2/14/2019 1 Aberrant Drug Related Behaviours Identifying and Managing a Spectrum of Risk Andrew J Smith, MDCM Staff Physician, Pain and Addiction Medicine Centre for Addiction and Mental Health, Faculty/Presenter Disclosure Faculty: Andrew J Smith, MDCM Relationships with commercial interests: None to report ADRBs: A Spectrum of Risk Learning Objectives 1. Define aberrant drug related behaviours 2. Describe at least three elements of structured treatment of chronic pain 3. Outline an approach to managing aberrant drug related behaviours Aberrant Drug Related Behaviours • Any medication-related behaviours that depart from the agreed-upon therapeutic plan of care • Problematic behaviors or “red flags” for clinicians • Watch the language! Culture-bound, but defined by conventional practice, laws and regulations, guidelines and TREATMENT AGREEMENT • Monitoring for ADRB essential part of opioid therapy • Should be viewed as “data,” which must be interpreted in a differential diagnosis of addiction White WL, Kelly JF: Alcohol/drug/substance “abuse”: The history and (hopeful) demise of a pernicious label. Alcoholism Treatment Quarterly. 2011; 29 (3):317-321 Spectrum of Prescription Opioid Use “Adherent” Nonmedical Users Pain Patients “Self-Treaters” Passik SD, Kirsh KL. 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. Aberrant Drug Related Behaviours • Selling medications / RX Forgery • “Street” sourcing • Crushing / Snorting / Injecting • Multiple dose-escalations or other non-compliance with therapy despite discussions • Multiple episodes of prescription loss or theft • Double doctoring • Functional deterioration seemingly related to drug use • Repeated resistance to change in therapy despite clear evidence of therapeutic failure or adverse effect
Transcript
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Aberrant Drug Related Behaviours
Identifying and Managing a Spectrum of Risk
Andrew J Smith, MDCM
Staff Physician, Pain and Addiction Medicine
Centre for Addiction and Mental Health,
Faculty/Presenter Disclosure
Faculty: Andrew J Smith, MDCM
Relationships with commercial interests:
None to report
ADRBs: A Spectrum of RiskLearning Objectives
1. Define aberrant drug related behaviours
2. Describe at least three elements of structured treatment of chronic pain
3. Outline an approach to managing aberrant drug related behaviours
Aberrant Drug Related Behaviours
• Any medication-related behaviours that depart from the agreed-upon therapeutic plan of care
• Problematic behaviors or “red flags” for clinicians
• Watch the language! Culture-bound, but defined by conventional practice, laws and
regulations, guidelines and TREATMENT AGREEMENT
• Monitoring for ADRB essential part of opioid therapy
• Should be viewed as “data,” which must be interpreted in a differential diagnosis of
addiction
White WL, Kelly JF: Alcohol/drug/substance “abuse”: The history and (hopeful) demise of a pernicious label. Alcoholism Treatment Quarterly. 2011; 29 (3):317-321
Spectrum of Prescription Opioid Use
“Adherent”
Nonmedical UsersPain Patients
“Self-Treaters”
Passik SD, Kirsh KL. 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.
Aberrant Drug Related Behaviours
• Selling medications / RX Forgery
• “Street” sourcing
• Crushing / Snorting / Injecting
• Multiple dose-escalations or other non-compliance with therapy despite discussions
• Multiple episodes of prescription loss or theft
• Double doctoring
• Functional deterioration seemingly related to drug use
• Repeated resistance to change in therapy despite clear evidence of therapeutic failure or adverse effect
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Criteria Suggestive of ADRB or Use Disorder
ASAM-APS-AAPM BEHAVIORAL CRITERIA
EXAMPLES OF SPECIFIC BEHAVIORS IN OPIOID THERAPY OF PAIN
Impaired control over use Compulsive use
Frequent loss/theft reportedCalls for early renewalsWithdrawal noted at appointments
• Concurrent physical illnesses, substance use, degree of pain-related limitation
• Concurrent anxiety and depression (cross-sectional, prospective studies)
• High levels of pain catastrophizing
• SU Hx: prior SUD, recent use of illicit drugs, prior legal problems related to drug or alcohol use, prior treatment for SUD
• Reduced sleep (every extra 1 hour in avg hours of sleep reduced odds of opioid misuse by 20%)
Hah JM et al. J Pain Res. 2017 May 3;10:979-987. doi: 10.2147/JPR.S131979. eCollection 2017.Hah JM et al. J Pain Res. 2017 May 3;10:979-987. doi: 10.2147/JPR.S131979. eCollection 2017.
Opioid misuse = 1) taking an opioid prescription in a manner or dose other than prescribed or 2) taking someone else’s opioid prescription
Predictors of Opioid Misuse in Patients with Chronic Pain: A Prospective Cohort Study.Ives, et al., BMC Health Serv Res. 2006 Apr 4;6(1):46
• Prospective, cohort study to examine one year prevalence of “opioid misuse” in chronic non-cancer pain pts (n=196)
• Opioid Misuse defined as:• Negative urine toxicological screen for prescribed opioids;
• UTS positive for opioids or controlled substances not prescribed by our practice;
• Evidence of procurement of opioids from multiple providers;
• Diversion of opioids;
• Prescription forgery; or
• Stimulants (cocaine or amphetamines) on UTS
Predictors of Opioid Misuse in Patients with Chronic Pain: A Prospective Cohort Study.
• Mean patient age was 52 years, 55% were male, and 75% were white.
• Sixty-two of 196 (32%) patients committed opioid misuse.
• Detection of cocaine or amphetamines on UTS most common (40.3% of misusers).
• Misusers more likely than non-misusers• Younger
• Male
• Past alcohol abuse
• Past cocaine abuse
• Previous drug or DUI conviction
• Race, income, education, depression score, disability score, pain score, and literacy not associated with misuse
• No relationship between pain scores and misuse
Ives, et al., BMC Health Serv Res. 2006 Apr 4;6(1):46
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Predicting Aberrant Use• In one prospective study, 32 % of patients in an academic chronic
pain practice were identified as using opioids aberrantly
Opioid Misuse 62 (31.6%) of N=196
Stimulants (cocaine or amphetamines) 25 (40.3%)
Negative urines 15 (21.2%)
Doctor collecting 10 (16.1%)
Inconsistent urines (other opioids) 9 (14.5%)
Prescription forgery 2 (3.2%)
Diversion 1 (1.6%)
TOTAL 62 (100%)
BMC Health Serv Res. 2006 Apr 4;6:46.
Unexpected UDT Results
MichnaE, Jamison RN, Pham LD, et al. Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings. Clin J Pain 2007; 23: 173-179.
55%
10.2%
14.5%
17.6%
2.6%
Normal
Missing opioid
Additional drug
Illicit substance
Adulterated
Aberrant Behaviors (n = 388)
0
10
20
30
40
50
60
0 2 to 3 3 to 4 5 to 7 8+
55.4
25.3
8.5 6.74.1
% of Patientsexhibiting behs.
Number of Behaviors Reported
(Passik, Kirsh et al, 2005)
Pillar 1 : Risk Assessment
• “Universal Precautions” history (Gourlay et al, 2005)• Current and previous pain treatment• Aberrant drug-related behaviours• Previous drug and alcohol use• Family history of drug or alcohol use• History of other addictions• History of physical, sexual or emotional trauma• Depression, anxiety, and other mental health issues • Urinary drug screen and identification
• Identify the individuals with the greatest risk of aberrant behaviour NOT to stigmatize, but to improve care
The Ten Steps of Universal Precautions in Pain Medicine
1. Diagnosis with appropriate differential
2. Psychological assessment including risk of addictive disorders – PREDICTING RISK
3. Informed consent (verbal vs written/signed) - MANAGING RISK
4. Treatment agreement (verbal vs written/signed) STRUCTURED TREATMENT
5. Pre/post intervention assessment of pain level and function
D Gourlay, HA Heit, A AlmahreziUniversal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic PainPain Medicine. 2005;6(2):107-12
How do Different Risk Measures Compare?
• A retrospective study of discharged patients at a pain practice in Tennessee
• N=48
• Risk rating of each patient with all four measures:
• Clinical semi-structured interview by a psychologist
• DIRE (Belgrade et al, 2006)
• ORT (Webster & Webster, 2005)
• SOAPP (Butler et al, 2004)
• “Medium” or “High” risk rating = Accurate prediction
• This measure assesses sensitivity (not specificity)
Moore TM, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Medicine. 2009; 10(8): 1426-1433.
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Accuracy in Predicting ADRBs
Measure % Accuracy Rate
Interview 77%
SOAPP 73%
ORT 45%
DIRE 17%
Moore TM, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Medicine. 2009; 10(8): 1426-1433.
Risk Assessment: Screening Tools
• ORT demonstrated high sensitivity and specificity for detecting individuals presenting to a pain clinic at risk for developing aberrant behaviors around use of opioids (Webster, 2005)
• BUT, none of the screening tools can be recommended with confidence, because samples were small and unrepresentative (Turk, 2008)
• A personal history of abuse of illicit drugs or alcohol remains the strongest predictor of opioid misuse and abuse
Turk DC, et al. Clinical Journal of Pain 2008 Jul;24(6):497-508.Webster LR, Webster RM. Pain Med. 2005;6:432-442.
ARDB Differential Diagnosis
OPIOID RECEPTOR ISSUES
• Opioid-induced hyperalgesia
• Opioid unresponsive pain
• Withdrawal-mediated pain
ORGANIC BRAIN DYSFUNCTION
• Concurrent benzodiazepine use
• Traumatic brain injury
• Confusion around schedules
ARDB Differential Diagnosis
PSYCHOLOGICAL ISSUES
• Personality Disorders - Cluster B
• Chemical coping
• Mood or anxiety co-morbidities
OPIOID USE DISORDER
“PSEUDOADDICTION” – NB CAUTION
DIVERSION
Addiction vs. Pseudoaddiction in Pain Management
Addiction – Prospectively
Patient’s behavior and complying with the treatment agreement becomes aberrant despite “Rational Pharmacotherapy.”
Pseudoaddiction - Retrospectively
Patient’s behavior and complying with the treatment agreement normalizes with “Rational Pharmacotherapy.”
Gourlay D, Heit HA et al. Pain Med. 2005;6(2):107-112.
Pseudoaddiction: Fact or Fiction• Undertreatment of pain (rather than addiction) is the
more pressing problem in opioid-seeking patients
• Pseudoaddiction cited in 224 articles (as of 2014)
• Only 18 questioned the concept
• NONE empirically tested or confirmed its existence
• 12 articles were proponents (and all 4 receiving pharma funding) “an iatrogenic disease resulting from withholding opioids for pain that can be diagnosed, prevented and treated with more aggressive opioid therapy”
• Has “pseudoaddiction” contributed to the real iatrogenic prescription opioid epidemic?
Greene, MS et al. Curr Addict Rep (2015) 2:310–317
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• Nobody wants to call it addiction
• It often doesn’t look like “addiction”
• It is pathological
• It does destroy lives
• It is avoidable, and it is treatable
Dependence on Opioid Pain Medications AIDS Patients and Aberrant Behaviors
Adequate
Analgesia
(n=49)
Inadequate
Analgesia
(n=24)
Total # of aberrant behaviors 305
(6.2)
152
(6.3)
Aberrant behaviors “probably
less predictive of addiction
239
(78%)
116
(74%)
Aberrant behaviors “probably
more predictive of addiction
66
(22%)
40
(26%)
Passik SD, et al. Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse. Clinical Journal of Pain. 2006; 22(2): 173-181.
Structured Treatment
• Based on assessment, categorize patient into low or high perceived risk• Structure the therapy to match the perceived risk
• Improves the ability to monitor
• May help the vulnerable patient maintain control
• Stigma can be reduced• Overall risk contained
• Patient care improved
Structured Treatment
• May initiate therapy with:
• Requirement of all prior records and permission to contact other health care professionals
• Requirement of consultation with addiction medicine specialist or other mental health professional
• Written agreement, perhaps a formal “contract”
• Prescription of long-acting drug only
• Frequent visits
• Small prescription (one-week or two-week supply)
Structured Treatment
• May initiate therapy with:• Urine drug screen
• Requirement that only one pharmacy be used
• Requirement that pill bottle be returned for count
• Instruction that there will be no early refills or replacement of loss drug without police report
• Requirement of concurrent nonpharmacologic therapy
• Requirement that others (e.g., spouse) be allowed to comment periodically on progress
Structured Treatment• Opioid “contract”: common elements
• Avoid improper use
• Terms of disciplinary termination
• Limitations for replacing or changing prescriptions
• Inform physician (e.g., side effects, other meds)
• Random drug screens
• Terms regarding appointments
• Requirement for consultation
• Limits on drug refills (e.g., phone allowances or in person)
• Side effects education (including withdrawal)
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Monitoring Outcomes
Monitoring drug-related behaviors:
• Step 1: Are there aberrant drug-related behaviors
• Step 2: If yes, REASSESS (consider consultations)
