Pain and Addiction: More Than a Feeling

1. Pain and Addiction: More Than a Feeling Walter Ling, MD Integrated Substance Abuse Programs (ISAP) UCLA Dept. of Psychiatry Pacific Southwest ATTC Tenth Annual Training and Educational Symposium September 18, 2013 lwalter@ucla.edu www.uclaisap.org

2. Pain and Addiction: Role of the Opioids • Scope of the talk: • Addiction: a brain disease • On becoming and staying addicted • Defining pain: acute and chronic pain • Addiction in pain patients: how to tell • Opioids: the two faces of Janus • Opioids in chronic pain • Overcoming addiction and chronic pain

3. Addiction: A Brain Disease What, Where, and How • Our Three Brains • Reptilian brain: Survival--feeding, fighting, fleeing, reproducing • Limbic brain: memory and emotion—love, attachment, consideration for others, foundation for community and civilization • Cortical brain: CEO and operating system--intelligence, intuition, insight flexibility, speed, efficiency, creativity, morality, free will, meaningful life, uniquely human, under construction

4. COCAINE AMPHETAMINE 1100 Accumbens 1000 400 900 800 DA 300 700 DOPAC % of Basal Release HVA 600 % of Basal Release 500 200 400 300 200 100 100 0 0 1 2 3 4 5 hr 0 0 1 2 3 4 5 hr Time After Amphetamine Time After Cocaine NICOTINE MORPHINE 250 Accumbens 250 Dose (mg/kg) Accumbens 200 0.5 200 1.0 Caudate % of Basal Release % of Basal Release 2.5 150 10 150 100 1 2 3 hr 0 100 0 0 0 1 2 3 4 5hr Time After Nicotine Time After Morphine Addiction: Why Do People Take Drugs? Dopamine People Take Drugs To: Feel Good (Sensation seeking) Feel Better (Self medication) One way or the other they like what drugs do to their brain

5. Dopamine Conditioned Response: Reward DrivenLearning, Memory and Behavior Dopamine: the brain’s motivational or “feel good” chemical. It makes us want to do it again—to repeat what activates its release Dopamine is also involved in reward-driven learning and memory: conditioning 1849-1936 Pavlov’s Dog Conditioned learning incorporates the drug use environment into drug use memories and adds weight –salience—to these memories, giving them higher priority in driving drug use behavior until it takes over everything. (

6. How the Brain Got Its Addiction • You begin with a normal brain and subject it to repeated exposures to drugs: dopamine spikes • Repeated reward-driven, salient, learning experiences became encoded as enduring conscious and unconscious memories. • The reward-driven salient drug use memories gain higher and higher priority in driving drug use behaviors until they take over everything—extreme take over. • This is how the brain got its disease of addiction. • “First the man takes a drink, • then the drink takes a drink, • then the drinks takes the man”. Japanese proverb Disconnection between the limbic and cortical brain, an extreme take over brain disease

7. Becoming and Staying Addicted: A Matter of Drugs and Memory • Becoming addicted is a matter of drugs • Staying addicted is a matter of memory • The problem of addiction is not getting off drugs; it’s staying off drugs. • Detoxification may be good for a lot of things, but staying off drugs is not one of them • To stay off drugs—relapse prevention—you have to deal with drug memories: no memory, no relapse • Relapse prevention means substituting drug memories with non-drug memories.

8. Defining Pain • Pain: An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. • It is always subjective. Each individual learns the application of the word through experiences related to injury in early life.—IASP IASP = International Association for the Study of Pain Early life -- historical Experience--learned Subjective--private Individual--unique

9. Acute Pain Physiological; protective Causes external; obvious Tissue damage; resolution expected within days/wks Symptom of illness Happens TO you Key issue: what pain? Meds/big role vs self Chronic Pain Pathological; non-protective Causes internal; obscured CNS changes; resolution depends on mastery/control Disease & way of life Happens IN you Key issue: what patient? Meds/limited role vs self Acute vs Chronic Pain: The Acute pain patient is afflicted; the Chronic patient is transformed. Chronic pain sufferer suffers for nothing

10. The one certain thing: treatment didn’t work Patient frustrated and lost faith in doctors Patient blamed for not getting better Lost “role”; becomes dependent on others Others must pick up slack and provide support Patient feels neglected when others can’t do all Patient becomes anxious, angry and depressed Patient assumes life style of chronic pain When Pain Becomes Chronic

11. Defining Addiction in Pain Patients • Addiction….is characterized by behavior that includes one or more of the following: impaired Control over drug use, Compulsive use, Continued use despite harm, and Craving AAPM/APS/ASAM • Addiction is not taking lots of drugs; it’s taking drugs and acting like an addict. • Addicts are addicts not for who they are, but for what they do.

12. Who’s at Risk and How to Tell? • 4 Ways to identify patients at risk • History—personal history and family history • Screening instruments • Behavioral checklists • Therapeutic maneuver

13. History • What predicts addiction? • Personal history of drug use • Family history of drug use • Current addiction to alcohol or cigarettes • History of problems with prescriptions • Co-morbid psychiatric disorders • Same predictors as in non-pain patients Screening Instruments • Several clinical tools are available that estimate risk of noncompliant opioid use1,2,3 • The results determine how closely a patient should be monitored during the course of opioid therapy3 • Scores implying a high risk of misuse are not reasons to deny pain relief3 • 1 Webster, et alr. Pain Med. 2005;6:432. • 2 Coambs, et al. Pain Res Manage. 1996;1:155. • 3 Butler, et al. Pain. 2004;112:65.

14. Mark each box that applies: Female Male • Family history of substance abuse • Alcohol 1 3 • Illegal drugs 2 3 • Prescription drugs 4 4 • Personal history of substance abuse • Alcohol 3 3 • Illegal drugs 4 4 • Prescription drugs 5 5 • Age (mark box if between 16-45 years) 1 1 • History of preadolescent sexual abuse 3 0 • Psychological disease • ADO, OCD, bipolar, schizophrenia 2 2 • Depression 1 1 • Scoring totals: Opioid Risk Tool (ORT) • Administration • On initial visit • Prior to opioid therapy • Scoring • 0-3: low risk (6%) • 4-7: moderate risk (28%) • > 8: high risk (> 90%) Webster, et al. Pain Med. 2005;6:432.

15. Screener and Opioid Assessment for Patients in Pain (SOAPP) • 14-item, self-administered form, capturing the primary determinants of aberrant drug-related behavior • Validated over a 6-month period in 175 chronic pain patients • Adequate sensitivity and selectivity • May not be representative of all patient groups • A score of ≥ 7 identifies 91% of patients who are high risk Butler, et al. Pain. 2004;112:65. SOAPP® V.1 – 24Q Butler S et al, Pain, 2005

16. Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient’s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Recurrent prescription losses Probably less predictive Aggressive complaining about need for higher dose Drug hoarding during periods of reduced symptoms Requesting specific drugs Acquisition of similar drugs from other medical sources Unsanctioned dose escalation 1 – 2 times Unapproved use of the drug to treat another symptom Reporting psychic effects not intended by the clinician Aberrant Drug-Taking Behaviors Passik and Portenoy, 1998

17. Aberrant Behaviors in Cancer and AIDS Passik et al. 2003

18. Probability of positive urine toxicology by number of aberrant behaviors Higher prevalence of SUD among pts on opioids for chronic pain than general population (8.1% current users) Katz N et al, Clin J Pain, 2002

19. Therapeutic Maneuver: Is the Pain Patient Addicted? Drug-seeking or increased requests for pain medication  Pathology/pain of new source Detailed pain work-up No new pain pathology  Opioid dose Improved functioning Absence of toxicity Unimproved functioning Presence of toxicity Therapeuticdependence Pseudoaddiction Addictive disease

20. Opioids in Chronic Pain: The Two Faces of Janus • Opioids: • Relieve pain • Relieve suffering • Relieve misery • Make you feel better • Make you feel good • Make you “high”

21. Use of Opioids for Chronic Pain

22. Treating Pain with Opioids: What Can We Expect to Achieve? • Reduction in pain and suffering • Meaningful pain reduction (Analgesia; Pain) • Acceptable side effects (Adverse effects; Price) • Improved functionality • Meaningful functional improvement (Activities; Performance) • No unacceptable aberrant behavior (Aberrant behavior; “Pees” The 4 A’s (Passik); the 4 “P’s”

23. Meaningful Pain Reduction • Using a VAS or Numeric scale of 0-10 • (4-6= mod pain; 7-10= severe pain) • For Moderate pain ( mean=6) • Meaningful reduction=2.4 (40%) • Very much better=3.5 (45%) • For Severe pain (mean=8) • Meaningful reduction=4.0 (50%) • Very much better=5.2 (56%) M. Soledad Cepeda et al. Proc 10th world Cong on Pain vol 24; pp 601-609 IASP press 2003

24. Meaningful Functional Improvement: My Favorites • Patient perspective of “improvement” • Used to do, can’t do now, would like to do again • Could be physical, social, recreational • With friends, family, church • Achievable, enjoyable, and meaningful • Hobbies • Volunteer work

25. Chronic Pain and Suffering: Some Basics • Chronic pain hurts, but seldom harms • Chronic pain patients are not bothered by pain; they are plagued by suffering. • Pain happens to you, suffering happens in you. • Pain is the enemy outside; suffering is the demon within. • Pain is inevitable and universal, suffering is optional and individual • Pain can be likened to how much money you owe; suffering is how poor you feel. • Suffering cannot be cured, it can only be conquered and mastered.

26. Characterized by aberrant behaviors that persist despite their being destructive and detrimental to one’s best interest. Behaviors are based on a distorted belief system rooted in deeply ingrained learning and memory of past experiences. Both involve brain changes that result in the hyperexcitability of a lower brain and loss of control from a higher rational brain Neither can be gotten rid of but must be overcome with new and different reward-driven learning life experiences creating a new memory bank and a new belief system and new behaviors. We are all created equal, but we don’t sit down at the table with the same hand; hence, different clinical expressions. Chronic Pain and Addiction: Memory Matters

27. Chronic pain Early trauma Loss of mastery Loss of control Loss of sense of self Cognitive error “Personalization” Over interpretation “Catastrophization” Addiction Early trauma Loss of mastery Loss of control Loss of self-efficacy Cognitive error “Nirvana” Denial Chronic Pain and Addiction:Common Overlapping Features

28. Overcoming Chronic Pain • The sufferer of chronic pain is permanently preoccupied by it and suffers as a result. • Overcoming chronic pain means learning to overcome suffering, no matter what happens. • Be prepared physically and emotionally • Actually engage in the act and take charge • Reconnect and become engaged with friends and family and community • Regain a meaningful balanced life

29. How Not to Succeed • 1. Don’t attend • 2. Try not to learn anything • 3. Don’t do any of the exercises • 4. Don’t try any of the techniques • 5. Keep a closed mind • 6. Resist change • 7. Look and act miserable • 8. Tell yourself “nothing will help me” • 9. Remain very serious and never smile • 10. Don’t share anything (R. N. Jamison)

30. Relapse: A Three-Character Play • Drug memories: …everything, seems to bring memories of you…(Eubie Blake) • Cues and triggers: external and internal; craving and desire for love lost—regression & comfort • Emotional buildup: justification for use—the internal dialogue making use okay and natural • Relapse does not happen by accident.

31. Treating Chronic Pain and Relapse Prevention: Forget It? • Addiction is memory; so is chronic pain • No memory, no relapse; no memory, no suffering • Both are brains transformed—cannot be gotten rid of, can only be conquered and controlled • Both require memory substitution • Behavior creates experience, experience creates memory, memory creates belief systems, belief systems determine new behavior, new behavior determines new outcome. • Change your memory, change your brain, change your brain, change your life. • The only way to have your life turn out different is to act differently.

32. Creating Non-Drug Memories: The Old Fashion Way • Experience–activities—leads to protein synthesis • Protein synthesis activates new gene expressions • Gene expressions create new brain connections • New brain connections produce new memories • New non-drug memories create non-drug belief systems that determine behaviors that determine how life turns out. • The only way to change your life is to do things differently so they will turn out different.

33. Preventing Relapse:Eight Steps to a Drug-Free Life • Sound physical health • Sound mental health • Stay off drugs and stay busy • Take care of business: out of jail and on the job • Take personal responsibilities • Live in harmony with family and friends • Be a good member of the community • Search for a meaning in life.

34. Spirituality, Mindfulness, and a Meaningful Life In a Nutshell • Mindfulness of motivation: Doing good for someone else is better than feeling good yourself; it’s the true path to happiness. • Mindfulness of wisdom: Conventional reality is an illusion; Inherent reality is emptiness. All things follow the laws of impermanence and non-self. Nothing lasts forever, nothing can be possessed, and you can’t take anything with you.

35. What Are We? Unique or Random? Thank you Thank you Thank you