Substance Abuse Issues in Chronic Pain Management

1. Substance Abuse Issues in Chronic Pain Management Steven D. Passik, PhD Director, Oncology Symptom Control and Research Community Cancer Care, Inc. Indianapolis, IN ALSAC, FDA 1/30/02

2. The Four “A’s” of Pain Treatment Outcomes • Analgesia (pain relief) • Activities of Daily Living (psychosocial functioning) • Adverse effects (side effects) • Aberrant drug taking (addiction-related outcomes) Passik & Weinreb, 1998

3. The 4 A’s: Analgesia Selected Questions Using a scale of 0 to 10, in which 0 means no pain and 10 means the worst pain imaginable, please rank the following: What was your pain level on average during the past week? 5.3 ±2.0 SD What was your pain level at its worst during the past week? 8.5 ±6.6 SD Compare your average pain during the past week with the average pain you had before you were treated with your current pain relievers. What percentage of your pain has been relieved? 57.8% ±26.1% SD

4. 90.3% (n = 250) Yes No 9.7% (n = 27) 84.7% (n = 227) Yes 3.4% (n = 9) No Unsure 11.9% (n = 32) The 4 A’s: Analgesia Selected Questions Is the amount of pain relief you are now obtaining from your current pain relievers enough to make a real difference in your life? (To doctor) Is the pain relief clinically significant?

5. The 4 A’s: Activities of Daily Living 100 Better Same Worse 80.8 80 78.2 70.1 59.9 60 54.7 Patients Reporting(%) 48.8 47.7 42.1 40 33.6 25.2 19.3 20 15.6 6.5 4.0 4.7 3.6 3.2 2.5 0 PhysicalFunctioning Mood FamilyRelationships SocialRelationships SleepPatterns OverallFunctioning

6. 98.8% (n = 250) Yes No 1.2% (n = 3) 63.0% (n = 172) Yes No 35.9% (n = 32) The 4 A’s: Adverse Side Effects Selected Questions Are you able to tolerate your current pain relievers? Are you experiencing any side effects from your current pain relievers?

7. 19.3% (n = 36) None 42.2% (n = 79) Mild 28.9% (n = 54) Moderate 9.6% (n = 18) Severe 93.5% (n = 217) Yes 3.9% (n = 9) No 2.6% (n = 6) Unsure The 4 A’s: Adverse Side Effects Severity of the constipation you are experiencing: (To doctor) Are the side effects tolerable for the patient?

8. Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient’s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Recurrent prescription losses Probably less predictive Aggressive complaining about need for higher doses Drug hoarding during periods of reduced symptoms Requesting specific drugs Acquisition of similar drugs from other medical sources Unsanctioned dose escalation 1 – 2 times Unapproved use of the drug to treat another symptom Reporting psychic effects not intended by the clinician Aberrant Drug-taking Behaviors: The Model Passik and Portenoy, 1998

9. Creating a Checklist for Monitoring Outcome During Long-term Opioid Therapy Steven D. Passik, PhDCommunity Cancer Care, Inc.Indianapolis, Indiana

10. 4th “A” - Aberrant Drug-related BehaviorAdverse consequences possibly resulting from drug use Frequency of behavior=0 n (%) Purposeful over sedation 241 (89.6) Negative mood Change 252 (92.6) Decline in psychological function 255 (94.1) Decline in social function 259 (94.9) Appearing intoxicated 260 (95.6) Decline in physical function 262 (96.0) Increasingly unkempt or impaired 266 (97.8) Worrisome drug effects (“Getting High”) 267 (98.2) Involvement in MVA 267 (98.5) Engages in sale of sex to obtain drugs 229 (100*) * No answer: 53

11. 4th “A” - Aberrant Drug-related BehaviorPossible loss of control or diversion of medications Frequency of behavior=0 n (%) Requests frequent early renewals 220 (81.8) Increases dose without authorization 235 (86.7) Reports lost or stolen prescriptions 246 (90.8) Requests higher doses in worrisome manner 248 (91.2) Attempts to obtain prescriptions from other doctors 255 (94.4) Uses medication for purpose other than described (to help sleep) 255 (95.2) Engages in staff splitting 223 (97.8) Changes route of administration 269 (98.5)

12. 4th “A” - Aberrant Drug-related BehaviorPreoccupation with opioids or other drugs Frequency of behavior=0 n (%) Asks for medication by name 238 (89.8) Does not comply with other recommended treatments 253 (93.0) Reports no effects of other medications 255 (94.4) Misses appointments except for medication renewal 256 (94.5) Contact with street culture 258 (97.0) Abusing alcohol and street drugs 265 (98.1) Hording of medication 267 (98.9)

13. 4th “A” - Aberrant Drug-related BehaviorOther occurrences of potential concern Frequency of behavior=0 n (%) Patient arrested or detained by police 266 (97.8) Patient a victim of abuse 269 (98.5) Associate(s) arrested or detained by police 269 (98.5)

14. Differential Diagnosis of Aberrant Drug-Taking Attitudes and Behavior • Addiction • Pseudo-addiction (inadequate analgesia) • Other psychiatric diagnosis • Encephalopathy • Borderline personality disorder • Depression • Anxiety • Criminal Intent (Passik & Portenoy 1996)

15. Defining the Problems • Difficulties in assessing the risk of aberrant behavior and addiction • Misunderstandings about what addiction is and the shortcomings of present definitions when applied to the clinical pain management situation • The absence of well-articulated management strategies for patients with different substance abuse-related problems and aberrant behavior

16. What is the Risk of Addiction and Aberrant Behavior? • Boston Collaborative Drug Surveillance Project: Porter and Jick, 1980. NEJM. • 4 cases of addiction in 11,882 patients with no prior history of abuse who received opioids during inpatient hospitalization • Dunbar and Katz, 1996. JPSM. • 20 patients with both chronic pain and substance abuse problems on chronic opioid therapy • Nine out of 20 abused medication • Of the 11 who did not abuse the medications, all were active in recovery programs with good family support

17. Spectrum of Risk of Addiction or Aberrant Behavior ~ 45% <1% HIGH Long-term exposure to opioids in addicts, Dunbar and Katz LOW Short-term exposure to opioids in non-addicts Porter and Jick Where is your patient?

18. Addiction or aberrant behavior results from a combination of • Chemical • Psychiatric • Social/Familial • Genetic • Spiritual Influences

19. “Pseudo-Addiction” • Pattern of drug seeking behavior of pain patients receiving inadequate pain management that can be mistaken for addiction • Cravings and aberrant behavior • Concerns about availability • “Clock-watching” • Unsanctioned dose escalation • Resolves with reestablishing analgesia Weissman DE, Haddox JD. Oploid pseudo addiction- an iatrogenic syndrome. Pain 1989;36:363.

20. Consider the Risk of Not Treating Pain in Addicts • Passik, et al. 2001. • Study comparing addicts with AIDS to cancer patients and their response to under-treatment • Aberrant behavior is set in motion by under-treatment

21. The Non-Addicted Pain Patient Who Is a “Chemical Coper” • Bears resemblance to addiction with regard to the “centrality” of the drug and drug procurement to the patient • CCs need structure, psych input, and drug treatments that decentralize the pain medicine to their coping • Decentralize pain medication: reduce its meaning, undo conditioning, undo socialization – accomplished through pain-related psychotherapy and prudent drug selection

22. Tailoring The Approach • The uncomplicated patient – minimal structure • The patient with comorbid psychiatric and coping difficulties – moderate structure and heavy psych/rehab input • Addicted patients – highly structured • The actively abusing • The patient in drug free recovery • The patient on methadone maintenance

23. Summary • There is a difference between addiction and the complex issues of noncompliance and aberrant behavior during pain management that has been poorly articulated • The pain population is diverse – the application of opioid therapy to this diverse population requires careful assessment and tailored approaches that recognizes this diversity

24. DSM-IV Substance Use Disorder and the Typical Pain Patient on Opioids A maladaptive pattern of substance use leading to significant impairment or distress as manifested by 3 or more of the following 9 symptoms: • Need for markedly increased doses to achieve effect • Diminished effect with same dose • Withdrawal syndrome • Taking substance to relieve or avoid withdrawal symptoms • Dose escalation or prolonged use • Persistent desire or unsuccessful efforts to cut down or control substance use • Excessive time spent obtaining, using or recovering from use of the substance • Activities abandoned because of substance use • Use despite harm

25. Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient’s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Recurrent prescription losses Probably less predictive Aggressive complaining about need for higher doses Drug hoarding during periods of reduced symptoms Requesting specific drugs Acquisition of similar drugs from other medical sources Unsanctioned dose escalation 1 – 2 times Unapproved use of the drug to treat another symptom Reporting psychic effects not intended by the clinician Behaviors That Raise the Suspicion of Addiction After Portenoy, in press.

26. Summary • Substance abuse issues are complex during pain management and they defy simple solutions • These issues require tactical and humane approaches that combine thoughtful diagnosis, structure and a team approach