Chronic Pain and Addiction

April 10-12, 2012 Walt Disney World Swan Resort

Learning Objectives:

1. Distinguish the differences between proper management of chronic pain and practices that contribute to over-prescribing and drug abuse. 2. Describe the effects and consequences of prescription pain abuse as it progresses over time. 3. Advocate the importance of continuing education on addiction for pain management providers.

Disclosure Statement •  Dr. Barbara Krantz has disclosed no relevant, real or apparent

personal or professional financial relationships. •  Dr. Lynn R. Webster has disclosed that he has a relationship with

AlphaBioCom, American Academy of Pain Management, American Board of Pain Medicine, Cephalon, Inc., Covidien Mallinckrodt, Pfizer, Adolor Corp, Alkermes Inc., Allergan Inc., Astellas, AstraZeneca, Bayer Healthcare, BioDelivery Systems International, Boston Scientific, Cephalon, Collegium Pharmaceuticals, Covidien, Eisai, Elan Pharmaceuticals, Gilead Sciences, GlaxoSmithKline, Identigene (Sorenson), King Pharmaceuticals, Meagan Medical, Medtronic, Merck, Naurex, Nektar Therapeutics, NeurogesX Inc., Novartis, SchaBar, Shionogi USA Inc., St. Renatus, SuCampo Pharma Americas USA, Takeda, TEVA Pharmaceuticals (Sub-1), Theravance Inc., Vanda, Vertex, Xandoyne Pharmaceuticals

Chronic Pain & Addiction

Lynn R. Webster, MD Medical Director, Lifetree Clinical Research

Salt Lake City, UT (801) 269-8200

LRWebsterMD@gmail.com Twitter: @LynnRWebsterMD

Finanical Disclosure

•  Consultant/Honoraria/Advisory Board –  AlphaBioCom, American Academy of Pain Medicine,

American Academy of Pain Management, Boston Scientific, Cephalon, Covidien, Medtronic, Pfizer

•  Research –  Adolor, Alkermes, Allergan, Astellas, AstraZeneca, Bayer

Healthcare, BioDelivery Sciences International, Boston Scientific, Cephalon, Collegium, Covidien, Eisai, Elan, F. Hoffman La-Roche, Gilead, GlaxoSmithKline, Identigene (Sorenson), King, Meagan Medical, Medtronic, Merck, Naurex, Nektar, NeurogesX, Novartis, Pfizer, Professional Service Solutions, Inc, SchaBar, Shionogi, Shire, St. Renatus, Sucampo, Takeda, TEVA, Theravance, US WorldMeds, Vanda, Vertex, Xanodyne Pharmaceuticals

The Opioid Pendulum

Avoidance  Even  dying  people  at  risk  

for  addic4on  

Balance  Risk  stra4fica4on  and  principles  of  addic4on  

medicine  applied  to  opioid  prescribing  regardless  of  the  pain  problem  at  hand  

Widespread  Use  Opiophobia  must  go  

Definition of Terms

Katz  N,  et  al.    Clin  J  Pain.  2007;23:648-­‐660.  

Misuse    Use  of  a  medica4on  (for  a  medical  purpose)  other  than  as  directed  or  as  

indicated,  whether  willful  or  uninten4onal,  and  whether  harm  results  or  not  

Abuse  

  Any  use  of  an  illegal  drug    The  inten4onal  self  administra4on  of  a  medica4on  for  a  non-­‐medical  

purpose  such  as  altering  one’s  state  of  consciousness,  e.g.  geFng  high  

Diversion    The  inten4onal  removal  of  a  medica4on  from  legi4mate  and  dispensing  

channels    

Addic0on  

  A  primary,  chronic,  neurobiological  disease,  with  gene4c,  psychosocial,  and  environmental  factors  influencing  its  development  and  manifesta4ons  

  Behavioral  characteris4cs  include  one  or  more  of  the  following:  Impaired  control  over  drug  use,  compulsive  use,  con4nued  use  despite  harm,  craving  

Major Opioid Risks

•  Opioid Use Outcomes – Misuse – Abuse – Addiction – Death

•  Diversion

Statistics on Substance Use and Chronic Pain in the United States

Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and

Mental Health Services Administration, 2011.

Category Statistic Chronic pain patients who may have addictive disorders

32 % (Chelminski et al., 2005)

People ages 20+ who report pain that lasted more than 3 months

56% (National Center for Health Statistics, 2006)

People experiencing disabling pain in the previous year

36% (Portenoy, Ugarte, Fuller & Haas, 2004)

People ages 65+ who experience pain that has lasted more than 12 months

57% (National Center for Health Statistics, 2006)

Civilian, noninstitutionalized U.S. residents ages 12+ who report nonmedical use* of pain relievers in past year

5% (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007)

People ages 12+ who report that they initiated illegal drug use with pain relievers

19% (SAMHSA, 2008)

People with opioid addiction who report chronic pain

29-60% (Peles, Schreiber, Gordon & Adelson, 2005; Potter, Shiffman & Weiss, 2008; Rosenblum et al., 2003; Sheu et al., 2008)

*Nonmedical  use  is  use  for  purposes  other  than  that  for  which  the  medica4on  was  prescribed  

Spectrum of Behaviors

“Recreational

users” “Adherent” “Chemical copers”

Nonmedical Users Pain Patients

“Self-Treaters”

Kirsh,  K.L.,  Passik,  S.D.  The  Interface  Between  Pain  and  Drug  Abuse  and  the  Evolution  of  Strategies  to  Optimize  Pain  management  while  Minimizing  Drug  Abuse.    Experimental  and  Clinical  Psychopharmacology  2008,  16  (5):  400-­‐404  

Webster  LR,  Webster  RM.  Pain  Med.  2005;6(6):432-­‐442.    

Prevalence of Opioid Abuse/Addiction

Aberrant  Behavior:  40%  

Abuse:  20%  Total  Pain  Popula0on  Addic0on:  2%  to  5%  

Significant Risk Factors for Abuse and Overdose

•  Pharmacologic substance –  Potency –  Tmax

–  Cmax

–  Availability

•  Patient risk factors –  Individual risk factors –  Environmental risk factors

•  Prescriber behavior –  Improper patient selection, dosing, and titration –  Improper patient counseling and management

Lifetime Opioid-Use Disorder Among Outpatients on Opioid Therapy for Non-Cancer Pain

Associated With:

Source: Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011 Jul-Sep;20(3):185-94.

N  =  705  

Katz NP, et al. Clin J Pain. 2007;23:103-118; Manchikanti L, et al. J Opioid Manag. 2007;3:89-100. Webster LR, Webster RM. Pain Med. 2005;6:432-442.

Cheatle MD. Depression, Chronic Pain, and Suicide by Overdose: On the Edge. Pain Medicine. 2011;12(s2):S43-S48. Utah Drug Overdose Mortality Report: Findings from interview with family and friends of Utah residents aged 13 and older who died of a drug overdose between

October 26, 2008 and October 25, 2009. Prepared by the Utah Department of Health.

•  Age  ≤45  years  

•  Gender  

•  Family  history  of  prescription  drug  or  alcohol  abuse  

•  Cigarette  smoking  

•  Physical  Illnesses  

•  Pain  severity  

•  Pain  duration  

•  Sleep  disorders  

•  Substance  use  disorder  

•  Preadolescent  sexual  abuse    (in  women)  

•  Major  psychiatric  disorder    (eg,  personality  disorder,  anxiety  or  depressive  disorder,  bipolar  disorder)  

•  Depression  

•  Prior  legal  problems  

•  History  of  motor  vehicle  accidents  

•  Poor  family  support  

•  Involvement  in  a  problematic  subculture  

•  Unemployed  

•  Isolation  

Biological Psychiatric Social  

Patient Risk Factors for Aberrant Behaviors/Harm

Biological   Psychiatric  

Pain, Opioid Use and Psychiatric Co-morbidities

Managing a critical interplay…

Pain Opioids Psychiatric Illness

The Chemical Coper

Key  Clinical  Features  

*Alexythymic  

*Soma4zing  

*Overly  drug  focused  

*Unmo4vated  for  non-­‐drug  therapies  

*Make  li_le  progress  towards  psychosocial  goals  

Major Depression & Pain

Blair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: A literature review. Arch Intern Med 2003; 163(20): 2433-45.

Depression & Pain

Chronic Pain

21.9%

Comorbid Depression 35%

N=  1,179  

Miller  LR,  Cano  A.  Comorbid  chronic  pain  and  depression:  Who  is  at  risk?    J  Pain  2009;  10(6):  619-­‐627  

Depression •  Patients who have CNCP and comorbid

depression tend to: –  Have high pain scores –  Feel less in control of their lives –  Use passive-avoidant coping strategies –  Adhere less to treatment plans than patients who

are not depressed –  Have greater interference from pain, including

more pain behaviors observed by others –  Respond less well to pain treatment, unless

depression is addressed

Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and

Mental Health Services Administration, 2011.

Depression and Pain vs Smoking Status

Hooten  WM,  Shi  Y,  Gazelka  HM,  Warner  DO.  (2011).  The  effects  of  depression  and  smoking  on  pain  severity  and  opioid  use  in  pa4ents  with  chronic  pain.  Pain  103,  16-­‐24.  

%

Mark  each  box  that  applies   Female   Male  

1.  Family  history  of  substance  abuse    Alcohol  

  Illegal  drugs    Prescrip0on  drugs  

 1    2  

 4    

 3    3  

 4  

2.  Personal  history  of  substance  abuse    Alcohol  

  Illegal  drugs    Prescrip0on  drugs  

 3    4  

 5    

 3    4  

 5  

3.  Age  (mark  box  if  16-­‐45  years)    1    1  

4.  History  of  preadolescent  sexual  abuse    3    0  

5.  Psychological  disease    ADD,  OCD,  bipolar,  schizophrenia  

  Depression  

 2    1  

 2    1  

ORT Validation

ADD,  attention  deficit  disorder;  OCD,  obsessive-­‐compulsive  

disorder.  

Webster  L,  Webster  R.  Pain  Med.  2005;6:432-­‐442.  

N=185  

Predicting Aberrant Drug Behavior

Importance of Abuse History

Michna  E,  Ross  EL,  Hynes  WL,  et  al.  Predic4ng  aberrant  behavior  in  pa4ents  treated  for  chronic  pain:  Importance  of  abuse  history.  Journal  of  Pain  &  Symptom  Management  2004;  28(3)250-­‐8.  

Opioid Use in High vs Low Risk Patients

%

Genetic Vulnerability to Addiction?

Fisher  344   Abs0nence   Drug  Rejec0ng  

Lewis   Polysubstance  Abuse  

Drug  Seeking  

Sprague-­‐Dawley   Average   Drug    Neutral  

Webster    L,  Dove  B;  Avoiding  Opioid  Abuse  While  Managing  Pain:  A  Guide  for  Practitioners.  1st  ed.  North  Branch,  MN:  Sunrise  River  Press;  2007.  

No  addic0ve  disease  with  exposure  

Addic0ve  Disease  aRer  opioid  exposure  

No  addic0ve  disease  due  to  lack  of  exposure  

Vulnerability to Opioid Addiction

Individuals  respond  differently  to  opioid  exposure  

Webster    L,  Dove  B;  Avoiding  Opioid  Abuse  While  Managing  Pain:  A  Guide  for  Practitioners.  1st  ed.  North  Branch,  MN:  Sunrise  River  Press;  2007.  

Pa0ent  Stress  Level  

Level of Abuse in Stressful Environments

Drug-­‐Abu

sing  Beh

avior  

Low   Moderate   High  

19991  

20061  

Suicide

1Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2005. NCHS Data Brief 2009;22:1-8.

2005  –  2007    

2Substance  Abuse  and  Mental  Health  Services  Administra4on,  Office  of  Applied  Studies.    Drug  Abuse  Warning  Network,  2007:  Es4mates  of  Drug-­‐Related  Emergency  Department  Visits.    Rockville,  MD:  Author,  2010.  

Why Suicide? Non-Pain Patients

Krao  TL,  Jobes  DA,  Lineberry  TW,  Conrad  A,  Kung  S.    Brief  report:  Why  suicide?    Percep4ons  of  suicidal  inpa4ents  and  reflec4ons  of  clinical  researchers.    Arch  Suicide  Res  2010;14(4):375-­‐82.  

Escape  from  severe  suffering  Only  option  

Hopelessness   Permanent  Solution  

Suicide Ideation in Chronic Pain Patients

•  Hitchcock1 –  50% chronic pain pts

had suicidal thoughts due to pain

•  Fishabain2 –  Pain severity –  Severe comorbidity

(depression)

1Hitchcock LS, Ferrell BR, McCaffery M. The experience of chronic nonmalignant pain. J Pain Symptom Manage 1994;9(5):213-8. 2Fishbain DA. The association of chronic pain and suicide. Semin Clin Neuropsychiatry 1999;4)3):221-7. 3Smith MT, Edwards RR, Robinson RC, Dworkin RH. Suicidal ideation, plans and attempts in chronic pain patients: Factors associated with increased risk. Pain 2004;111(1-2):201-8.

N=153  

Risk for Suicide Pain Patients

 Family history of suicide

 History of childhood abuse

 Previous suicide attempts

 History of mental disorder, particularly depression

 Hopelessness

 History of substance abuse

  Impulsive and aggressive behaviors

 Losses such as work, family, self-esteem

  Isolation  Physical illness

1Fishbain DA. The association of chronic pain and suicide. Semin Clin Neuropsychiatry 1999;(3):221-7. 2Tang NK, Crane C. Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. Psychol Med 2006;36(5):575-86.

+1:  Access  to  poten0ally  lethal  doses  of  prescrip0on  medica0ons  (ie  opioids)  

32  

Mitigate Risk

•  Prescription monitoring programs •  Urine drug test •  Opioid agreements •  Mental health evaluations •  Limit dose where appropriate

Mitigate Risk

Cheatle  MD.    Depression,  Chronic  Pain,  and  Suicide  by  Overdose:  On  the  Edge.    Pain  Medicine.    2011;12(s2):S43-­‐S48.  

Risk Stratification

Adapted  from  Gourlay  DL,  Heit  HA,  Almahrezi  A.  Universal  precautions  in  pain  medicine:  A  rational  approach  to  the  treatment  of  chronic  pain.  Pain  J  Med.  2005;6(2):107–112  and    Webster  LR  Webster  RM.  Predicting  aberrant  behaviors  in  opioid-­‐  treated  patients:  

preliminary  validation  of  the  Opioid  Risk  Tool.  Pain  Med.  2005;  6(6):432-­‐442.  

Lower  Risk   Moderate  Risk   Higher  Risk  

Primary  Care  Patients  

Primary  Care  Patients  with  Specialist  Support  

Pain  Specialist  Patients  

• May  be  a  past  history  of  substance  use  disorders  

• May  be  family  history  of  problematic  drug  use  

• May  have  past  or  concurrent  psychopathology    

• Not  actively  addicted  • Usually  consistent  UDT  • PMP    consistent  • Mild  to  severe  pain  

• No  past  or  current  history  of  substance  use  disorders  

• No  family  history  of  past  or  current  substance  use  disorders  

• No  major  or  untreated  psychopathology  

• Consistent  UDT  • PMP    consistent  • Pain  mild  to  moderate  

• Active  substance  use  disorders  

• Major,  untreated  psychopathology    

• Poor  social  support    • Actively  addicted  •  Inconsistent  UDT  • PMP  multiple  prescribers  • Moderate  to  sever  pain  

ORT  Score:  0-­‐3   ORT  Score:  4-­‐7   ORT  Score:  8+  

8  Prescribing  Guidelines  

1.  Assess  risk  for  opioid  abuse  

2.  Assess  and  treat  co-­‐morbid  mental  health  3.  Use  conversion  tables  cau4ously  4.  Avoid  benzodiazepines  with  opioids  

5.  Start  opioids  low  and  advance  slowly  6.  Assess  for  sleep  apnea  at  >  100  mg/day  7.  Reduce  opioids  with  URI’s,  flu  and  asthma  

8.  Avoid  long  ac4ng  opioids  with  acute  pain  

http://www.painfoundation.org/painsafe/safety-tools-resources/

8  Ways  Pa4ents  can  Prevent  Overdose  Deaths  

1.  Never  take  prescrip4on  pain  medica4on  that  is  not  prescribed  to  you  

2.  Never  adjust  your  own  doses  3.  Never  mix  with  alcohol  4.  Taking  sleep  aids  or  an4-­‐anxiety  medica4ons  together  with  

prescrip4on  pain  medica4on  can  be  dangerous  5.  Always  tell  your  healthcare  provider  about  all  medica4ons  

you  are  taking  from  any  source  6.  Keep  track  of  when  you  take  all  medica4ons  7.  Keep  your  medica4ons  locked  in  a  safe  place  8.  Dispose  of  any  unused  medica4ons  

http://www.painfoundation.org/painsafe/safety-tools-resources/

37  

Conclusion

•  Pain is the most common cause of disability in America

•  Substance abuse is a serious public health issue

•  Co-occurring pain and substance abuse is common and major challenge for clinicians

•  Treating pain while minimizing opioid abuse requires vigilances and compassion

Thank you!