Pain and Addiction: Minding the Medicine

Cabinet

Jennifer Sharpe Potter, PhD, MPHAssociate Professor of Psychiatry

Associate Dean for Research

Division of Alcohol And Drug AbuseDepartment of Psychiatry

School of MedicineUniversity of Texas Health Science Center San Antonio

Citation available upon request

Video

Opioid analgesics may benefit people when used correctly and under a medical provider’s care.

But when abused, they can be just as dangerous as illicit drugs, especially when taken with alcohol or illicit drugs.

Pain medicines

Addictive!

Pain!

Safe!

Not safe!It depends…

Addiction?

Start at the beginning: Low back pain (often chronic)

Unique characteristics of pain• Pain is a subjective experience

Patients experience and “interpret” it differently No test for pain (only for unpleasantness)

• Pain tolerance varies from person-to-person Genetic and cultural differences “Significance” of pain plays a role

• Requires comprehensive clinical evaluation Health care providers struggle to treat pain effectively Few health care providers are taught adequately how

to diagnose and treat Failure to treat/under-treatment common

Related Opioid Trends

Prescription drug epidemic is unique• Prescription drugs are not inherently bad

when use appropriate, under a health providers supervision, and when they provide pain relief• Threat comes from abuse and diversion• Just because prescription drugs are legal and

are prescribed by an MD, they are not necessarily safer than illicit substances.

Source of Pain Relievers for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2010-2011

National Survey on Drug Use and Health 2011

Weiss, Potter et al. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase randomized controlled trial. Archives of General Psychiatry, 68(12), 1238-46.

POATS: Study locationsWA: Providence Behavioral Health SvcOR: ADAPT, Inc.CA: SF General HospitalCA: UCLA ISAPSC: Behavioral Health Services of Pickens CoIN: East Indiana Treatment CenterWV: Chestnut Ridge HospitalNY: Bellevue Hospital CenterNY: St. Luke's Roosevelt Hospital CenterMA: McLean Hospital

POATS: Study schema

Successful outcomes at 3 time points

SuccessPhase 1 4-week taper + 8 weeks f/u 7%

Phase 2Week 12 - End of stabilization 49%Week 24 - 8 weeks post-taper 9%

Chronic pain locationHead/face 16.1%

Chest/abdomen 5.5%

Upper extremities 29.6%

Cervical 27.0%

Thoracic 26.3%

Lumbar/sacral 65.0%

Lower extremities 52.9%

Multiple spinal areas 36.1%

Primary reason for use: Past and presentMajor reason for first use among CP patients

• pain 83.2%

• get high 13.1%

Major reason for current use among CP patients whose first reason was pain

• pain 22.6%

•get high 13.9%

•avoid withdrawal 56.5%

% of CP Participants with Clinically Meaningful Reductions in PainReduction at Ph2 wk

12 from baselineMinimal (>10% Δ)

Moderate(>30% Δ)

Substantial(>50% Δ)

BPI Intensity Scale 69% 51% 35%Worst pain 66% 51% 34%Average pain 67% 55% 43%

BPI – (0-10) worst, least, average, and “right now” Results presented for overall sample; no difference between

treatment groups n=121 (149 Phase 2 CP participants)

(IMMPACT recommendations, Dworkin et al, Pain, 2008)

Clinically meaningfulreductions in pain interference

Reduction at Ph2 wk 12 from baseline

Minimal(>1 point Δ)

Moderate(>2 point Δ)

BPI Interference 59.5% 43.0%

Results presented for overall sample; no difference between treatment groups

n=121 (149 Phase 2 CP participants)

ACT: Acceptance and Commitment Therapy

Cognitive-behavioral therapyMindfulnessPhysical activityDiet Social support

ACT: What we did• Some patients were randomized to health

education – learning about pain and health – while other patients were randomized to ACT. Brain imaging was done before and after the 8-week treatment program.• Task - Chronic pain patients who were also

addicted to opiates were exposed to experimentally induced pain delivered via a thumb screw. • Resting state - We also look at their brains at rest

Pain region connections during resting state (p<0.05 uncorrected)Solid cyan = connectivity ACT pre- > ACT post-treatmentDashed cyan = connectivity ACT post- > ACT pre-treatmentSolid red = connectivity HEC post-treatment > ACT post-treatment

Correlations of clinical variables in ACT group post-treatment:

Green brackets = Pain intensity correlation

Magenta brackets = Pain interference correlation

Yellow brackets = AAQ-II correlation

Values = Fisher’s Z

Take home message•After treatment, the brains of ACT

patients were more resilient at rest, and less reactive to pain even when it was deliberately induced. The ACT patients learned how to carry their pain is a less entangling way: chronic pain and induced pain. – Steve Hayes

CAVEATS!!!

“The nation's defense rests on the comprehensive fitness of its service

members ― mind, body, and spirit. Chronic pain and use of opioids carry the risk of

functional impairment of America's fighting force.”

-Jonas and Schoomaker

PDMPs: Prescription Drug Monitoring Programs: By State

PDMP Training & Technical Assistance Center

Study AimsExamine military trends and trajectories in

opioid prescribing Build military-specific tools and strategies to

alert clinicians of potential opioid misuse in the military

Develop reports and guidelines for addressing opioid misuse in the military context

The road ahead…

Nonmedical Use of Pain Relievers in the Past Year among Youths Aged 12 to 17, by State: Percentages, Annual Averages Based on 2010 and 2011 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2010 (Revised March 2012) and 2011

What do teens say?Over half of teens (56 percent or 12.8 million) do not see great risk in trying prescription pain relievers without a doctor’s prescription Prescription drugs are easy to get; 70 percent of kids age 12 and

older say they get them from friends or relatives, often for free

Teens say they abuse prescription painkillers because… they believe they are safer to use than illicit drugs (41%) there is less shame attached to using them (37%) there are fewer side effects than illicit drugs (31%) and parents don’t care as much if you get caught (20%)

What can parents do?• Talk with and listen to your kids• Know what your kids are doing – parental

awareness/monitoring of their kids’ activities is one of the best predictors of well-being for most behavioral health issues including drug abuse• Teens whose parents express disapproval about

drug abuse are less likely to engage in substance use• Universal precautions

Specific steps parents can take• Safeguard all drugs at home

Monitor quantities Control access

• TALK-talking to your children is not dangerous Set clear rules for teens about all drug and alcohol use, INCLUDING not sharing medicine and following the medical provider’s

advice and dosages

• Be a good role model by following these same rules with your own medicines – don’t share medications

• Properly dispose of old or unneeded medicines• Ask friends and family to safeguard their prescription drugs as

well

CollaboratorsErin Finley, PhDMary Jo Pugh, PhDDon McGeary, PhDBill Kazanis, MSKangwon Song, PharmDDon Robin, PhDKristen Rosen, PhD, MPHSuyen Warzinski, MSSamantha PaniaguaAshley GarciaLt Col (Ret) Vikhyat Bebarta, MDMaj Josephy Maddry, MDLt Col David Carnahan, MD COL Robert GibbonsMaj Gen(Ret) Byron Hepburn, MDLTC Brandon Goff, DOLee Ann Zarzabal, MSAlan Sim, PhDSandra Valtier, PhD (program officer, 59th MW)

Division of Alcohol and Drug Addiction, School of MedicineUniversity of Texas Health Science Center at San Antonio

Questions?