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Pain and Chemical Dependency
Not an “Either – Or” Not an “Either – Or” propositionproposition
Douglas Gourlay, MD, FRCPC, FASAMWasser Pain Centre, Toronto ON
DL Gourlay, MD, FRCPC, FASAM 2
The Problem
• Pain and Addiction CAN coexist• Addiction in General Population
– Varies 3 – 16% prevalence– Varies with the drug, gender, economic status,
race, age…
• Addiction in the Chronic Pain Population– We really have no idea– We use the same terms, with different
meaning
• Lack of precision in definitions around abuse/dependency/addiction
DL Gourlay, MD, FRCPC, FASAM 3
Definitions
•Addiction: Addiction is a primary, chronic, neurobiologic 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 drug use, compulsive use, continued use despite harm, and craving. (LCPA)
DL Gourlay, MD, FRCPC, FASAM 4
Definitions
• Physical Dependence: Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (LCPA)
DL Gourlay, MD, FRCPC, FASAM 5
Definitions
• Tolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.
• Tolerance develops at different rates, in different people, to different effects
DL Gourlay, MD, FRCPC, FASAM 6
Definitions
• Pseudoaddiction: Iatrogenic, maladaptive behavior resulting from inadequate pain control
• Not to be used “instead of” addiction• Unwise to diagnose in patient with
history of addictive disorder, even in other substance
DL Gourlay, MD, FRCPC, FASAM 7
Addiction *
Biology
Environment
Drug
*
DL Gourlay, MD, FRCPC, FASAM 8
Diagnosis• DSM-IV criteria - dependence
– Maladaptive behavior having at least three of the following in a 12 month period• Withdrawal• Tolerance• Use in larger amounts or over longer period than
intended• Persistent use, or unsuccessful attempts to cut-
down or control use• XS time spent using or recovering from use• Narrowing of focus due to substance use• Continued use despite harm
DL Gourlay, MD, FRCPC, FASAM 9
Pain and Addictionas Co-morbid Conditions
• Pain often complicate the Dx of Addiction
• Pain and Addiction can coexist– Pain plus
• Alcoholism• Cocaine • Cannabis
– Relatively simple to use current tools to assess addiction i.e. DSM-IV
DL Gourlay, MD, FRCPC, FASAM 10
Pain and Opioid Addiction
• What happens when the ‘drug of choice’ is both the problem AND the solution, depending on point of view?– Addiction Specialist
• Aberrant behavior is due to opioid abuse/addiction
– Pain Specialist• Aberrant behavior is due to inadequate
treatment of pain (pseudoaddiction)
DL Gourlay, MD, FRCPC, FASAM 11
Pain-Addiction Continuum
PainPainAddictionAddiction PatientPatient
PatientPatient
PatienPatientt
DL Gourlay, MD, FRCPC, FASAM 12
Boundary Setting
• 90%+ of patients don’t need strict boundary setting– Most patients have their own internal
set
• For remaining ~10%, strict boundary setting is essential
• Treatment Agreements, Urine Testing, interval / contingency dispensing
DL Gourlay, MD, FRCPC, FASAM 13
Boundaries – Identification and Enforcement
Discharge Patient
DL Gourlay, MD, FRCPC, FASAM 14
Boundaries – Identification and Enforcement
Consultation with Addiction Medicine
DL Gourlay, MD, FRCPC, FASAM 15
Aberrant Drug-Related Behaviors
• Selling prescription drugs• Prescription forgery• Stealing or “borrowing”
drugs from another patient• Injecting oral formulations• Obtaining prescription drugs
from non-medical sources• Concurrent abuse of related
illicit drugs• Multiple unsanctioned dose
escalations• Repeated episodes of lost
prescriptions
• Aggressive complaining about the need for higher doses
• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs• Prescriptions from other
physicians• Unsanctioned dose
escalation• Unapproved use of the drug• Reporting psychic effects
not intended by the physician
More PredictiveMore Predictive Less PredictiveLess Predictive
Jaffee, 1996Jaffee, 1996
DL Gourlay, MD, FRCPC, FASAM 16
Assessing Aberrant Behavior
• What does it mean?– Aberrant behavior is a late and often
unreliable sign of an addictive disorder– When used to trigger UDT, more often
used in punitive fashion
• Aberrant behavior does NOT equal inadequate pain management in all patients
DL Gourlay, MD, FRCPC, FASAM 17
Assessment Strategies
• 1st address pain complaints– Explore AM pain and role of IR opioids
• Carefully document medication use– Dosing intervals, what worked, what didn’t– Lost/stolen, early refills, double doctoring,
problems with control, withdrawal symptoms
• Family history of drug/EtOH problems• Personal psychiatric history
DL Gourlay, MD, FRCPC, FASAM 18
Assessment Strategies
• Personal Substance Use History– Alcohol, tobacco, street drugs– Time of last use
• Drug Treatment History• Legal Issues• Social• Physical Examination• Lab Tests: Liver, Hepatitis, HIV, CBC, UDS
DL Gourlay, MD, FRCPC, FASAM 19
Pain and Chemical Dependency
Program• Pain and CD Clinic CAMH
– Initially at the AMC– Problems with stigma (many “no show’s”)
• Pain and CD division at the Wasser– Easier for patients to comfortably attend
• Very few patients fail to attend appointments• But difficult to manage dominant SUD pts
– “Easier to teach pain docs about addiction”
DL Gourlay, MD, FRCPC, FASAM 20
Pain and Chemical Dependency
Program• Strong bridge between the Wasser Pain
Centre and CAMH was needed– Currently fellows and residents from CAMH
spend time at the Wasser Clinic on Thursday
– Queen Street Lab does UDT for Wasser– Stabilized Pain and CD pts are seen at
Wasser• But we don’t have a place to manage
complex pharmacotherapy problems; we’re not integrated
DL Gourlay, MD, FRCPC, FASAM 21
Pain and Chemical Dependency
Program• 2004, Purdue Canada donated $300,000
over 3 yrs for a Pain and CD division at the Wasser Pain Management Centre– We are now discussing possibilities of
having a “Rationalization of Pharmacotherapy Unit” at the Donwood Site
– Pts will be assessed and medically stabilized before deciding what services might next be offered
DL Gourlay, MD, FRCPC, FASAM 22
Conclusions
• Pain and Addiction can coexist• Successful treatment of either often
requires assessment and management of both
• The Pain and CD Division of the Wasser Pain Centre will do what neither CAMH nor Wasser could do alone