diagnosing addiction in chronic pain patients n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Diagnosing Addiction in Chronic Pain Patients PowerPoint Presentation
Download Presentation
Diagnosing Addiction in Chronic Pain Patients

Loading in 2 Seconds...

play fullscreen
1 / 32

Diagnosing Addiction in Chronic Pain Patients - PowerPoint PPT Presentation


  • 171 Views
  • Uploaded on

Diagnosing Addiction in Chronic Pain Patients. Karen Miotto, M.D. UCLA/MATRIX Addiction Medicine Service. Terminology of Abuse. Dependence - the need to maintain administration of a substance to prevent the appearance of an abstinence syndrome

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Diagnosing Addiction in Chronic Pain Patients' - Audrey


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
diagnosing addiction in chronic pain patients

Diagnosing Addiction in Chronic Pain Patients

Karen Miotto, M.D.

UCLA/MATRIX Addiction Medicine Service

terminology of abuse
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
continuum of problematic opiate use

Continuum of Problematic Opiate Use

mild indiscretionrepeated misuse 

 opiate abuse opiate addiction

slide4

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
slide5

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
the grey areas
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
addiction consultation clarify the question
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
addiction consultation the interview
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
questions to probe for prescription drug abuse
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
questions to probe for prescription drug use
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
acquisition of prescribed drugs
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
clinical features of prescription drug abuse
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
clinical features of prescription drug abuse1
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
evaluation of the family
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
slide15

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

slide16

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

slide17

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

evaluation of psychosocial factors
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
slide19

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
patient education
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
recommendations treatment tools
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
recommendations treatment tools1
Recommendations: Treatment Tools
  • Diversion safeguards
  • Small amounts of medication dispensed
    • family member, friend, pharmacy
  • Comprehensive pain treatment program
  • Addiction treatment
addiction treatment for chronic pain patients
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
similarities in effective drug and chronic pain treatment
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
analgesic agents
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
acetaminophen
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
meperidine demerol
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
meperidine demerol1
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
butorphanol stadol
Butorphanol (Stadol)
  • Transnasal butorphanol
  • Acute migraine treatment
  • Agonist/antagonist
  • Intranasal dose 0.5 to 2 mg
  • Abuse potential
codeine
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
slide31

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

slide32

Myorelaxants

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