Pain and Dependence: Pain and Dependence: screening for addiction screening for addiction

in a pain settingin a pain setting

North British Pain AssociationNorth British Pain AssociationMay 2008May 2008

Drs Steve Gilbert and Alex BaldacchinoDrs Steve Gilbert and Alex BaldacchinoNHS FifeNHS Fife

OverviewOverview

Drugs and dependence in a pain setting: Drugs and dependence in a pain setting: what does the literature tell uswhat does the literature tell us

The process of changeThe process of change DependenceDependence AssessmentAssessment Objective signsObjective signs

Historical PerspectiveHistorical Perspective

Opiophobia!Opiophobia! The Hospice movement 1960’sThe Hospice movement 1960’s WHO Pain LadderWHO Pain Ladder

BUT……BUT…… European Pain In Cancer 2007 (EPIC)European Pain In Cancer 2007 (EPIC) 50% had moderate to severe pain50% had moderate to severe pain Option of strong opioids not offered Option of strong opioids not offered 20% had no pain treatment20% had no pain treatment

PAIN IN EUROPE 2004 PAIN IN EUROPE 2004 •Strong opioids for non malignant pain

– Ireland - 13%

– Britain – 12%

– Denmark -11%

– Holland – 5%

– France Germany & Poland - 4%

– Spain - 1%

– Italy - 0% Britain had the highest

proportion of patients on opioids - 50% on “weak opioids”

+ 12% on “strong”

Where are we now?Where are we now?

Do opiates improve pain & function in Do opiates improve pain & function in chronic pain?chronic pain?

Portenoy & Foley 1986 - YES!Portenoy & Foley 1986 - YES!BUT! BUT! short term – focusing on pain scoreshort term – focusing on pain scoreLong term follow up not so optimisticLong term follow up not so optimistic

The Danish experienceThe Danish experience

Eriksen & the Danish ExperienceEriksen & the Danish Experience

Cross sectional census of populationCross sectional census of population Those on opiates had more pain Those on opiates had more pain AND less abilityAND less ability Mounting levels of prescription drug abuseMounting levels of prescription drug abuse More rather than less health service utilisationMore rather than less health service utilisationEriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. CriticalEriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical

issues on opioids in chronic non-cancer pain. An epidemiologicalissues on opioids in chronic non-cancer pain. An epidemiological

study. Pain 2006;125:172–9study. Pain 2006;125:172–9

Good Advice?Good Advice?

Problem Use and DependenceProblem Use and Dependence

Drug use terminologyDrug use terminology What is problem use?What is problem use? What is dependence?What is dependence? The alcohol dependence syndromeThe alcohol dependence syndrome Relationship between problems and Relationship between problems and

dependencedependence

Drinking and drug using careersDrinking and drug using careers

What is a drug-taking career?What is a drug-taking career? Why do we need to know about drug Why do we need to know about drug

taking careers?taking careers? Moving into and out of the drug-taking Moving into and out of the drug-taking

careercareer Does treatment alter drug and alcohol Does treatment alter drug and alcohol

careers?careers?

The process of changeThe process of change

Why is it important to understand change?Why is it important to understand change? How does it feel?How does it feel? A process of change modelA process of change model Motivational interviewingMotivational interviewing

WHAT CAN I OFFER A NEWLY PRESENTING WHAT CAN I OFFER A NEWLY PRESENTING DRUG USER?DRUG USER?

Accept your limits & define your philosophy / Accept your limits & define your philosophy / boundariesboundaries

What can I do?What can I do? What can’t I do?What can’t I do? What will I do?What will I do? What won’t I do?What won’t I do? With what do I need help?With what do I need help? Where can I get it?Where can I get it?

The Assessment ProcessThe Assessment Process

The drug & medical history The drug & medical history ExaminationExamination Screening for drug useScreening for drug use Therapeutic boundaries and goal settingTherapeutic boundaries and goal setting Objective investigationsObjective investigations

The Drug & Medical HistoryThe Drug & Medical History

Why has the patient presented to you now?Why has the patient presented to you now? How has the patient presented?How has the patient presented? Screening: AUDIT and DUDITScreening: AUDIT and DUDIT Assessment of their current drug use (last 4 weeks)Assessment of their current drug use (last 4 weeks) Past drug historyPast drug history Previous treatmentsPrevious treatments Assessing risk-taking behaviourAssessing risk-taking behaviour Assessment of physical healthAssessment of physical health Assessment of psychological health and motivationAssessment of psychological health and motivation Assessment of social situationAssessment of social situation

ExaminationExamination

• General state

• Examination of the skin

• Assessment of Resp & CVS systems

• Abdominal examination

• Musculoskeletal system

• CNS

• Special problems for women users– Contraception

– Osteoporosis

Objective signs for drug useObjective signs for drug use

Why do this?Why do this? To confirm the patient is using drugs and which To confirm the patient is using drugs and which

onesones To help decide on the treatment planTo help decide on the treatment plan For your medicolegal protectionFor your medicolegal protection For the patients protectionFor the patients protection To help reduce street diversionTo help reduce street diversion To encourage honestyTo encourage honesty

Objective signsObjective signs

Routine urinalysisRoutine urinalysis Routine bloods may be difficultRoutine bloods may be difficult Hepatitis and other BBV serologyHepatitis and other BBV serology

Goal settingGoal setting

Important to identify goals so that treatment has Important to identify goals so that treatment has direction and focusdirection and focus

Clearly identified collaboratively with the patientClearly identified collaboratively with the patient Specific, attainable and measurable split into Specific, attainable and measurable split into

short and long termshort and long term Help the patient to think about how these Help the patient to think about how these

changes may be brought aboutchanges may be brought about Assessment is a process and should be Assessment is a process and should be

sequential and ongoing as an individuals needs sequential and ongoing as an individuals needs developdevelop

WHAT CAN I OFFER A NEWLY PRESENTING WHAT CAN I OFFER A NEWLY PRESENTING DRUG USER?DRUG USER?

Brief interventionsBrief interventions FFeedbackeedback RResponsibilityesponsibility AAdvicedvice MMenuenu EEmpathympathy SSelf-efficacyelf-efficacy