Problem Patient or Problem Prescription?

Ken Roy, MD

Tulane Department of Psychiatry

Addiction Recovery Resources of New Orleans

504-780-2766

www.arrno.org

Scope

Problem patients

Problem prescriptions

Classes of addicting drugs

Recognition of addiction

What to do about problem patients

Potential Problem Patients

Family history of alcoholism

External locus of control

Pain persistent or out of proportion

Litigation

Multiple meds

Problem Prescriptions

Soma, Fiorinal, Valium, Xanax

Ritalin, Adderall

Vicodin, Percodan, Ultram, OxyContin

Classes of Addicting Drugs

Related to the reinforcing pathway

Three main classes

Sedative hypnotics and opioids contain the vast

majority of problem prescriptions

Sedative Hypnotics

Active in the GABA system Alcohol Benzodiazepines (Rohypnol) Barbiturates (Fiorinal) Anxiolytics & Hypnotics (Ambien, Soma,

Sonata)

Opiates

Active in the endorphin systems

Vicodin, other oxy & hydro codones Especially ES formulations & OxyContin

Ultram

Methadone

Stimulants

Active in the dopamine system

Amphetamines (Adderall)

Others (Ritalin, Cylert)

*Decongestants

The Case AgainstChronic Sedative Hypnotics

Short term anxiolytic in non-recovering patients No controversy

Effects on the GABA system

Effects on mood, anxiety and insomnia

Alternatives

The GABA System

Cause tolerance (40,42,43)

Down regulate receptors (36,37,38) And receptor function (39,40)

Decrease effect of endogenous anxiolytics

(41)

Cause physical dependence (59)

Mood, Anxiety and Insomnia

Paradoxical anxiety with long term use (45)

Cause depression (54,55,56,57)

Not effective long term for sleep (44)

Make opiates less effective (58)

No evidence of long term efficacy for PTSD (60)

Alternatives to Sedative Hypnotics (Benzo’s)

SSRI’s and TCA’s Better for GAD (46,47,48,49)

Better for panic (49,50,51,52)

Better for agoraphobia (53)

Better for “stress” (61)

Quetiapine, Trazodone, Doxepin, etc.

The Case Against Chronic Opiates in Chronic Pain

Acute vs. chronic pain

The effects on the endogenous opiate system

The effects on the perception of pain

The effects on activity and behavior

Alternatives to chronic opiate analgesia

Acute vs.Chronic Pain

Acute - perioperative, traumatic, infectious No controversy (except monitoring for relapse)

Chronic Malignant or progressive

No controversy

Non malignant Huge controversy (1)

Chronic Non-Malignant Pain

Subjective pain relief Few studies

Urban - 5 patients (2)

Taub & Tennant - both anecdotal (3,4)

Portnoy - reduced perception of pain in 1/3 (5)

Improvement in function Not demonstrated (1,6)

It Doesn’t Work

“Overall, the use of opioids in chronic pain of non malignant origin will achieve analgesic benefit in some patients, while improved function has not yet been adequately demonstrated.”(1)

“Until opioid therapy can be shown to yield long term outcomes that are superior, we cannot endorse it as a treatment of choice for chronic non cancer pain.” (7)

Even in Non Addicts

“In patients with treatment resistant chronic

regional pain of soft tissue or musculoskeletal

origin, nine weeks of oral morphine in doses of up

to 120 mg daily may confer analgesic benefit with

a low risk of addiction, but is unlikely to yield

psychological or functional benefit.” (6)

The Endogenous Opiate System

Tolerance B-Endorphin neurons become tolerant after chronic

morphine administration (8)

Release of Pro-opiomelanocortin-derived peptides

decreased in tolerance (9)

Pro-opiomelanocortin synthesis and B-Endorphin

utilization down-regulated in morphine tolerance

(10,11)

The Perception of Pain

Chronic opiates cause sensitization Hyperalgesia caused by noxious stimulation is

similar to hyperalgesia caused by chronic

opiates (15)

Thermal hyperalgesia develops in morphine

tolerance (16)

Activity and Behavior

Depression Opiates and opiate system implicated in

model of learned helplessness (17,18)

Opiates cause depression (19,20)

Potential for relapse Opiate use increases potential for relapse

(21,22,23)

Alternatives

Multidisciplinary chronic pain treatment

programs Nerve Blocks (24)

Psychotherapy (25,26,27,28,29)

Acupuncture (30)

Exercise (25,31,32)

Spiritual growth and recovery (33)

Substance Abuse

Ubiquitous Social problem Legal problem Economic Problem

Criteria for Substance Abuse

Recurrent use affecting role obligations Recurrent use where hazardous Recurrent use causing legal problems Recurrent use causing social or

interpersonal problems

Prevalence

Almost 50% of persons age 21 abuse alcohol 70% drink

22% of persons 18 – 22 years of age use illicit drugs 76% are employed Rate in college students 21%

Treatment Harm reduction strategies

Designated Driver Education and conversation

Response to behavior Don’t excuse behavior Don’t remove consequences

Most people discontinue SUBSTANCE ABUSE unless they develop SUBSTANCE DEPENDENCE

Criteria for Substance Dependence

Criteria for Substance Dependence

A maladaptive pattern of use, causing significant impairment or distress as manifested by three (or more) of the following seven criteria, occurring at any time in the same twelve months Tolerance, as defined by:

a need for increased amounts to achieve effect markedly diminished effect from using the same

amount

Substance Dependence continued

Substance Dependence continued

withdrawal, as manifested by: characteristic withdrawal syndrome the same substance is used to avoid or relieve

withdrawal symptoms the substance is taken in larger amounts or over

a longer period than was intended there is a persistent desire or unsuccessful

efforts to cut down or control use

Substance Dependence continued

Substance Dependence continued

a great deal of time is spent in activities necessary to obtain or use the substance or recover from it’s effects

important social, occupational, or recreational activities are given up or reduced because of substance use

Substance Dependence continued

Substance Dependence continued

the substance use is continued despite knowledge of having a persistent or recurring physical or psychological problem that is likely to have been caused or exacerbated by the substance (ulcer, depression, etc.)

Incidence of Substance Dependence

Incidence of Substance Dependence

14.1% National Comorbidity Study 1994 Other drug dependencies in 7.5% of these

5% to 15% is the range in previous studies

Substance Dependence Shorthand

Substance Dependence Shorthand

Compulsion Loss of Control Continued use in the face of adverse

consequences

The Disease of Addiction

Criteria for a disease Recognizable symptoms Predictable Course Common Cause

The Course of Addictive Disease Progressive Affects all organ systems Associated with the cause of death A disease of relationships

Disturbance in the relationship with self and others

Based on dishonesty in the form of denial

The Cause of Addictive Disease

Genetic Experience - Family History Family Studies Twin Studies Adoption Studies

Importance of Disease Orientation

Cause - not Effect of Something Else Therefore a primary illness

Helps to understand Denial Providers don’t blame their patients Patients Have a Healthy Target to Work on

Impact on Treatment

Abstinence is the Only Reasonable Goal Use Alters Neurotransmitters

Denial is the Primary and Universal Symptom Preserves the Right to Drink or Use

Identification With Others Possible OK Not to Have Coping Skills

Treatment Takes Time Levels of Care can provide time

Contribution of EnvironmentContribution of Environment

Similarity to TB Impact of Using on Emotional

Development

AbstinenceAbstinence

Similarity to Diabetes AA/NA/GA/RR not MM

Common Experiences Fellowship Impact on Emotional Development

Getting Help

Public Sector Overcrowded, under funded, restrictive 32 Detox beds – 900 waiting for treatment

Private Sector Effective, welcoming, shame reducing Requires Parity (Non-discrimination) for

maximal effectiveness Current insurance coverage inadequate and

often inappropriate

So, what do I do? Call it like you see it Don’t shame the patient

May point out consequences Be realistic, don’t try to “scare” the patient

Refer to appropriate addiction specific practices JPSAC

Public ARRNO

Private – Insurance, etc