Objectives • Understand which disorders are frequently found among medication misusers • Understand the impact of these disorders on pain treatment • Understand prescription medications can be used to self medicate • Know resources available for help for patients
Prescription Medication Misuse Definition • Taking medications for non-intended uses, differently than prescribed, without a prescription or with interacting substances.
PMM and Co-morbid Psychiatric Disorders • Patients may attempt to self medicate through symptoms of depression or anxiety • Khantzian E. The self medication theory of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry 1985; 142: 1259-64. • Survey showing only a small percentage of medication misuse is for recreational reasons only - 13% (civilian data – no data on Service Members) • McCabe S, Boyd C, Teter C. Subtypes of nonmedical prescription drug use. Drug and Alcohol Dependence. 2009, 102: 63-70. • May also be due to shared vulnerability for depression or anxiety or a combination of both
Disorders Frequently Found In Patients Who Misuse Prescription Medication -Potential Triggers for Self Medication • Post traumatic stress disorder • Anxiety disorder • Depression • Bipolar Disorder
PTSD and PMMEvidence of a Relationship • Higher rates of PTSD among medication misusers • Higher rates of PMM among individuals with PTSD • Simultaneous increases in PTSD and PMM rates among Service Members • Certain groups of Service Members are higher risk for both PMM and PTSD
PTSD Among Medication Misusers • Data from Service Members survey – not reported for US population (only reported as serious mental illness and depression in civilian survey) • Higher possible PTSD rate among Service Members who misuse medications than those who don’t • Possible PTSD rate in medication misusers is 19% • Possible PTSD rate in other Service Members is 8.5% • 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. Research Triangle Institute, Research Triangle Park NC 2009 • Possible PTSD rate in Service Members who misuse medications was comparable to possible PTSD rate among heavy drinkers and smokers • PTSD rate in heavy drinkers 18.1% vs. 7.9% in non-drinkers • PTSD rate in heavy smokers 22% vs. 7.9% in non-smokers • 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. Research Triangle Institute, Research Triangle Park NC 2009 Table 4.43
PMM Among Patients with PTSD • Individuals with PTSDare at higher risk for misusing medications - observational study of pain patients in civilian health care systems • OR 2.45 (CI 1.88-3.19) • White AG, Birnbaum HG, Shiller M, Tang J, Katz NP. Analytic models to identify patients at risk for prescription opioid abuse. Am J Manag Care. 2009; 15: 897-906. • High rate of SUD (including PMM) among civilian patients with PTSD -21-46% • Jacobsen LK, Southwick SM, Kosten TR. Substance Use Disorders in Patients With Posttraumatic Stress Disorder: A Review of the Literature Am J Psychiatry 2001; 158: 1184–1190 • Higher rate with combat related PTSD - 75% • Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS: Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. New York, Brunner/Mazel, 1990
PTSD and PMM Rates Rising in Service Members – Evidence of a Relationship • PMM rates increasing since 2002 • 1.8% in 2002 • 11.1% in 2008 • Possible PTSD prevalence among Service Members increasing as well • 10.4% of Service Members may have PTSD on 2008 survey • Up from 6.7% in 2005 • 2008 Department of Defense survey of health related behaviors among military personnel, Research Triangle Institute, Research Triangle Park NC 2009, Table 4.22
PTSD and PMM – Service Member Selective Sub-groupings Show a Possible Relationship • Deployed vs. non-deployed • Females at higher risk for both
Higher Rates of PTSD and PMM Among Service Members Who Have Been Deployed Also Suggests A Relationship • Higher rate of PMM in Service Members who have been deployed to Iraq or Afghanistan • 12% higher PMM rates in SMs who have been deployed (17% in SMs who have not deployed, 19% in SMs who have deployed) • 2008 Department of Defense survey of health related behaviors among military personnel, Research Triangle Institute, Research Triangle Park NC 2009 • Up to 17 percent of troops screened after deployment may have PTSD (compared to 10% of all SMs) • Hogue C, Castro C, Messer S, McGurk D, Cotting D, and Koffman R. Combat duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. NEJM. 2004; 351: 13-22.
Higher Rates of PTSD and PMM Among Female Service Members Also Suggests Relationship • Female Service Members at increased risk for PTSD • OR 2.33, CI 1.8-3.03 • LeardMann CA, Smith TC, Smith B, Wells TS, Ryan MA. Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: prospective US military cohort study. BMJ. 2009; 338: b1273. • Female Service Members also had higher rate of PMM • 13.2% of female Service Members • 11.2% of male Service Members • 3.2% of females in the US population • 2008 Department of Defense survey of health related behaviors among military personnel, Research Triangle Institute, Research Triangle Park NC 2009
PTSD and PMM • Evidence suggests a link between the two • Causal? • Bidirectional? • Likely self medication of PTSD with medications
PTSD and PMM • Does treating PTSD reduce the risk for PMM? • Unknown – possible based on data on treating ISA and PTSD treatment
Treating PTSD and the Potential Effect on PMM Rates • Treating PTSD may be beneficial in reducing PMM based on evidence of impact with illicit substance abuse (ISA) • PTSD responsive to treatment renders patients less prone to substance abuse • Ouimette P, Brown P, Najavits L. Course and treatment of patients with both substance use and posttraumatic stress disorders. Addict Behav 1998; 23:785–795 • Substance abusers with unremitting PTSD had more relapses and felt less able to prevent relapses • Ouimette P, Coolhart D, Funderburk J, Wade M, Brown P. Precipitants of first substance use in recently abstinent substance use disorder patients with PTSD. Addict Behav. 2007. 32(8):1719-27.
PTSD Treatment • Specific serotonin reuptake inhibitors (SSRIs) are effective • Viewig, WV; Et al. Posttraumatic stress disorder: clinical features, pathophysiology, and treatment. Am J Med 2006; 119: 383-390. • Most effective when continued for 9-12 months after symptom remission. • Ursano RJ, Bell C, Eth S, et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry 2004;161:3–31. • Cognitive behavioral therapy (CBT) lead by a consulting psychiatrist is also effective. • Stein DJ, van derKolk BA, Austin C, et al. Efficacy of sertraline in posttraumatic stress disorder secondary to interpersonal trauma or childhood abuse. Ann Clin Psychiatry 2006;18: 243–9.
PTSD and PMM • Patients with active PTSD are high risk for PMM and should only be managed in close consultation with a psychiatrist and preferentially by the appropriate specialist (pain management, psychiatrist, etc.) • PCMs must still be engaged in patient care and aware of medical interactions which could impact the pharmacology of potentially misused medications • PCMs must also be able to identify PTSD and properly risk stratify patients
Depression and PMM • Depressive symptoms may trigger PMM • Review evidence of a direct link • Review possible evidence of an indirect link through the interaction of depression with PTSD and chronic pain
Direct Link between Depression and PMM • Patients with depression are at an increased risk for PMM (civilian data from chronic pain patients receiving chronic opioid therapy) • Probable Depression increases the risk for PMM • OR 2.4 (CI 1.6-3.4) • MDD increases the OR to 3.2 (CI 2.9-3.6) • Any mood disorder increases the risk for PMM • OR 3.5 (CI 3.1-3.9) • Major references on depression and PMM: • Becker W, Fiellin D, Gallagher R, Barth K, Ross J, Oslin D. The association between chronic pain and prescription drug abuse in Veterans. Pain Medicine 2009; 10: 531-536. • Martins S, Keyes K, Storr C, Zhu H, Chilcoat H. Pathways between nonmedical opioid use/dependence and psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions Drug and Alcohol Dependence. 2009: 16–24. • Survey data (National Survey on Drug Use and Health) shows a strong relationship between a major depressive episode and PMM
Indirect Relationship Between Depression and PMM Through Chronic Pain • Depression may indirectly increase PMM through its interactions with chronic pain • Patients with depression experience more severe pain and pain catastrophizing and are more likely to develop an SUD • Jamison R, Link C, and Marceau L. Do pain patients at high risk for substance misuse experience more pain? A longitudinal outcomes study. Pain Med. 2009 Sep;10(6):1084-94. • Patients with chronic pain and comorbid depression have worse outcomes and potentially greater drive to self medicate • Eicsson M, Poston W, Linder J, Taylor J, Haddock C, and Foreyt J. Depression predicts disability in long term chronic pain patients. DisabilRehabil 2002; 24: 334-340. • Providers must be aware that depression and comorbid pain may increase the risk of suicidal ideation/attempts • Spiegel B, Schoenfeld P, Naliboff B. Systematic review: the prevalence of suicidal behaviour in patients with chronic abdominal pain and irritable bowel syndrome. Aliment PharmacolTher. 2007 Jul 15;26(2):183-93.
Treating Depression – Impact on PMM • Treating depression will possibly reduce PMM • Impact on PMM inferred from studies on the impact of treating depression in illicit substance use • Adherence to depression treatment leads to a lowered rate of substance abuse among drug users • Stein M, Herman D, Solomon D, Anthony J, Anderson B, Ramsey S, and Miller I. Adherence to treatment of depression in active injection drug users: the Minerva study. J Subst Abuse Treat. 2004. 26(2):87-93. • Nunes E and Levin F. Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. JAMA 2004; 291 (15): 1887-1896
Depression and PMM • These patients are high risk for PMM and should be managed by a specialist in the appropriate discipline in conjunction with a psychiatrist and the PCM • Providers must be able to screen for depression to identify need for specialty care • Providers must know interactions between medications prescribed to avoid interactions
TBI and PMM • Service Members who have sustained a TBI in combat may be at increased risk for PMM • No studies exist • Anecdotal evidence • Personal communications • Media reports • Some evidence that patients with a combat related TBI may have an increased drive for self medication due to increased incidence of chronic pain, PTSD and depression
TBI and PMM • Civilians may suffer a TBI as a result of intoxication and then have a decrease in substance abuse rates • Ponsford J, Whelan R, Bahar-Fuchs A. Alcohol and drug use following traumatic brain injury: a prospective study. Brain Inj. 2007. (21):1385–1392 • Military TBI patients have different circumstances leading to the injury
TBI and PMM – Suicide Risk • TBI patients have a 2-4 fold increased suicide rate, particularly with depression or substance use disorders – danger for fatal prescription medication misuse • Simpson G, Tate R. Suicidality after traumatic brain injury: demographic, injury and clinical correlates. Psychol Med. 2002;32:687–697. • Irresponsibly prescribed medications may be the equivalent of a loaded gun
Conclusion • Many gaps but evidence suggestive that PTSD, depression, chronic pain, and TBIs may predispose patients to PMM • These patients are high risk for PMM • PCMs must be able to identify these disorders • PCMs must interact with specialists involved in caring for these patients to ensure optimal care
Patient Scenario – Sam Coleman – Present Complaint • A 35 year old female patient with an unremarkable physical exam presents complaining of chronic headaches. • She also complains of insomnia, waking frequently and difficulty falling asleep five nights a week. • She avoids eye contact, sits low in the chair and is tearful in between heavy sighing. • The patient would like a refill for oxycodone which was prescribed to her for a recent sprained ankle, since it helps with her headache pain.
Sam Coleman – History • The patient has had insomnia for 2 years. • She is in a difficult custody battle for a young daughter, who lives with her ex-husband. He was mentally and physically abusive during their marriage. She alludes to possible sexual assaults by her husband as well. She has not seen her daughter in two years. • She is a lab director working long hours under high pressure. She has little time for friends and her current husband. • The patient does not drink alcohol, but smokes one pack of cigarettes per day.
Sam Coleman - Questions • What are her risk factors for prescription medication misuse? • Do you think this patient might also suffer from depression? If so, what treatment plan would you consider? Medications? Therapy? Complementary medicine? • What are the symptoms of depression? • What are the symptoms of post-traumatic stress disorder? • What impact do depression and/or PTSD have on pain? • Would you refill her oxycodone? • How would you treat the insomnia?
Military Resources • Military Homefront Support • 800-342-9647 • www.militaryonesource.com • Branch Specific Support is also available: • Army Substance Abuse Program (ASAP) • Navy Alcohol and Drub Abuse Prevention (NADAP) • Marine Substance Abuse Combat Center (SACC) • Air Force Alcohol and Drub Abuse Prevention and Treatment (ADAPT)
Non-Military Resources • Substance Abuse and Mental Health Services Administration (SAMSHA) www.findtreatment.samsha.gov • 1-800-662-HELP • National Suicide Prevention Lifeline 800-273-TALK • National Alliance on Mental Illness www.nami.org • Mental Health America www.mentalhealthamerica.net • American Academy of Addiction Psychiatry www.aaap.org • American Academy of Child and Adolescent Psychiatry www.aacap.org • National Drug Abuse Clinical Trials www.drugabuse.gov/CTN/ or www.clinicaltrials.gov • Narcotics Anonymous www.na.org/ • Alcoholics Anonymous www.aa.org