Pain Management and Substance Abuse

1. Pain Management and Substance Abuse Mary Lynn McPherson, Pharm.D., BCPS, CPE Professor and Vice Chair, University of Maryland School of Pharmacy Hospice Consultant Pharmacist mmcphers@rx.umaryland.edu

2. Objectives • Define abuse and addiction, and describe the prevalence of each in patients with and without a history of substance abuse. • Identify predictors of aberrant drug-related behavior and addiction in hospice patients. • Identify strategies to limit drug abuse and diversion in the home environment, and a plan for the management of pain in the terminally ill patient with a history of substance abuse.

3. YOU Are Here www.nancydoran.com/2.html

4. HCPs are obligated not to prescribe, dispense, or administer fradulent prescriptions HCPs are obligated to provide optimal palliative care for their patients HCPs – health care providers

5. Pain and Chemical DependencyDefinitions Key Terms and Concepts • Physical Dependence • Tolerance • Aberrant drug-related behavior • Pseudoaddiction • Abuse • Addiction

6. Physical Dependence • Pharmacologic property of some drugs • Defined solely by the occurrence of an abstinence syndrome on abrupt dose reduction, continuation of dosing, or administration of an antagonist drug. • NOT a problem if abstinence is avoided • Should NEVER be labeled “addiction”

7. Tolerance • Declining effect with drug exposure • Tolerance to side effects is desirable; tolerance to analgesia may be a problem • Should NEVER be labeled “addiction”

8. Abuse • Defined as the intentional misuse of a medication • For nonprescribed effects such as mood alteration • Drug use outside of socially accepted norms • Illicit drugs and aberrant use of prescription drugs • DMS IV: Psychoactive Substance Abuse • A maladaptive pattern of drug use that results in harm or places the individual at risk

9. Substance Abuse • Use of a substance in a manner outside of sociocultural conventions; according to this definition, all use of illicit drugs is abuse, as is use of a licit drug in a manner not dictated by convention (i.e., according to a physician’s order).

10. Substance Abuse • Actively using drugs or alcohol • Actively using drugs or alcohol and on methadone or buprenorphine • An ex-user on methadone or buprenoprhine maintenance • An ex-user who is drug and alcohol-free • A recreational or social user (occasional pot or alcohol)

11. Addiction • Task Force of APS, AAPM and ASAM – new definition of addiction • A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors, influencing its development and manifestations. • It is characterized by behaviors that include onr or more of the following: • Impaired control over drug use • Compulsive use • Continued use despite harm • Craving J Pain Symptom Management 2003;26:655-667.

12. Pseudoaddiction • “…individuals who have severe, unrelieved pain may become intensely focused on finding relief for their pain. Sometimes, such patients may appear to observers to be preoccupied with obtaining opioids, but the preoccupation is with finding relief of pain, rather than using opioids, per se.” American Society of Addiction Medicine

13. Pseudoaddiction • Drug-seeking behavior resulting from inadequate pain management • Patient may become angry, hostile, mistrustful • Can be differentiated from abuse when an increased dose stops the behavior • Increase dose by 50% and assess behavior

14. Other Definitions • Drug-seeking behaviors • Directed or concerted efforts on the part of the patient to obtain opioid medication or to ensure an adequate medication supply; may be an appropriate response to inadequately treated pain. • Therapeutic dependence • Patients with adequate pain relief may demonstrate drug-seeking behaviors because they fear not only the re-emergency of pain but perhaps the emergence of withdrawal symptoms. Alford DP et al. Ann Intern Med 2006;144:127-134.

15. Differential Diagnosis of Aberrant Drug-Taking Behavior • Pseudoaddiction (unrelieved pain) • Addiction (substance-abuse disorder) • Other psychiatric disorders • depression, anxiety • borderline personality diorder • organic mental syndrome • Criminal intent

16. Results from the 2008National Survey on Drug Use and Health:National Findings http://www.oas.samhsa.gov

17. Past Month Illicit Drug Use among Persons Aged 12 or Older: 2008 http://www.oas.samhsa.gov

18. Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons Aged 12 or Older: 2002-2008 http://www.oas.samhsa.gov

19. Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons Aged 12 or Older: 2002-2008 http://www.oas.samhsa.gov

20. Past Year Initiates for Specific Illicit Drugs among Persons Aged 12 or Older: 2008 http://www.oas.samhsa.gov

21. NSDUH 2008 Survey Highlights • Acquisition of pain relievers used nonmedically in past 12 months: • 55.9% - from a friend or relative for free • 18.0% - from one doctor • 8.9% - bought from a friend or relative • 4.3% - drug dealer or stranger • 0.4% - bought from Internet http://www.oas.samhsa.gov

22. 48 year old TV sportscaster in Baltimore charged with two counts first degree burglary Victim was a 64 year old neighbor with cancer Caught on video – entering residence, taking opioid, and returning to wipe fingerprints away BUSTED! The Devil Made Me Do It! 1-26-06: http://wjz.com/topstories/local_story_025165138.html

23. I’ve Got My Eye On You! Nanny Cam!

24. http://DAWNinfo.samhsa.gov http://www.samhsa.gov http://www.oas.samhsa.gov

25. Opioid Analgesics – DAWN Data https://dawninfo.samhsa.gov/files/ED2006/DAWN2k6ED.pdf

26. Physical dependence Drug-seeking behavior Addiction Tolerance Pseudoaddiction Abuse Therapeutic dependence Pain and the Addiction Continuum

27. Ten Steps of Universal Precautions in Pain Medicine • Make a diagnosis with appropriate differential • Psychological assessment including risk of addictive disorders • Informed consent • Treatment agreement • Pre- and post-intervention assessment of pain level and function Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.

28. Ten Steps of Universal Precautions in Pain Medicine • Appropriate trial of opioid therapy +/- adjunctive medication • Reassessment of pain score and level of function • Regularly assess the four “A’s” of pain medicine • Periodically review pain diagnosis and comorbid conditions, including addictive disorders • Documentation Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.

29. Patient Triage – 3 Groups • Group I • No past or current history of substance abuse disorders • Noncontributory family history with respect to substance use disorders • Lack major or untreated psychopathology • Represents the majority of patients seen in palliative care Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.

30. Management of Group I • Apply good principles of pain management • Use common sense and prudently monitor patient; recognize lower addiction risk • Remain alert for substance abuse in the home (not the patient necessarily) • Differentiate physical dependence from addiction • Don’t mistake pain relief seeking (pseudoaddiction) for drug-seeking

31. Patient Triage – 3 Groups • Group II • May be a past history of treated substance use disorder, or a significant family history of problematic drug use • May have a past or concurrent psychiatric disorder • Not actively addicted, but are at increased risk • May include patients in recovery (opioid maintenance) Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.

32. Patient Triage – 3 Groups • Group III • Complex cases due to active substance abuse or major, untreated psychopathology • Patient are actively addicted and pose significant risk to both themselves and to practitioners Gourlay, Heit, Almahrezi. Pain Medicine 2005;6(2):107-112.

33. Group IV?? • Drug abuse or diversion in the home (or workplace) • Patient suffering consequences of undertreated pain • We are obligated to care for the patient, but analgesics are being diverted

34. Aberrant Behavior Less Suggestive of Addiction • Aggressive complaining about the need for more drugs • Drug hoarding during periods of reduced symptoms • Requesting specific drugs • Opening acquiring similar drugs from other medical sources

35. Aberrant Behavior Less Suggestive of Addiction • Unsanctioned dose escalation or other noncompliance with therapy on one or two occasions • Unapproved use of the drug to treat another symptom • Reporting psychic effects not intended by the clinician

36. Aberrant Behavior Less Suggestive of Addiction • Resistance to a change in therapy associated with tolerable adverse effects accompanied by expressions of anxiety related to the return of severe symptoms.

37. Aberrant Behavior More Suggestive of Addiction • Selling prescription drugs • Prescription forgery • Stealing or borrowing drugs from others • Injecting oral formulations (or transdermal) • Obtaining prescription drugs from nonmedical sources • Concurrent abuse of alcohol or illicit drugs

38. Aberrant Behavior More Suggestive of Addiction • Multiple dose escalations or other noncompliance with therapy despite warnings • Repeatedly seeking prescriptions from other clinicians or from emergency rooms without informing prescriber

39. Aberrant Behavior More Suggestive of Addiction • Evidence of a deterioration in the ability to function at work, in the family, or socially that appears to be related to drug use • Repeated resistance to changes in therapy despite clear evidence of drug-related diverse physical or psychological effects

40. CAGE-AID C – have you felt you ought to CUT DOWN on your drinking or drug use? A – have people ANNOYED you by criticizing your drinking or drug use? G – have you felt bad or GUILTY about your drinking or drug use? E – have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (EYE-OPENER)? AMA. Assessing and treating pain in patients with substance abuse concerns.

41. CAGE-AID AMA. Assessing and treating pain in patients with substance abuse concerns.

42. Assessment Cues to Medication Diversion • Is the patient specific or vague regarding the pain? • Is there a history of chronic pain? • Is there a condition resulting in chronic pain? • Is the reported pain congruent with the expected presentation of the condition? • Are there any accommodations for pain level in daily life (physical, emotional, spiritual, relationships, interactions)? • Can the pain be attributed to something else? Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO

43. Assessment Cues to Medication Diversion • Does the patient or caregiver appear more interested in obtaining a specific medication than in alleviating pain? • Does the patient or caregiver create barriers to changing drugs or routes of administration? • Are the patient or caregiver resistant to adjuvants? • Has the patient or caregiver ever presented as overmedicated, sedated, or physically or cognitively impaired? • Is there a pattern of weekend or evening calls for more medication? Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO

44. Red Flags - Medications • Patient/family unable to find • Dropped on floor (in toilet) • Pharmacy did not dispense enough • Dog/cat/canary (insert animal of choice) ate medication • Run out at night/weekends when nurse not available • Medications present that team or physician did not order Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO

45. For all those health care professionals who question whether patients actually dropped their narcotics down the drain, here is the first scientific proof that it can happen (all by itself).

46. Red Flags – Family/Patient Behavior • Multiple physicians/pharmacies • Family members under influence • Patient/family members have extensive drug knowledge • PDR in home • Patient hoards medication • Patient protects medications from family members Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO

47. Red Flags – Family/Patient Behavior • Estranged family members • Family cannot go to establishments because of history (e.g., shoplifting at the pharmacy) • Vague regarding sources of income • Calls nurse the “narcotics police” • Uncomfortable with nurse counting medications • Requests nurse count medications every visit Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO

48. Red Flags - Environment • Drug paraphernalia present • Requests to get out of court hearing, jail, probation/parole requirements • Camera on doorstep or extensive security measures • Bare cupboards, empty refrigerator • Weapons readily accessible/visible Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO

49. Red Flags - Environment • Aggressive animals (rottweilers or pit bulls) in house “for protection” • Large amounts of cash around house • Minimal furniture, new entertainment equipment, many pagers/answering machines • Many roommates, people coming and going Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO

50. Red Flags - System • Physician will not prescribe, or only prescribe in limited amount, not early, or only if he/she sees patient • Copy company calls – “We found a prescription on a copier with your clinic’s name on it” • Patient not allowed in or welcome at the ED • Other hospices expelled/will not accept patient Giles C, St. Clair T. 4th Joint Clinical Conference, April 10-12, 2003. Denver, CO