Diagnosing Addiction in Chronic Pain Patients

1. Diagnosing Addiction in Chronic Pain Patients Karen Miotto, M.D. UCLA/MATRIX Addiction Medicine Service

2. Terminology of Abuse • Dependence - the need to maintain administration of a substance to prevent the appearance of an abstinence syndrome • Tolerance - decreased effectiveness of a pharmacologic agent after prior administration • Physical dependence (Habituation) - dependence and tolerance in the non-addicted patient

3. Continuum of Problematic Opiate Use mild indiscretionrepeated misuse   opiate abuse opiate addiction

4. Complexity of Addiction • Drug craving and pain, conditioned withdrawal • Rebound pain associated with subclinical withdrawal • Difficulty with time contingent dosing • Supplemental dosing • Tolerance • Medical procedures and the pursuit of drugs

5. Pseudo-addiction • Drug-seeking behaviors • Medications taken in larger amounts than prescribed • Premature running out of medications • Family concerns about medication • Withdrawal symptoms • Weissman, DE, Pain vol 36, 1989

6. The Grey Areas • Drug and Narcotic Codes • Describes circumstances when addicts can be treated with narcotics • terminology problems “dependent or addicted” • High dose patients more often labeled addicted. Does tolerance = addiction? • Leading trigger for Medical Board Review is “overprescribing” • Large variations in doctors assessment of pain and addiction • Problems of documentation

7. Addiction Consultation: Clarify the Question • Suspected addiction • Increased tolerance • Side effects of opiate analgesics • Fear of regulatory sanction • Desire to terminate care • Detoxification recommendations • sources of information, doctor, office staff, nurses, family

8. Addiction Consultation: The Interview • Normalize the process • Inquire about the patient’s pain • Determine the patients understanding of why the consultation was requested • Appreciate the fear and stigma associated with an addiction consultation for many pain patients

9. Questions to Probe for Prescription Drug Abuse • Pain source • single or multiple sources of pain • Chronic pain syndrome • Relationship with doctors • Have doctors terminated care or refused to prescribe • Legal involvement

10. Questions to Probe for Prescription Drug Use • Patients with a remote history of substance abuse • Patients with a history of opiate abuse on methadone maintenance • Patients currently abusing drugs • Family history of drug abuse • Drug use patterns of friends or spouse

11. Acquisition of Prescribed Drugs • Preference for specific opiates or routes • Non-medical sources of purchase • Prescription drug sale • Prescription forgery • Contacts with multiple medical doctors, dentists • Frequent ER visits

12. Clinical Features of Prescription Drug Abuse • Repeated unsanctioned dose escalation • Repeated use of opiates to treat symptoms other than those targeted by the therapy • Hoarding drugs • Supplementing with other drugs • History of overdose

13. Clinical Features of Prescription Drug Abuse • Difficulty stopping opiates when alternative treatment is available • Lack of cooperation with alternative pain management techniques • Disproportionate complaints of pain • Adverse life consequences due to medication use • Sees & Clark, J Pain Symp Manage, 1993

14. Evaluation of the Family • Family history of addiction • Family history of pain/pain syndrome • Family member with access to narcotics • Contribution to “illness behavior” • Contribution to addiction

15. Questionnaire Responses Multiple providers MD/DDS MD/DDS limited care No Addiction Physician Addiction dx addiction Self report addiction 0 10 20 30 40 50 60 70 80 90 100 percentage affirmative

16. 0 10 20 30 40 50 60 70 80 90 Questionnaire Response Route of admin preference Supplements with drugs/etoh Use opiates for other sx No Addiction Addiction Increased dose/frequency Multiple providers percentage affirmative

17. Questionnaire Responses Previous opioid detox Hx of addiction tx Pt hx of addiction No Addiction Addiction Hx of chronic pain relative Hx of addiction in relative 0 10 20 30 40 50 60 70 percentage affirmative

18. Evaluation of Psychosocial Factors • Pain is unavoidable, misery is optional • Intensifiers of pain: fear, anger, guilt, loneliness, helplessness • Repeated victimization • workers compensation • Catastrophizing and coping

19. Multiple Pains and Psychiatric Disturbance • Multiple pain conditions are common in the population • Multiple pains are associated with anxiety and depressive disorders • Less predicative of depression are pain intensity, severity, or persistence • Somatization hypothesis • Dworkin, S Arch Gen Psy, Vol 47, 1990

20. Patient Education • Lack of euphoria does not exclude addiction • Individual nature of opiate withdrawal • rebound pain • Role of a responsible patient • Triggers for problematic medication use • Factors which exacerbate pain

21. Recommendations: Treatment Tools • Treatment contract • S Fishman et al J Pain and Sym Management, July, 1999 • Medication log/Single pharmacy • Random urine monitoring (GC/MS) • Feedback from family and friends

22. Recommendations: Treatment Tools • Diversion safeguards • Small amounts of medication dispensed • family member, friend, pharmacy • Comprehensive pain treatment program • Addiction treatment

23. Addiction Treatment for Chronic Pain Patients • Detoxification • When continued opiate analgesia is indicated • Participation in substance abuse programs • Participation in 12-step programs • Medically ill substance use group

24. Similarities in Effective Drug and Chronic Pain Treatment • Cognitive therapy • Behavior modification • Involvement of the family • Treating concurrent psychological or psychiatric problems • Relaxation, exercise and conditioning • Group support • Structured activity

25. Acetaminophen Aspirin NSAID Fioricet, Repan, Esgic Fiorinal, Lanorinal, Marnal Tylenol with Codeine No 1 (7.5mg), No 2 (15mg) No 3 (30mg), No 4 (60mg) Acetaminophen with synthetic codeine preparations Demerol Other narcotics, administered orally, intranasally, transdermally or parenterally Analgesic Agents

26. Acetaminophen • Variable amounts of acetaminophen in analgesic preparations • Total daily dose should not exceed 4000 mg • Hepatotoxicity may occur after a single dose of 10 -15 grams • N-acetyl-benzoquinoneimine • 20 to 25 grams are potentially fatal • Renal tubular necrosis, hypoglycemic coma

27. Meperidine - (Demerol) • Mu agonist, 75 to 100 mg = 10 mg morphine (parenterally) • Oral bioavailability limited • Duration of analgesia 3 to 5 hours (t1/2 3 hrs.) • Metabolite normeperidine t1/2 15 to 20 hrs • Normeperidine active metabolite

28. Meperidine - (Demerol) • Urinary excretion primary route of drug elimination • Renal dysfunction promotes increase normeperidine • Acidic urine increased elimination of normeperidine • CNS excitation - anxiety,delirium, psychosis,hyper-reflexia, tremors, multifocal myoclonus, seizure

29. Butorphanol (Stadol) • Transnasal butorphanol • Acute migraine treatment • Agonist/antagonist • Intranasal dose 0.5 to 2 mg • Abuse potential

30. Codeine • Metabolism in humans exhibits genetic polymorphism • Metabolism of codeine to morphine by cytochrome P450 IID6 isoenzyme • Multiple metabolites (morphine-6-glucuronide) • Poor metabolizers less pain tolerant

31. Smooth Muscle Relaxants D r u g B r a n d N a m e H a l f - l i f e C a r i s o p r o d o l S o m a 8 h P a r a f l e x 1 - 2 h C h l o r z o x a z o n e F l e x e r i l 1 - 3 d a y s C y c l o b e n z a p r i n e R o b a x i n 1 - 2 h M e t h o c a r b a m o l O r p h e n a d r i n e N o r f l e x 1 - 3 d a y s

32. Myorelaxants • Chemical heterogeneity of agents • Depress polysynaptic reflexes • Nonspecific sedative properties • Carisoprodol (Soma) meprobamate precursor (abuse potential) • Cyclobenzaprine (Flexeril) structurally similar to tricyclic antidepressants