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When is your pain patient addicted?

When is your pain patient addicted?. Richard L. Stieg, M.D., MHS www.centen.net www.richardlstiegmd.com May 16, 2012. Centennial Rehabilitation Associates Chronic Pain Specialists. Dr. Richard Stieg, MD MHS and Centennial Rehabilitation Associates.

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When is your pain patient addicted?

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  1. When is your pain patient addicted? Richard L. Stieg, M.D., MHS www.centen.net www.richardlstiegmd.com May 16, 2012 Centennial Rehabilitation Associates Chronic Pain Specialists

  2. Dr. Richard Stieg, MD MHS and Centennial Rehabilitation Associates • One of the founders of the field of Pain Medicine and instrumental in training fellows • President of the American Academy of Pain Medicine (1990-present) • President of the Colorado Society of Clinical Neurologists (1979-1980) • President Western USA Pain Society (1983-1984) • Board certified in Neurology and Pain Medicine, holds a Specialty Certificate in Addiction Medicine • Level II physician with the Colorado Division of Workers' Compensation • Medical Director, Pinnacol Assurance (1994-2001) • Associate Medical Director of Centennial Rehabilitation Associates since 2002 Centennial Rehabilitation Associates provides a multidisciplinary approach to chronic pain treatment that is unique to Colorado and the surrounding area. Based on the “gold standard” set by the Colorado Division of Workers’ Compensation, our program is designed to address both the physical and behavioral components of chronic pain.

  3. Outline Part I Definitions and incidence of chronic pain and addiction in America Dual diagnosis patients: introduction to problems in evaluation and treatment Part II Treatment options Use of prescription drugs Standards of care Buprenorphine and Methadone Solutions

  4. Chronic Pain Any pain which is unremitting or lasts beyond expected healing time, when associated with disease or injury. May defy easy explanation. The patient usually expresses the problem in terms of an injured or diseased body part. There is now evidence that for some people it is a chronic disease characterized by physiological changes in the central nervous system that may be altered by biological, social and spiritual factors.

  5. Pain Disorder, Chronic (DSM-IV) • Pain in one or more area, sufficient to need clinical attention • Pain causes distress or impairment in social, occupational or other functional areas • Psychological factors playing an important role in the severity, exacerbation or maintenance of pain • The symptoms are not being intentionally produced or feigned (as in Malingering) • The pain is not better accounted for by a Mood, Anxiety or Psychotic disorder

  6. The estimated prevalence of chronic pain in the US is ~70 million

  7. Addiction -- ASAM/AAPM/APS A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over use, compulsive use, continued use despite harm and craving.

  8. Substance Abuse (DSM-IV ) • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12 month period: - A failure to fulfill major role obligations at work, school or home (e.g. repeated absences, truancy, child neglect) - Recurrent use in situations in which it is physically hazardous (e.g. driving while impaired) - Recurrent substance-related legal problems - Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance • The symptoms have never met the criteria for “Substance Dependence” for this class of substance

  9. Substance Dependence (DSM-IV) • A syndrome characterized by a maladaptive pattern of substance abuse, leading to clinically significant impairment or distress, as manifested by 3 or more of the following, occurring in the same 12 month period: • Withdrawal • Tolerance • Substance is taken in larger amounts or for longer than Rx • Persistent desire or unsuccessful efforts to cut down or control • A great deal of time spent in activities to obtain substance • Important social, occupational or recreational activities are given up or reduced because of substance use • Use continues despite the user’s knowledge that he/she has a persistent or recurrent problem that is caused by or exacerbated by the substance

  10. Incidence of illicit drug usefrom DAWN (Drug Abuse Warning Network) from 1990-2001 • Marijuana: 15,706 - 110,512 (up 604%) • Heroin: 33,884 - 94,804 (up 180%) • Cocaine: 80,000 - 180,000 (up 125%) • Methamphetamine/speed varied between 15,000 - 19,000 (n/c) • Prescription drugs: sedative-hypnotics, benzodiazepines, narcotics, stimulants

  11. Dual Diagnoses----Who Gets Treatment?(U.S. Government study) • 18 million have Serious Mental Illness/ 4 million with associated alcohol and/or drug problem 34% mental illness rx only 2% addiction rx 12% dual rx 52% no rx • 20 million need alcoholor drug rx 14% received it

  12. Reasons for inadequate care of pain patients in the United States • Inadequate training of healthcare professionals • Poor public and professional knowledge • Public fear of narcotics • Charlatanism in pain treatment • Few outcomes-based practice standards • Roadblocks to access

  13. FROM THE NATIONAL CENTER FOR HEALTH STATISTICS MMWR / August 20,2010 / Vol. 59 / No. 32

  14. Published rates of abuse/addiction in chronic pain population are ~ 10% (3-18%) • This suggests that known risk factors for • abuse or addiction in the general population would be good predictors for problematic prescription opioid use: • > History of early substance use • > Personal/family history of substance abuse • > Co-morbid psychiatric disorders

  15. Is the pain “real”? Physiological Pain Non-organic factors contributing to pain Factitious or malingering? The use of pain medications to manage emotions

  16. Tolerance Need for more drug for same effect Diminished effect with same amount of drug

  17. Withdrawal Physiological and psychological consequences of decreased dose Use of substance to avoid withdrawal

  18. Behavioral Indicators of Medication Use Problems Runs out of medications early Has multiple prescribers Obtains medications from others Has difficulty functioning due to over-medication Watches the clock for next dose Takes medication for other than pain relief Gradually increasing dose to manage pain Poor pain control with medication

  19. Appropriate use of narcotics • Psychological assessment does not suggest substance abuse problem • Patient has physiological pain • Patient has a pain disorder

  20. Centennial Rehabilitation Associates Chronic Pain Specialists Half-Time Q&A

  21. Addiction and Chronic Pain Distinct biological entities May coexist Pharmacologic treatment is different Physical treatment is different Psychosocial treatment shares some common elements (e.g. learning to cope, 12-step tx.)

  22. Traditional treatment doesn’t address both pain and addiction – important to treat both the pain and the addiction

  23. Who is best qualified to evaluate and treat dual diagnosis patients? • There are many good addiction programs: almost all emphasize abstinence as part of treatment • The literature strongly supports the use of multidisciplinary pain programs as the gold standard, but these have largely disappeared • Today’s pain specialists emphasize interventional strategies: most have no interest in treating addiction • There are very few dual programs or practitioners

  24. The use of prescription drugs in dual diagnosis patients This is the major public health issue How has the problem evolved? What are the solutions?

  25. Treating the dual diagnosis patient • Non-pharmacological treatment is the ideal • The ideal is rarely accomplished • The reasons: lack of funding, lack of specialists, persistent disease (e.g. chronic pain requiring opioid management or opioid addiction requiring maintenance) • Presence of psychiatric disease confounding care

  26. Why use opioids for chronic non-malignant pain before end-of-life care? The drugs may adequately control pain They may help to maintain physical and emotional functionality They may be the only treatment available

  27. Important questions about usage Who are appropriate candidates for chronic opioid therapy? When is it time to remove narcotics? How should “breakthrough pain” be treated? What is the “downside” of lifetime use? How will government regulatory agencies continue to deal with users and dispensers of these drugs?

  28. Important questions (continued) • How many problem drug users are we creating? • How can we best identify the problem drug user? • How is problem drug use treated/does it always require opioid withdrawal? • Is Buprenorphine the “dream medication” for opioid withdrawal/opioid maintenance?

  29. What do we know about standards of care in evaluating and treating patients with drugs that can be abused? 1. Numerous published guidelines by state medical boards and medical specialty organizations 2. An abundant literature in peer-reviewed publications, trade journals and the lay press about the dangers involved 3. Availability of prescription drug monitoring programs

  30. Common themes in published guidelines1. Careful history and physical exam with attention to risk factors associated with potential substance abuse 2. Periodic reassessment of risk factors, drug efficacy, need for continued use of specific drugs3. Utilization of less risky treatment when available4. Proper utilization of specialty consultations5. Attention to drug interactions, signs of overdosing, abusing, diverting, use of drug monitoring programs and urine drug testing6. Written documentation of drugs dispensed and all of the standards listed above

  31. Drug Testing Should be used to manage care---not to punish Should be consensual with honest explanation to patient Provides objective evidence of compliance with a mutually agreed-upon treatment plan Aids in diagnosis and treatment of all disorders present Can be an advocate for patient in family and social issues Assesses only the presence of a drug class or a particular drug in a specific concentration at a moment in time It does not diagnose drug abuse, dependency or addiction Clinical judgment should dictate use

  32. Buprenorphine • Binds tightly to the opioid receptor (“high affinity”) • Long half-life (30 hours) • Partial agonist (70 percent activity) • Produces little or no euphoria • Generally has fewer untoward reactions • Requires special DEA license

  33. Buprenorphine plus Naloxone • SubutexBuprenorphine 2 mg or 8 mg • SuboxoneBuprenorphine with Naloxone 2.0mgm/0.5mgm 8.0mgm/2.0mgm • Buprenorphine 2 mg with naloxone 0.5 mg • Buprenorphine 8 mg with naloxone 2 mg • The only purpose of the naloxone is to prevent people from crushing and injecting the tablet - naloxone is not absorbed from the mouth

  34. Why use Buprenorphine for Chronic pain? Crossover from short acting opioids Presence of suspected or known opioid dependency/addiction Safety profile/ “ceiling effect” Convenience of administration Withdrawal usually mild Analgesia less than morphine

  35. Methadone for the treatment of opioid addiction and chronic pain Only licensed clinics can treat addiction Any provider can write for pain treatment, but few have the requisite expertise An excellent drug for central neuropathic pain with unique pharmacological properties Extremely dangerous if used improperly/rising death rate in the U.S. and modern countries Very inexpensive ($30-$40/month for pain tx)

  36. References • Savage,S. Long-term Opioid Therapy:Assessment of Consequences and Risks. J.Pain and Symptom Management:11(5).274-286, 1996. • Webster,L. & Fine,P. Approaches to Improve Pain While MinimizingOpioid Abuse Liability. The Journal of Pain: 11(7). 602-611,2010 • Becker,WC et al. Nonmedical Use of Opioid Analgesics Obtained Directly From Physicians: Prevalence and Correlates. Arch.Intern.Med. 171(11). 1034-1036, 2011 • Radley Balko. The War Over Prescription Painkillers. http://www.huffingtonpost.com/radley-balko/prescription-painkillers_b_1240722.html?ici... • Institute of Medicine 2011 Report. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Resear

  37. Website References 1.American Pain Society : www.ampainsoc.org 2.AAPM: www.painmed.org 3.American Chronic Pain Assoc:http://theacpa.org 4. www.enotifications@pain-topics.org 5.http://www.uspainfoundation.org

  38. Centennial Rehabilitation Associates Chronic Pain Specialists Next Webinar • Wednesday, June 20th from 12-1pm (MT) “Behavioral Interventions with Chronic Pain Patients” • Presented by Beverly Noyes, PhD This program has been submitted to The Commission for Case Manager Certification for approval to provide board-certified case managers with 1 clock hour. To register, go to www.centen.net

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