><ul><li>Fragmented, inappropriate and ineffective care </li></ul></ul>
  64. 66. Treatment of Co-occurring Disorders <ul><li>Sequential Model </li></ul><ul><ul><li>Treat SA Disorder, then MH disorder </li></ul></ul><ul><ul><li>Treat MH Disorder, then SA disorder </li></ul></ul><ul><ul><li>Urgency of needs often makes this approach inadequate </li></ul></ul><ul><ul><li>Disorders are not completely independent </li></ul></ul><ul><ul><li>Diagnoses are often unclear and complex </li></ul></ul>
  65. 67. Treatment of Co-occurring Disorders <ul><li>Parallel Model </li></ul><ul><ul><li>Treat SA disorder in SA system, while concurrently treating MH disorder in MH system. Connect treatments with ongoing communication </li></ul></ul><ul><ul><li>Easier said than done </li></ul></ul><ul><ul><li>Languages, cultures, training differences between systems </li></ul></ul><ul><ul><li>Compliance problems with patients </li></ul></ul>
  66. 68. Treatment of Co-occurring Disorders <ul><li>Integrated Model </li></ul><ul><ul><li>Model with best conceptual rationale </li></ul></ul><ul><ul><li>Treatment coordinated best </li></ul></ul><ul><ul><li>Challenges </li></ul></ul><ul><ul><ul><li>Funding streams </li></ul></ul></ul><ul><ul><ul><li>Staff integration </li></ul></ul></ul><ul><ul><ul><li>Threatens existing system </li></ul></ul></ul><ul><ul><ul><li>Short term cost increases (better long term cost outcomes). </li></ul></ul></ul>
  67. 69. Thank you, thank you, and thank you…