Chronic Pain and Addiction
April 10-12, 2012 Walt Disney World Swan Resort
Learning Objectives:
1. Distinguish the differences between proper management of chronic pain and practices that contribute to over-prescribing and drug abuse. 2. Describe the effects and consequences of prescription pain abuse as it progresses over time. 3. Advocate the importance of continuing education on addiction for pain management 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, MD Medical Director, Lifetree Clinical Research
Salt Lake City, UT (801) 269-8200
[email protected] 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
for addic4on
Balance Risk stra4fica4on and principles of addic4on
medicine applied to opioid prescribing regardless of the pain problem at hand
Widespread Use Opiophobia must go
Definition of Terms
Katz N, et al. Clin J Pain. 2007;23:648-‐660.
Misuse Use of a medica4on (for a medical purpose) other than as directed or as
indicated, whether willful or uninten4onal, and whether harm results or not
Abuse
Any use of an illegal drug The inten4onal self administra4on of a medica4on for a non-‐medical
purpose such as altering one’s state of consciousness, e.g. geFng high
Diversion The inten4onal removal of a medica4on from legi4mate and dispensing
channels
Addic0on
A primary, chronic, neurobiological disease, with gene4c, psychosocial, and environmental factors influencing its development and manifesta4ons
Behavioral characteris4cs include one or more of the following: Impaired control over drug use, compulsive use, con4nued use despite harm, craving
Major Opioid Risks
• Opioid Use Outcomes – Misuse – Abuse – Addiction – Death
• Diversion
Statistics on Substance Use and Chronic Pain in the United States
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.
Category Statistic Chronic pain patients who may have addictive disorders
32 % (Chelminski et al., 2005)
People ages 20+ who report pain that lasted more than 3 months
56% (National Center for Health Statistics, 2006)
People experiencing disabling pain in the previous year
36% (Portenoy, Ugarte, Fuller & Haas, 2004)
People ages 65+ who experience pain that has lasted more than 12 months
57% (National Center for Health Statistics, 2006)
Civilian, noninstitutionalized U.S. residents ages 12+ who report nonmedical use* of pain relievers in past year
5% (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007)
People ages 12+ who report that they initiated illegal drug use with pain relievers
19% (SAMHSA, 2008)
People with opioid addiction who report chronic pain
29-60% (Peles, Schreiber, Gordon & Adelson, 2005; Potter, Shiffman & Weiss, 2008; Rosenblum et al., 2003; Sheu et al., 2008)
*Nonmedical use is use for purposes other than that for which the medica4on was prescribed
Spectrum of Behaviors
“Recreational
users” “Adherent” “Chemical copers”
Nonmedical Users Pain Patients
“Self-Treaters”
Kirsh, 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
Webster LR, Webster RM. Pain Med. 2005;6(6):432-‐442.
Prevalence of Opioid Abuse/Addiction
Aberrant Behavior: 40%
Abuse: 20% Total Pain Popula0on Addic0on: 2% to 5%
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
Lifetime Opioid-Use Disorder Among Outpatients on Opioid Therapy for Non-Cancer Pain
Associated With:
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.
N = 705
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.
• Age ≤45 years
• Gender
• Family history of prescription drug or alcohol abuse
• Cigarette smoking
• Physical Illnesses
• Pain severity
• Pain duration
• Sleep disorders
• Substance use disorder
• Preadolescent sexual abuse (in women)
• Major psychiatric disorder (eg, personality disorder, anxiety or depressive disorder, bipolar disorder)
• Depression
• Prior legal problems
• History of motor vehicle accidents
• Poor family support
• Involvement in a problematic subculture
• Unemployed
• Isolation
Biological Psychiatric Social
Patient Risk Factors for Aberrant Behaviors/Harm
Biological Psychiatric
Pain, Opioid Use and Psychiatric Co-morbidities
Managing a critical interplay…
Pain Opioids Psychiatric Illness
The Chemical Coper
Key Clinical Features
*Alexythymic
*Soma4zing
*Overly drug focused
*Unmo4vated for non-‐drug therapies
*Make li_le progress towards psychosocial goals
Major Depression & Pain
Blair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: A literature review. Arch Intern Med 2003; 163(20): 2433-45.
Depression & Pain
Chronic Pain
21.9%
Comorbid Depression 35%
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 addressed
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.
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.
%
Mark each box that applies Female Male
1. Family history of substance abuse Alcohol
Illegal drugs Prescrip0on drugs
1 2
4
3 3
4
2. Personal history of substance abuse Alcohol
Illegal drugs Prescrip0on drugs
3 4
5
3 4
5
3. Age (mark box if 16-‐45 years) 1 1
4. History of preadolescent sexual abuse 3 0
5. Psychological disease ADD, OCD, bipolar, schizophrenia
Depression
2 1
2 1
ORT Validation
ADD, attention deficit disorder; OCD, obsessive-‐compulsive
disorder.
Webster L, Webster R. Pain Med. 2005;6:432-‐442.
N=185
Predicting Aberrant Drug Behavior
Importance of Abuse History
Michna 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.
Opioid Use in High vs Low Risk Patients
%
Genetic Vulnerability to Addiction?
Fisher 344 Abs0nence Drug Rejec0ng
Lewis Polysubstance Abuse
Drug Seeking
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.
No addic0ve disease with exposure
Addic0ve Disease aRer opioid exposure
No addic0ve disease due to lack of exposure
Vulnerability to Opioid Addiction
Individuals respond differently to opioid exposure
Webster L, Dove B; Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. 1st ed. North Branch, MN: Sunrise River Press; 2007.
Pa0ent Stress Level
Level of Abuse in Stressful Environments
Drug-‐Abu
sing Beh
avior
Low Moderate High
19991
20061
Suicide
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.
2005 – 2007
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
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.
Escape from severe suffering Only option
Hopelessness Permanent Solution
Suicide Ideation in Chronic Pain Patients
• Hitchcock1 – 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. 2Fishbain DA. 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 with increased risk. Pain 2004;111(1-2):201-8.
N=153
Risk for Suicide Pain Patients
Family history of suicide
History of childhood abuse
Previous suicide attempts
History of mental disorder, particularly depression
Hopelessness
History of substance abuse
Impulsive and aggressive behaviors
Losses such as work, family, self-esteem
Isolation Physical illness
1Fishbain DA. The association of chronic pain and suicide. Semin Clin Neuropsychiatry 1999;(3):221-7. 2Tang NK, Crane C. Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. Psychol Med 2006;36(5):575-86.
+1: Access to poten0ally lethal doses of prescrip0on medica0ons (ie opioids)
32
Mitigate Risk
• Prescription monitoring programs • Urine drug test • Opioid agreements • Mental health evaluations • Limit dose where appropriate
Mitigate Risk
Cheatle MD. Depression, Chronic Pain, and Suicide by Overdose: On the Edge. Pain Medicine. 2011;12(s2):S43-‐S48.
Risk Stratification
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.
Lower Risk Moderate Risk Higher Risk
Primary Care Patients
Primary Care Patients with Specialist Support
Pain Specialist Patients
• May be a past history of substance use disorders
• May be family history of problematic drug use
• May have past or concurrent psychopathology
• Not actively addicted • Usually consistent UDT • PMP consistent • Mild to severe pain
• No past or current history of substance use disorders
• No family history of past or current substance use disorders
• No major or untreated psychopathology
• Consistent UDT • PMP consistent • Pain mild to moderate
• Active substance use disorders
• Major, untreated psychopathology
• Poor social support • Actively addicted • Inconsistent UDT • PMP multiple prescribers • Moderate to sever pain
ORT Score: 0-‐3 ORT Score: 4-‐7 ORT Score: 8+
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/
37
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
Thank you!