Tools, Tips & Rational Responses to Aberrancy in Chronic Pain Management

1. Tools, Tips & Rational Responses to Aberrancy in Chronic Pain Management Lynda K Williamson, D.O. Consultant in Chronic Pain Management Spokane Pain Conference ~ September 2014

2. I have no conflicts of interest.

3. Objectives • ~Recognize aberrancy in chronic pain management • ~Assess the risk of the behavior • ~Understand the role of physiologic dependency to chronic opioid treatment ~Document the objective evidence of aberrancy and the clinician’s response • ~Employ the uniform pain management agreement as a management tool

4. What is “Aberrant Behavior” &Why does it matter? • If it walks like a duck, sounds like a duck, and looks like a duck, then it’s a DUCK. We have all felt like something was wrong but we haven’t been able to identify “IT” • IT increases the risk of providing safe, effective care • IT puts everyone: the patient, their family, the provider, and their community at risk of harm • IT is usually illegal • IT can be remedied in most situations • IT isn’t helping anyone

5. Where you live, is your home. The chronic pain patient is your grandma, your neighbor, your spouse. They drive on the same streets that you and I drive.

6. Substance use/abuse-related behaviors: • Patients injured while under the influence fill 50% of U.S. trauma beds • Often what lead to development of chronic pain, was a traumatic injury while under the influence of ______ • 3rd leading cause of death in U.S.

7. The evidence about addiction: • Addiction affects 22 million Americans • 75% of addicts are in the workforce • Only 9% of Americans who need treatment receive it • New medications can help control craving • Relapse is a normal part of the disease • Treatment can work

8. ASAM* definition of ADDICTION • Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. • Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. • This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. • Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. • Like other chronic diseases, addiction often involves cycles of relapse and remission. • Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. • *American Society of Addiction Medicine

9. Simply put: Addiction is characterized by: • Inability to consistently Abstain • Impairment in Behavioral control • Craving; or increased “hunger” for drugs or rewarding experiences • Diminished recognition of significant problems with one’s behaviors and interpersonal relationships • Dysfunctional Emotional response.

10. Addiction VS Dependency Opioid dependency is physiologic Addiction is always a risk, and may be pre -existing

11. VULNERABILITY TO ADDICTION • Genetics – 40 to 60 percent of the vulnerability to addiction is genetic. • Related to genetic alterations in alcohol dehydrogenase, cytochrome P450, GABA, and D2 receptor • Environmental Factors • Low socioeconomic status, Poor parental support, Drug availability • Comorbidity with mental illness, or past history of abuse. • The abuse may have been: mental, spiritual, emotional, sexual or physical abuse. Abuse in childhood results in high risk for substance use disorder or addiction later in life.

12. Pain management tools and choicesthere are so many options! • Relevant surgical procedures • Trial of osteopathic diagnosis and treatment • Physical therapy/Physical modalities (massage, TENS, chiropractic etc.) • Interventions: botox, spinal cord stimulators • Injections: epidural injection, trigger point, facet block, etc. • Meditation, yoga, exercise • Thermal: ice, heat, soaking baths • Medications: systemic or local analgesic, anti-inflammatory, anti-seizure, TCA, anti-depressants • Bio-behavioral with biofeedback, Cognitive Behavioral Counseling, Meditation, relaxation • Nutritional, weight management

13. Justification for opioid trial • This patient continues to have moderate to severe chronic pain and/or unsatisfactory functional outcomes in response to non-opioid pain management strategies. • Trials of the following strategies (titrated to target dose) have been completed (describe): • Medications • Non-steroidal anti-inflammatory drugs: • Tricyclic anti-depressants • Adjunctive analgesics (gabapentin, duloxetine, pregabalin, etc.): • Muscle relaxants: • Topical agents (lidocaine, capsaicin, voltaren, pennsaid, compounded) • Other medications:

14. Opioid therapy trial should NOT be initiated if any of the following absolute contraindications are evident • Severe respiratory instability • Acute psychiatric instability or uncontrolled suicide risk • Diagnosed substance use disorder not in remission or under treatment • True allergy to opioids • Prior trials of specific opioids discontinued due to serious adverse effects. • Potentially lethal drug-drug interaction • (methadone only) QTc interval > 500 milliseconds • Active diversion of controlled substances

15. Basic Principles • practice an attitude of “no shame, no blame” • Use objective findings: Urine toxicology, lab results (GGT), Vital Signs, pharmacy log of dates dispensed/requested & who wrote the rx, Prescription Monitoring Programs, police records, physical exam (track marks, etc)

16. VERY HIGH RISKAberrant Behaviors • Purposeful over-sedation • Appears intoxicated • Increasingly unkempt or impaired • Negative mood changes

17. HIGH RISKAberrant Behaviors • Involvement in MVA or other accident • Abusing alcohol or illicit drugs • Changes route of administration • Arrested by police • Insists on specific named medications • Contact with street drug culture

18. DRUG-SEEKINGAberrant Behaviors • Requests early renewals • Increases dose without authorization • Hoarding or stockpiling of medications • Reports lost or stolen rx’s • Attempts to obtain rx’s from other providers

19. What are the RISKS of this behavior? Risk Stratification Determine lethality • High risk behavior? • Relative risk behavior? • Low risk behavior? • LETHAL risks? self harm, intentional or otherwise • LETHAL RISKS? Harm to others • POTENTIAL RISKS of medical complications, further harm to the patient by our care? • Deeply annoying and makes it difficult to provide “no shame/no blame” care for this person

20. Remember the duck? • 1. Uses more than intended, or for longer than intended • 2. Efforts to control or cut back when needed have been unsuccessful • 3. Large amounts of time are spent obtaining, using, or recovering from opioid use DSM V

21. Remember the duck? • 4. Cravings (this symptom may be present even after remission) • 5. Recurrent use resulting in problems at work, home, or school • 6. Continued use despite recurrent social or interpersonal problems resulting from opioid use • 7. Curtailing important activities in favor of opioid use DSM V

22. DSM V Criteria for Substance Use Disorder • 8. Opioid use despite potentially hazardous outcomes • 9. Continued opioid use despite knowledge that its use is causing or exacerbating a persistent physical or psychological problem • 10 Tolerance or a need for increased amounts of opioid • 11. Withdrawal symptoms

23. Neurobiology of Addiction • A disease of the brain and the associated abnormal behavior is the result of dysfunction of brain tissue • Drug exposure during adolescence might result in different neuroadaptations from those that occur during adulthood • Drugs of abuse increase extracellular dopamine concentrations in the limbic regions, including the Nucleus accumbens • Dopamine is involved in many aspects of reward and pleasure • Chronic Drug exposure alters the morphology of neurons in dopamine regulated circuits

24. Cognitive Deficits Model • Proposes that individuals who develop addictive disorders have abnormalities in the prefrontal cortex. • The PFC is important for regulation of judgment, planning, and other executive functions. • Normally , the PFC sends inhibitory signals to the neurons of the mesolimbic reward system to help overcome some of our impulses for immediate gratification. • Stimulant drugs appear to damage the specific brain circuit (frontostriatal loop) that carries inhibitory signals from the PFC to the mesolimbic reward system • Opiates apparently damage the PFC itself

25. Consider:

26. What’s the behavior? What’s the risk? • DEEPLY ROOTED PERSONALITY DISORDER AND OR PSYCHIATRIC CO-MORBIDITY possibly not previously diagnosed • Diversion of medication to others in a position of power over the patient • High risk if history: Victim of abuse, in childhood or now • Uses pain medications in response to situational stressors • Presence of family member with substance use disorder • Undiagnosed psychiatric illness or learning disability

28. Types of craving • Cue-based craving • Response to environmental cue • Cue creates internal state which is recognized as craving • Most notable in cocaine & nicotine • State or stress-based craving • Emotional tone, level of perceived stress, state of self care set the state • Craving appears to emerge out of difficult emotional states • Most notable in alcohol & sedatives

29. Aberrant Behaviors • Purposeful over-sedation • Appears intoxicated • Increasingly unkempt or impaired • Negative mood changes • Involvement in MVA or other accident • Abusing alcohol or illicit drugs • Changes route of administration • Arrested by police • Insists on specific named medications • Contact with street drug culture • Requests early renewals • Increases dose without authorization • Hoarding or stockpiling of medications • Reports lost or stolen rx’s • Attempts to obtain rx’s from other providers • High risk if history: Victim of abuse, in childhood or now • Uses pain medications in response to situational stressors • Presence of family member with substance use disorder • Undiagnosed psychiatric illness or learning disability

30. Risk levels associated with ABERRANT BEHAVIOR VERY HIGH RISK OF unintentional or deliberate SELF HARM, substance use disorder or excessive dosage or drug-drug interactions • VERY HIGH RISK OF HARM TO OTHERS, substance use/abuse disorder, drug-seeking behavior • DEEPLY ROOTED PERSONALITY DISORDER AND OR PSYCHIATRIC CO-MORBIDITY possibly not previously diagnosed • Diversion of medication to others in a position of power over the patient • HIGHLY MANIPULATIVE, ADDICT/drug-seeking BEHAVIOR

31. Use objective findings: • Urine toxicology • lab results (GGT) • Vital Signs • pharmacy log of dates dispensed/ r/f’s requested & who wrote the rx (Prescription monitoring programs) • police records • physical exam (track marks, etc) • ER Visits

32. How do we respond? Patient Education The Management Agreement • It is the provider’s responsibility to clearly explain expected behavior from the chronic pain patient, especially if they are being prescribed chronic opioid therapy for chronic non-cancer pain. • Fortunately, there is a good tool for this: the Pain Medication Management Agreement • The “Agreement” is not a contract

33. Rational Response toVERY HIGH RISK BEHAVIOR: • Purposeful over-sedation—Appearing intoxicated: HOSPITALIZE, medical detox, remove all medications from individual access, identify a medication manager, simplify the regimen • Negative mood changes, increasingly unkempt or impaired: review and analyze drug-drug interactions, urine toxicology with confirmations, TOOLS: pill box, disp only 1 or 2 weeks of medication at a time, counsel and education, evaluate for substance use disorder or is there a previously missed: dual diagnosis?

34. Rational Response toHIGH RISK Aberrant Behaviors • MVA, abuse of alcohol or illicit drugs, changing route of administration, police involvement, demanding particular medication by name, contact with street drug Toxicology documentation. Refer for substance use disorder evaluation, medical detox then substance abuse program, rapid taper of opioids, address any benzodiazepine usage, change to adjuvant medications as quickly as is safe to do so. Be very sure the source of pain is objectively verifiable and that it is being treated appropriately**(this is a much bigger topic)

35. Rational Response toDRUG-SEEKING Aberrant Behaviors • Requests early renewals, stock-piling medications, missing rx’s, multiple providers writing for pain medications or psycho-tropics, changes dosage without authorization PMP-documentation, pharmacy logs, toxicology documentation Patient medication agreement, review it, discuss it, explain it. Bring in other family members. Limit dispensing to 1 or 2 weeks of medication at a time. Make the structural framework of care stronger, better boundaries. Consistent prescriber. More frequent clinic visits. Confirm that the source of pain is being appropriately treated and not under-treated (pseudo-addiction). Get a substance use d/o evaluation and consider referral for treatment.

36. Remember the substances, whether prescribed or illicit may have abused the patient and not the other way around

37. Questions? Discussion?Case studies tomorrow with the Spokane Opioid Task Force Panel will demonstrate application of these principles.

38. Uniform Pain Management AgreementSpokane County Medical Society • Patient:________________ Physician:______________ • Patient’s DOB: __________ Designated Pharmacy: • _______ONE prescriber for controlled medications and ONE pharmacy: • I agree to receive pain medications only from my treating physician (named above) or from someone designated by my treating physician. I agree to receive my pain medications only from my designated pharmacy (listed above) unless my treating physician agrees otherwise. • If you receive controlled medications from another health care professional because of a true emergency, injury or accident requiring urgent care, you agree to tell that practitioner (or have a family member/friend tell that practitioner) about your agreement with this office.

39. ONE Pharmacy continued • If you receive controlled medications from another health care professional, you agree to call this office within 24 hours and tell us who prescribed or gave you which controlled medications and why. This requirement is for your safety and allows us to consider possible drug interactions. • You also understand that you should use the same pharmacy every time you fill a prescription. You agree to call us if there is a reason to use a different pharmacy. This requirement is also for your safety.

40. ______ Drug testing and medication counts: • I give my permission for urine, saliva or blood screening as requested by my treating doctor at any time. I understand that it is my doctor’s responsibility to make sure my treatment plan is safe, effective and that I am following the treatment plan. I understand that a drug screen is a laboratory test of samples of my urine, saliva or blood that I provide to check the drugs that I have been taking. I understand that my drug screening test results will be part of my medical record. I understand that I may be asked to bring in all of my medications at any time to be counted. This is one measure of how well I am able to follow my treatment plan. • We use drug testing and pill counts in this practice to look at risk and safety issues. We do not perform drug testing or medication counts to punish you. We do this to monitor risk and safety as required by professional medical guidelines and rules

41. __ Take medications ONLY as prescribed. • I agree to take each of my medications at the prescribed dose and frequency. This means I will not run out early. If I think my medication is not working, or that I am having a medication problem, I will call this office and ask to speak with my doctor for guidance. • Controlled medications are powerful and can cause harm if not taken according to the doctor’s instructions. Using controlled medications in any way other than as directed by your doctor may cause you to have more health problems and could kill you. Follow the written directions on your prescription bottles and call your pharmacist and this office if you have questions.

42. ______ Medication safety: • I will safeguard my medications and prescriptions. I understand that lost, stolen or damaged medication will not be replaced. I will store my medications in a safe, secure, locked place to prevent theft, loss or use by others. I will keep all medications away from children of any age. • Allowing someone else to take your medication can make another person sick or cause them to die. These medications are prescribed for you and only you. We emphasize the safe use, storage, and disposal of all medication. Use medication ONLY as directed.

43. __ Is this the right medication for me: • I understand that my physician may stop, taper, or change my prescribed medication: • -IF my activity and functional level have not improved • -IF I do not show improvement of pain • -IF I develop significant side-effects from the medication • -IF I give, sell or misuse any of my medications • -IF I demonstrate that I am unable to follow this agreement and my physician feels she/he can no longer prescribe my pain medications safely and effectively. • This will be documented in my medical record.

44. _ Agreement NOT to use illegal drugs or other pain medications: • I agree not to use illegal or street drugs. I agree not to abuse alcohol. I agree not to take any medications prescribed for someone else. I agree not to use over-the-counter medicines or any other medically active substance without the agreement of my treating physician. I may be prescribed medication by another licensed provider and I will notify EVERY treating physician of all medications I am taking • . If I am prescribed other or additional pain medications due to surgery or to injury I will notify the health care provider caring for me that I have a pain medication agreement. I will promptly let my pain medicine prescriber know that I have received additional medication.

45. Agreement NOT to use illegal drugs or other pain medications: • Using illegal or street drugs is a bad idea. Using other medication not prescribed by your pain medicine prescriber to treat your pain or pain-related medical problems is a bad idea. If you use illegal drugs or other controlled medications, your doctor may decide to stop prescribing controlled medications for you.

46. __ Consent to share this agreement with other health care professionals and the hospital for coordination of my medical care: • I give my permission for my treating physician to share the contents of this agreement and to discuss all my medical conditions and treatment details with pharmacists, physicians (including Emergency Departments and Urgent Care Centers), or other healthcare professionals for the purpose of coordinating my care. I give permission for all the above to report violations of this agreement to my physician. I understand that this agreement may be added to my medical record at the hospital so that if I do have an emergency visit, or surgery, my treatment plan will be considered. I understand this is to help keep me safe. • I understand that my permission is not required for my physician and my pharmacy to cooperate fully with any city, state or federal law enforcement agency in the investigation of any possible misuse, sale or other diversion of my pain medicine. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.

47. By signing this document, you agree that we can share this agreement with any health care professional in the coordination of your medical care. In this case, coordination of care means the evaluation of your health, medical treatment and safety issues associated with the use of controlled medication. • Patient signature ____________________________________ • Date_________________ • Patient name PRINTED ___________________________________________ • Prescribing Physician signature _____________________________________________ • Copy of this signed Agreement to be given to the pt’s chart, the patient, SHMC ED for hospital EMR.

49. Questions? Discussion?Case studies tomorrow with the Spokane Opioid Task Force Panel will demonstrate application of these principles.

50. DSM V Criteria for Substance Use Disorder • 1. Uses more than intended, or for longer than intended • 2. Efforts to control or cut back when needed have been unsuccessful • 3. Large amounts of time are spent obtaining, using, or recovering from opioid use • 4. Cravings (this symptom may be present even after remission) • 5. Recurrent use resulting in problems at work, home, or school • 6. Continued use despite recurrent social or interpersonal problems resulting from opioid use • 7. Curtailing important activities in favor of opioid use • 8. Opioid use despite potentially hazardous outcomes • 9. Continued opioid use despite knowledge that its use is causing or exacerbating a persistent physical or psychological problem • 10 Tolerance or a need for increased amounts of opioid • 11. Withdrawal symptoms