PAIN AND ADDICTIONPAIN AND ADDICTIONSteven Rapaport, MD Steven Rapaport, MD

Attending Physician Attending Physician Comprehensive HIV Center Comprehensive HIV Center

Saint Vincent’s Catholic Medical Center Saint Vincent’s Catholic Medical Center A Local Performance Site of the NY/NJ AIDS A Local Performance Site of the NY/NJ AIDS

Education and Training CenterEducation and Training CenterNew York City New York City

Medical Director Medical Director West Midtown Medical Group West Midtown Medical Group

New York CityNew York City

Case Case Alex is a 44 year old man having difficulty with pain Alex is a 44 year old man having difficulty with pain

medications medications

He has AIDS He has AIDS CD4 nadir 75 several years agoCD4 nadir 75 several years agoCurrently on Kaletra and CombivirCurrently on Kaletra and CombivirRecent CD4 325 Viral Load <50 Recent CD4 325 Viral Load <50 Also has hepatitis C infection with documented viremiaAlso has hepatitis C infection with documented viremia(type 1A) and mild elevation in AST and ALT(type 1A) and mild elevation in AST and ALT

Pain problem: avascular necrosis of left hip for severalPain problem: avascular necrosis of left hip for severalyears, requiring opioid analgesicsyears, requiring opioid analgesics

Initially treated with percocet, up to 8 tablets daily

Switched to MS Contin due to concern over tylenol exposure

Eventually stabilized on MS Contin 30 mg twice daily and

hydromorphone (dilaudid) 2 mg to 4 mg every 4 hours for

break-though pain

S/P total hip replacement 6 months ago

After hospital discharge, he was given Rx for percocet by orthopedist

He is currently taking 8 percocets daily

His primary provider has tried unsuccessfully to discontinue the percocets

He no longer has hip pain, but he complains of irritability, malaise, insomnia, generalized body pain, abdominal cramping, diarrhea, sweats and chills when he doesn’t take them

Both the patient and his primary provider are concerned that he has developed an addiction to pain medications

What is your assessment?

PHYSICAL DEPENDENCEPHYSICAL DEPENDENCE

A state of adaptation characterized by a class A state of adaptation characterized by a class specific drug withdrawal syndrome that can be specific drug withdrawal syndrome that can be produced by the abrupt cessation, rapid dose produced by the abrupt cessation, rapid dose reduction, decreasing blood level of the drug, or reduction, decreasing blood level of the drug, or administration of an antagonistadministration of an antagonist

A predictable drug effectA predictable drug effect

Consensus statement of the American Pain Society, American Consensus statement of the American Pain Society, American Academy of Pain Medicine, and the American Society of Addiction Academy of Pain Medicine, and the American Society of Addiction Medicine (2001)Medicine (2001)

ADDICTIONADDICTION A primary, chronic condition characterized by:A primary, chronic condition characterized by:

Impaired control over drug use, compulsive useImpaired control over drug use, compulsive use

Craving, preoccupation with obtaining and using the drug Craving, preoccupation with obtaining and using the drug

Continued use despite harm (physical, psychologic, Continued use despite harm (physical, psychologic, social)social)

Consensus statement of the American Pain Society, American Consensus statement of the American Pain Society, American Academy of Pain Medicine, and the American Society of Academy of Pain Medicine, and the American Society of

Addiction Medicine (2001)Addiction Medicine (2001)

DSM-IV CRITERIA NOT WELL DSM-IV CRITERIA NOT WELL SUITED FOR PAIN PATIENTSSUITED FOR PAIN PATIENTS

SUBSTANCE DEPENDENCE DISORDER SUBSTANCE DEPENDENCE DISORDER (three or more)(three or more)

Larger amounts used for longer time than intended Larger amounts used for longer time than intended Persistent desire or unsuccessful attempts to control use Persistent desire or unsuccessful attempts to control use Great deal of time spent in activities related to use Great deal of time spent in activities related to use Important social, occupational, or recreational activities Important social, occupational, or recreational activities given up or reduced due to substance usegiven up or reduced due to substance useContinued use despite problems caused or exacerbated Continued use despite problems caused or exacerbated by use by use Tolerance Tolerance Withdrawal (physical dependence)Withdrawal (physical dependence)

KEY QUESTIONS:KEY QUESTIONS:

What percentage of patients treated with opioids forWhat percentage of patients treated with opioids forchronic pain will develop an addiction disorder?chronic pain will develop an addiction disorder?

Are there risk factors for the development ofAre there risk factors for the development ofaddictions?addictions?

How can you tell if the patient is developing anHow can you tell if the patient is developing anaddiction disorder?addiction disorder?

““MALIGNANT” VS. “NON-MALIGNANT”MALIGNANT” VS. “NON-MALIGNANT”

Concerns about addiction are usually irrelevant in Concerns about addiction are usually irrelevant in palliative care at the end of lifepalliative care at the end of life

Nonetheless, fear of addiction contributes to Nonetheless, fear of addiction contributes to unnecessary pain and suffering, even at the end of life.unnecessary pain and suffering, even at the end of life.

Fear of regulatory scrutiny inhibits appropriate Fear of regulatory scrutiny inhibits appropriate prescribing by physicians, even at the end of life.prescribing by physicians, even at the end of life.

On the other hand, opioid analgesic therapy for chronic On the other hand, opioid analgesic therapy for chronic non-malignant pain should involve a careful assessment non-malignant pain should involve a careful assessment of benefits and risks, including addiction.of benefits and risks, including addiction.

PAIN AND AIDSPAIN AND AIDS

Late stage AIDS is often associated with painLate stage AIDS is often associated with pain

Before the advent of HAART, AIDS was always a Before the advent of HAART, AIDS was always a terminal disease, similar to incurable cancerterminal disease, similar to incurable cancer

Chronic pain in the HIV/AIDS in the post-HAART era is Chronic pain in the HIV/AIDS in the post-HAART era is more often similar to other non-malignant pain conditions more often similar to other non-malignant pain conditions (chronic back pain, arthritis) and the use of opioid (chronic back pain, arthritis) and the use of opioid analgesics should involve a careful risk-benefit analysisanalgesics should involve a careful risk-benefit analysis

PAIN AND ADDICTIONPAIN AND ADDICTION

What percentage of patients treated with opioidsWhat percentage of patients treated with opioidsfor chronic pain will develop addiction?for chronic pain will develop addiction?

Pain specialist have reported that addiction is aPain specialist have reported that addiction is arare occurrence among chronic pain patientsrare occurrence among chronic pain patients

Published rates of addiction in chronic painPublished rates of addiction in chronic painpopulationspopulations

3% to 18%3% to 18%

PAIN AND ADDICTIONPAIN AND ADDICTION

On the other hand…On the other hand…

Rates of addiction problems in the general USRates of addiction problems in the general USpopulation:population:

Alcoholism: 10%Alcoholism: 10%Drug abuse: 5%Drug abuse: 5%

Many patients with opiate addiction (up to 25% in some Many patients with opiate addiction (up to 25% in some surveys), report that their addiction resulted from surveys), report that their addiction resulted from prescribed opioid analgesics. prescribed opioid analgesics.

PAIN AND ADDICTION PAIN AND ADDICTION

In retrospective analyses, nearly all In retrospective analyses, nearly all chronic pain patients who developed chronic pain patients who developed problems with opioid use had a prior problems with opioid use had a prior history of addiction.history of addiction.

However, prospective longitudinal studies, However, prospective longitudinal studies, in well-characterized patient populations, in well-characterized patient populations, are lackingare lacking

RISK FACTORS FOR ADDICTIONRISK FACTORS FOR ADDICTION(not evidence-based)(not evidence-based)

Prior history of addiction Prior history of addiction

Family history of addictionFamily history of addiction

Co-occurring psychiatric disorders Co-occurring psychiatric disorders

Use of short-acting opioids which are more Use of short-acting opioids which are more “reinforcing” than long-acting opioids “reinforcing” than long-acting opioids

CASE:CASE:Used drugs extensively in the 1980’s and 1990’s,Used drugs extensively in the 1980’s and 1990’s,especially cocaine, crystal methamphetamine, alcohol, andespecially cocaine, crystal methamphetamine, alcohol, andMarijuana, while working in the fashion industry, whereMarijuana, while working in the fashion industry, wheredrug use was very common.drug use was very common.

He injected heroin several times in college, but He injected heroin several times in college, but ““didn’t really like it” didn’t really like it”

He lost several jobs due to inability to control his drug use.He lost several jobs due to inability to control his drug use.Attended detox and rehab in 1996 after a suicide attempt.Attended detox and rehab in 1996 after a suicide attempt.

He continues to drink alcohol on weekends, up to 4 to 5He continues to drink alcohol on weekends, up to 4 to 5drinks per night, despite having been told that he shoulddrinks per night, despite having been told that he shouldstop because of his hepatitis C infection. Denies otherstop because of his hepatitis C infection. Denies otherdrugs since leaving the rehab. drugs since leaving the rehab.

FAMILY HISTORY:FAMILY HISTORY:

His father was an alcoholic, died of cirrhosis. His father was an alcoholic, died of cirrhosis.

His brother was addicted to heroin, now in aHis brother was addicted to heroin, now in a

methadone program. methadone program.

MENTAL HEALTH:MENTAL HEALTH:

He has a history of depression in past, which wasHe has a history of depression in past, which was

associated with periods of drug use. He is notassociated with periods of drug use. He is not

currently depressed and is on effexor.currently depressed and is on effexor.

CASECASE

Alex is concerned that he is having difficultyAlex is concerned that he is having difficultygetting off the pain medications, but he:getting off the pain medications, but he:

Denies craving for the pain medications Denies craving for the pain medications Has a half-full bottle of percocet at home andHas a half-full bottle of percocet at home andleft-over MS Contin from an old prescription. left-over MS Contin from an old prescription. Never takes them for a euphoric effect orNever takes them for a euphoric effect orfor any other effects other than to eliminatefor any other effects other than to eliminatethe withdrawal symptoms.the withdrawal symptoms.

What is your assessment? What is your assessment?

SIGNS OF ADDICTION IN PAIN SIGNS OF ADDICTION IN PAIN PATIENTS:PATIENTS:““ABERRANT BEHAVIORS”ABERRANT BEHAVIORS”

Lost or stolen Rx Lost or stolen Rx Escalating doses, early renewalsEscalating doses, early renewalsObtaining medication form other sources Obtaining medication form other sources Use of pain medications for psychic effects, Use of pain medications for psychic effects, e.g. to relieve anxiety, increase energy, or for e.g. to relieve anxiety, increase energy, or for euphoriaeuphoriaUnwillingness to try non-opioid mediationsUnwillingness to try non-opioid mediationsDeterioration in functionDeterioration in function

ADDICTION IN PAIN PATIENTS:ADDICTION IN PAIN PATIENTS:

Impaired control, compulsive use Impaired control, compulsive use

Craving, preoccupation Craving, preoccupation

Continued use despite harm, which leads Continued use despite harm, which leads to deterioration in functionto deterioration in function

PSEUDOADDICTIONPSEUDOADDICTION

Behaviors that resemble addiction that occur when pain is Behaviors that resemble addiction that occur when pain is under-treated. under-treated.

““Watching the clock” for pain medications in hospitalWatching the clock” for pain medications in hospital““Drug seeking” and “doctor shopping”Drug seeking” and “doctor shopping”Asking for specific medications by name Asking for specific medications by name Hoarding of medications Hoarding of medications Unsanctioned escalation in dose Unsanctioned escalation in dose

These behaviors resolve when the pain is adequately These behaviors resolve when the pain is adequately treated. treated.

CASE:CASE:

In order to treat opioid withdrawal, Alex received aIn order to treat opioid withdrawal, Alex received along acting opioid which slowly tapered off overlong acting opioid which slowly tapered off overthe course of several weeks. the course of several weeks.

He completed the taper without any complicationsHe completed the taper without any complicationsand did not display any aberrant behaviors. and did not display any aberrant behaviors.

Despite being advised to abstain completely fromDespite being advised to abstain completely fromalcohol and cigarettes, he continues to drink andalcohol and cigarettes, he continues to drink andsmoke as before. smoke as before.

CASE: version #2CASE: version #2

The surgery was unsuccessful and he The surgery was unsuccessful and he continues to have severe pain continues to have severe pain

How should his pain be managed?How should his pain be managed?

PAIN AND ADDICTIONPAIN AND ADDICTION

Chronic pain is very common among patients with Chronic pain is very common among patients with addictions disordersaddictions disorders

traumatrauma

medical illnessmedical illness

Chronic opioid use, e.g. methadone maintenance, Chronic opioid use, e.g. methadone maintenance, may lead to increased sensitivity to pain (hyperalgesia)may lead to increased sensitivity to pain (hyperalgesia)

PAIN AND ADDICTIONPAIN AND ADDICTION

Should you prescribe opioid analgesics for patients with Should you prescribe opioid analgesics for patients with addiction disorders?addiction disorders?

Regulatory issues (will you get in trouble with the DEA?)Regulatory issues (will you get in trouble with the DEA?)

Clinical issues (is it good medicine?)Clinical issues (is it good medicine?)

PAIN AND ADDICTIONPAIN AND ADDICTION

REGULATORY ISSUESREGULATORY ISSUESThe use of opioids to treat opioid addiction is limited to The use of opioids to treat opioid addiction is limited to federally approved Opioid Treatment Programs federally approved Opioid Treatment Programs (Narcotic Drug Treatment Act of 1974) and is monitored (Narcotic Drug Treatment Act of 1974) and is monitored by the DEA and State authoritiesby the DEA and State authorities

Office-based treatment of opioid addiction with Office-based treatment of opioid addiction with buprenorphine is allowed under the Drug Addiction buprenorphine is allowed under the Drug Addiction Treatment Act of 2000Treatment Act of 2000

Physicians may prescribe opioids to addicts Physicians may prescribe opioids to addicts for pain, for pain, as as long as the chart clearly documents that the opioids are long as the chart clearly documents that the opioids are being used to treat being used to treat painpain and not and not addiction addiction

DIVERSION DIVERSION

The diversion of prescribed controlled substancesThe diversion of prescribed controlled substancesfor other than legitimate medical uses poses afor other than legitimate medical uses poses athreat to the individual and society. threat to the individual and society. Prescribers have a responsibility to minimize thePrescribers have a responsibility to minimize thepotential for the abuse and diversion of controlledpotential for the abuse and diversion of controlledsubstances, but efforts to stop diversion should notsubstances, but efforts to stop diversion should notinterfere with the legitimate use of opioids for paininterfere with the legitimate use of opioids for painmanagement. management.

from Model Policy on Controlled Substances for from Model Policy on Controlled Substances for Treatment of Pain: Federation of State Medical Treatment of Pain: Federation of State Medical

Boards Boards (2004)(2004)

PATIENT EVALUATION PATIENT EVALUATION

Complete history and physical Complete history and physical Detailed pain history, physical exam, prior treatment Detailed pain history, physical exam, prior treatment history, indications for opioid analgesic (under accepted history, indications for opioid analgesic (under accepted medical standard of care)medical standard of care)

History of substance abuseHistory of substance abuse

Psychiatric history Psychiatric history

Communicate with prior clinicians, obtain prior recordsCommunicate with prior clinicians, obtain prior records

INFORMED CONSENTINFORMED CONSENT

Discussion of risks and benefitsDiscussion of risks and benefits

Consider use of a written agreementConsider use of a written agreement

INFORMED CONSENTINFORMED CONSENT

WRITTEN AGREEMENTWRITTEN AGREEMENTOne prescriberOne prescriber

One pharmacyOne pharmacy

Patient agrees to safeguard medicationPatient agrees to safeguard medication

No replacement of lost or stolen medicationNo replacement of lost or stolen medication

No illegal substancesNo illegal substances

No diversion (selling, sharing)No diversion (selling, sharing)

Urine toxicology testingUrine toxicology testing

PERIODIC REVIEW PERIODIC REVIEW

Analgesic responseAnalgesic response

Aberrant behaviors, signs of addiction or Aberrant behaviors, signs of addiction or diversiondiversion

Functional status: patients on effective analgesia Functional status: patients on effective analgesia should have improved function; patients with should have improved function; patients with addiction disorders will get worseaddiction disorders will get worse

Do the benefits of opioid analgesics continue to Do the benefits of opioid analgesics continue to outweigh any risks?outweigh any risks?

DocumentationDocumentation

Chart everything!Chart everything!