pain and addiction common threads

1. Pain and AddictionCommon Threads Brian A. McCarroll, DO, MS Medical Director, BioMed Behavioral Healthcare Assistant Professor, Dept of Family Practice MSU/COM

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3. Educational Objectives: 3

4. Educational Objectives: 4

5. 5 What is Addiction? Physiologic Dependence? Lack of willpower? An �amoral� condition? A brain disease?

6. 6 Physiologic Dependence: Tolerance and Withdrawal Tolerance: requiring increasing amounts of drug to get the same effect Withdrawal: the opposite effect of the drug when it is removed NEITHER of these imply chemical dependency (addiction)

7. 7 Lack of Willpower?

8. 8 An �amoral� condition?

9. 9 A Brain Disease?

10. 10 The Pleasure Center Nucleus Accumbens Responds to dopamine (DA) Responds to drugs Responds to food Responds to sex Sends signals to your frontal cortex THE PLEASURE CENTER IS ABNORMAL (DAMAGED) IN ADDICTION

11. 11 Nucleus Accumbens = the Pleasure Center Responds to dopamine (DA) Part of the LIZARD BRAIN Responds to drugs Responds to food Responds to sex Sends signals to your frontal cortex THE PLEASURE CENTER IS ABNORMAL (DAMAGED) IN ADDICTION

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13. 13 VTA: supplies DA to the N AccThe NA: GO!!!Frontal Cortex: STOP!!!!

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15. 15 Which came first? Do some people develop addiction because they have �reward deficiency syndrome� (decreased dopamine) OR: Do people with addiction have low dopamine because they have �burned out� their pleasure centers?

16. 16 Abnormal response to Ritalin (methylphenidate) is due to abnormal brain chemistry

17. 17 Predisposed to addiction? Those who �enjoyed� methylphenidate (amphetamine) had lower levels of dopamine. Those who found it �unpleasant� had NORMAL levels of dopamine Conclusion?

18. 18 �I feel like I don�t belong in my own skin�.� anonymous alcoholic Decreased Dopamine receptors =decreased Dopamine = Decreased Hedonic Tone Salsitz 2006

19. 19 Can you find the (alleged) future alcoholic?

20. 20 How to Recognize Addiction: DSM IV definition Tolerance Withdrawal Take more/take longer than intended Can�t cut down or control use Great deal of time spent in obtaining/using /recovering Important activities given up 2� to use Use despite physical/psych problem

21. 21 But what about addiction masquerading as �pain�? You are more likely to become addicted to prescription medication than heroin. Most opiate addicts that you see now began their addiction with prescription medications. Many of these patients will see you claiming to have (pelvic/back/head/neck) pain. We will discuss how to recognize these patients!

22. 22 And what about chronic pain patients? Have physiologic withdrawal Have physiologic tolerance Spend a lot of time getting their medication Give everything up to get their medication May have �uncontrolled� use of their medication. Appear to be addicts� but they aren�t!

23. 23 Chemical Dependence vs. Chronic Non Cancer Pain (CNCP) Tolerance Withdrawal Take more/take longer than intended Can�t cut down or control use Great deal of time spent in obtaining/using /recovering Important activities given up 2� to use Use despite physical/psych problem

24. 24 How to recognize addiction: working definition A chronic progressive disease characterized by the following physical and psychological symptoms (the four (five) C�s): Craving Compulsion Loss of Control Continued use despite consequences, and Chronic use

25. 25 Chemical Dependence

26. 26 Behavioral Dependence

27. Your Patient: Polly Substance I�m an alcoholic. I don�t have problem with pain pills!!! I�m an opiate addict. I just take my Xanax as prescribed! It�s OK, it�s prescribed by my other doctor. Are you really a doctor? I want to see someone who cares about me!!!! 27

28. 28 �Hi�I�m Joe. I�m cross addicted�

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30. 30 Obese subjects have decreased DA: just like methamphetamine addicts

31. 31 Abuse vs. dependence You interview a new patient. She has a 20 year history of heavy drinking and has just been diagnosed with hypertension and hyperlipidemia. You advise her to quit. To your surprise, she does so, without any treatment. How did she do it?

32. 32 Is it abuse�or is it dependence? Failure to fulfill work/school/social obligations Continued use is risky situations (ie, drunk driving) Recurrent legal problems (DUI)* Continued use despite social or interpersonal problems (MOR) Never fit the criteria for dependence

33. 33 Abuse vs. dependence The majority of patients you see with drug/alcohol problems do NOT have addiction Most people with drug/alcohol problems will be able to stop on their own. (William White) The 4Cs helps you to determine which ones need to be treated!

34. 34 Is addiction a myth? Most people who have a problem with alcohol or drugs will stop on their own The majority of people who stop do so without treatment. Even many heroin �addicts� will �quit� and resume normal lives.

35. How do you recognize when you are fueling addiction rather than treating pain? 35 ADDICTION ? PAIN

36. 36 Pain and Addiction: �common threads� Patients will present with uncontrolled medication use, tolerance and withdrawal Often have a legitimate (=surgical) reason for their pain (ie, back pain, endometriosis, intersitial cystis)

37. 37 Is it Addiction or Pain? You see a patient referred by an OB Gyn. She has been using Vicodin (hydrocodone) for pelvic pain. Over the past year, she has increased her use from 1 pill/day to 4/day. Her Gyn believes she is �hooked�. Your diagnosis?

38. 38 More on Addiction and Pain: Differential Diagnosis of Chronic Pain Legit: Hooked: Crazy:

39. 39 More on Addiction and Pain: Differential Diagnosis of Chronic Pain Legit: Chronic non cancer pain Hooked: Addiction/secondary gain Crazy: Chronic pain syndrome

40. 40 Differential diagnosis for chronic pain with uncontrolled medication use: Chronic non cancer pain Pseudoaddiction Chronic pain syndrome Addiction with secondary gain Malingering Co-occurring pain and chemical dependency

41. 41 ? A patient with recurrent endometriosis is being treated with vicodin. She has gone from 1 to 4 vicodin/day. She requests surgery to �get off the pills�. No sign of compulsive use, cravings, loss of control. Doesn�t smoke. No psychiatric diagnosis.

42. 42 Chronic non cancer pain A patient with recurrent endometriosis is being treated with vicodin. She has gone from 1 to 4 vicodin/day. She requests surgery to �get off the pills�. No sign of compulsive use, cravings, loss of control. Doesn�t smoke. No psychiatric diagnosis.

43. 43 ??? You referred a patient with cervical cancer to your gyn oncologist 3 years ago. She was treated with XRT with multiple complications. The gyn onc calls you and says: �you can have her back. She forged a scrip�.

44. 44 ? You find out she was being given small doses of (short acting) pain meds for radiation necrosis. She had been drug seeking with different Drs and forged a scrip for MS. When she got adequate (long acting) pain medication, her drug seeking disappeared.

45. 45 Pseudoaddiction You find out she was being given small doses of (short acting) pain meds for radiation necrosis. She had been drug seeking with different Drs and forged a scrip for MS. When she got adequate (long acting) pain medication, her drug seeking disappeared.

46. Pseudoaddict? 46

47. 47 Oxy-Moron?

48. 48 ??? You are referred a patient with endometriosis, CPP, IC, IBS, back pain, fibromyalgia and radon poisoning. She is also being treated for anxiety and depression. She is being treated with alprazolam (Xanax) and hydromorphone (Dilaudid) �nothing seems to work� Your exam shows diffuse abdominal pelvic tenderness without any localizing findings.

49. 49 Chronic pain syndrome �pain and psychologic distress� Complaints not supported by exam Excessive use of medical resources Co-existing psychiatric complaints Often seeking disability diagnosis �honeymoon� with new treatments DSM IV: a somatoform disorder

50. 50 Fibromyalgia vs. CPS? FM patient wants to get better FM patient wants to go back to work May respond to pregabalin (Lyrica), amitriptyline (Elavil), exercise regimen NOT seeking disability

51. 51 ??? A patient sees you for pain medication. He had back surgery one year ago (fusion). Prior to the surgery, he was on Dilaudid which failed to control his pain. Because of his pain, he lost his job and now has lost his insurance. His pain continues, even though your orthopedic surgeon declared the surgery a �success�. He continues to use large amounts of dilaudid. He requests that you label the meds �DAW�. His urine drug screen is negative for opiates.

52. 52 Malingering A patient sees you for pain medication. He had back surgery one year ago (fusion). Prior to the surgery, he was on Dilaudid which failed to control his pain. Because of his pain, he lost his job and now has lost his insurance. His pain continues, even though your orthopedic surgeon declared the surgery a �success�. He continues to �use� large amounts of dilaudid. He requests that you label the meds �DAW�. His urine drug screen is negative for opiates

53. 53 ??? A patient comes to see you at 14 weeks gestation, seeking Vicodin. She had a �back injury� during her first childbirth 4 years ago. She smokes 1 ppd. She does not have custody of the child. She declines to let you speak to her previous OB Gyn (�she�s an idiot�).

54. 54 ??? She refuses to take a urine drug screen. She becomes hostile and tearful when you express concern for her narcotic use during pregnancy. When you ask about family history, she reveals that her sister died from a methadone overdose.

55. Addiction with Secondary Gain (�Drugstore Cowboy�) 55

56. 56 Addiction with Secondary Gain: Warning Signs Friday afternoon appointments Can�t tell you who their referring doc was Just moved from �out of state� Vague complaints, normal physical exam Asking for specific narcotics by name Most prognostic sign��.

57. 57 Your prescription pad is now missing.

58. 58 Warning signs of Addiction in patients presenting with Chronic Pain: red flags ? Tobacco addiction! ? Legal history (esp DUI) MAPS (Michigan Automated Prescription Service) discrepancies MJ use Family history Non-prescribed/prescribed sedative use BEHAVIORAL ADDICTION

59. 59 Family history - Genetics? The biological children of alcoholics are more likely to become alcoholics. If they are raised by another family, they are STILL more likely to become alcoholics. Non-alcoholic offspring raised in alcoholic homes are NOT more likely to become alcoholics.

60. 60 Techniques to Evaluate for signs of addiction in your pain patient Review of Medical Records (refusal?) ? Physical exam: Stigmata of addiction: nicotine, opiates, cocaine Obvious intoxication/withdrawal UDS MAPS Family interviews Multiple visits, evaluate for reliability

61. 61 Urine Drug Screens Check for meds that you have been prescribing. (missing meds = malingering) Check for meds that indicate abuse (MJ, cocaine) = addiction Remember your medication may not show up (methadone, fentanyl, suboxone) TELL THE PATIENT YOU ARE TESTING THEM FOR SAFETY�S SAKE TELL THEM YOU PRACTICE UNIVERSAL SCREENING!

62. 62 Michigan Automated Prescription System (MAPS) A 23 year old was diagnosed with an IUFD at 22 weeks. She was transferred to Hutzel after her attempted D&E could not be done. Successful dilation and evacuation was performed under laparoscopic guidance.

63. 63 Techniques to Evaluate for signs of addiction in your pain patient Review of Medical Records (refusal?) Physical exam: Stigmata of addiction: nicotine, opiates, cocaine Obvious intoxication/withdrawal UDS MAPS Family interviews ? Multiple visits, evaluate for reliability

64. 64 Family interviews Look for confirmation of patient�s history (remember, addiction is a mental illness!) Look for secondary gain (in the patient) Look for TERTIARY gain (in the family) Look for enabling! Will be a barrier to treatment for pain OR addiction.

65. 65 Techniques to Evaluate for signs of addiction in your pain patient Review of Medical Records (refusal?) Physical exam: Stigmata of addiction: nicotine, opiates, cocaine Obvious intoxication/withdrawal UDS MAPS Family interviews Multiple visits, evaluate for reliability ?

66. WHY BOTHER TO TREAT ADDICTION? 66

67. Why Treat Addiction? 67

68. Drug Dependence, a Chronic Medical Illness: McLellan 2000 68 Only about 40% of patients will be abstinent at one year after treatment. Failure rates may be due to lack of aftercare, often due to insurance difficulties Low economic status, psych comorbidity and lack of family/social supports also predict relapse. Relapse is often viewed as �inevitable� and drug dependence as �hopeless�*

69. Drug Dependence, a Chronic Medical Illness: McLellan 2000 69 ONLY 60% OF TYPE I DIABETICS ADHERE TO MEDICATION SCHEDULE LESS THAN 40% OF ASTHMATICS ADHERE TO TREATMENT REGIMEN LESS THAN 40% OF HYPERTENSIVES ADHERE TO THEIR TREATMENT REGIMEN DRUG DEPENDENCE =40 TO 60% ADHERENCE

70. Addiction: a chronic illness 70 If you were to stop taking your insulin, and you wound up in a coma in the ICU, your doctor would say: �you need to go back on insulin! You could have died!� If you were to stop your Suboxone/methadone/12 step treatment, and wind up in the ICU, your doctor would say: �You�re an addict. You�re hopeless!!!!!�

71. Benefits of Opioid Maintenance Therapy (OMT) 71 Decreased HIV infection rates Decreased incarceration Decreased drug use Decreased mortality McLellan, 2000

72. Drug Dependence, a Chronic Medical Illness: McLellan 2000 72 �There is little evidence of effectiveness from detoxification or short-term stabilization alone without maintenance or monitoring such as in (opioid) maintenance or AA.�

73. 73 How do you treat addiction? Medications Cognitive Behavioral Therapy (CBT) Motivational Interviewing (MI) 12 step programs (AA/NA)

74. 74 Medications for Opiate Addiction Antagonists: Oral naltrexone (Rivea) Parenteral naltrexone (Vivitrol) (not approved for opiate dependence) Agonists: Methadone: Requires methadone clinic STIGMA Buprenorphine Suboxone Subutex Buprenex*

75. Buprenorphine Vs Methadone 75 Don�t need to go to a methadone clinic Less stigma Visits less frequent No travel restrictions Maintain the patient � healthcare provider relationship Safety

76. Buprenorphine Vs Methadone 76 More sedating/euphoric-some patients will prefer Daily dosing may assure compliance Structured groups Breaks the patient-healthcare provider relationship! Often seen by funding agencies as the more �stable� treatment

77. Safety of opioid agonists 77 Methadone: has �black box� warning; may result in lethal concentration if escalated too quickly. The majority of methadone deaths occur in pain patients and methadone diversion, not methadone clinic patients. 4 deaths reported in the US from bup. Gagjewski, J Forensic Sci 2003

78. Who can have an outpatient detox on Suboxone? Dependence on short acting opiates Ability to get outside counseling Minimal polypharmacy No indication for residential RX No major medical comorbidities (cardiac!) Using long acting opiates (oxycontin) Polypharmacy (benzodiazepines) Needs residential rx Major medical problems PREGNANT ON METHADONE 78 Who should use suboxone? Who should not*?

79. 79 How do you treat Chronic Pain? I Avoid short acting opiates!!!!!!! Use long acting opiates: MS Contin Fentanyl Methadone If opiates fail: stop them! Use non opioid medications SNRI: venlafaxine (Effexor); duloxetine (Cymbalta) AED: gabapentin (Neurontin); pregabalin (Lyrica)

80. 80 How do you treate Chronic Pain? II Avoid benzos: Found to increase disability (downhill spiral hypothesis, Ciccone 2000) Potential additive effect Addiction potential Has been source of criminal prosecution (YOU) when morbidity/mortality occurs

81. 81 How do you treate Chronic Pain? III Get the patient involved in a �spiritual program� Increase FUNCTION, don�t just decrease pain Treat chronic pain as a chronic disease Validate, don�t commiserate!

82. 82 How do you treat co-occurring addiction and chronic pain? Don�t rush into surgical procedures! Find an addictionist (http://ASAM.org) Find a chronic pain specialist/pain clinic Get their �OK� before surgery DON�T prescribe short acting meds/benzos!

83. 83 Which one is the addict? You are asked to see a patient for a severe pain crisis due to SS disease during pregnancy. She is using extremely high doses of Dilaudid IV. She is found to be cleaning her room, but when you see her, she throws herself on the bed. Her erratic behavior leads you to order a hemoglobin electrophoresis. It is normal.

84. 84 Which one is the addict? A patient of yours comes to see you for �a problem with her pills�. She had a hysterectomy complicated by abdominal wound infection and necrotizing fasciitis, followed by multiple abdominal wall surgeries. She has been on morphine and dilaudid for the past 5 weeks and found that �she can�t stop�. She complains of the �flu�, insomnia, and increased pain when she attempts to stop the medication.

85. 85 TOLERANCE & WITHDRAWAL A patient of yours comes to see you for �a problem with her pills�. She had a hysterectomy complicated by abdominal wound infection and necrotizing fasciitis, followed by multiple abdominal wall surgeries. She has been on morphine and dilaudid for the past 5 weeks and found that �she can�t stop�. She complains of the �flu�, insomnia, and increased pain when she attempts to stop the medication.

86. 86 Which one is the addict? A patient is referred to you for �chronic pelvic pain�. She has been prescribed Vicodin for her pain. She has been diagnosed with endometriosis and has had laser ablation and GnRH therapy, eventually a hysterectomy. All therapies work, only to fail later. Your exam shows diffuse pelvic tenderness without adnexal tenderness, mass, or other findings. She requests that you refill the Vicodin and Xanax that her previous OB Gyn has prescribed.

87. 87 (Chronic) Pain Syndrome A patient is referred to you for �chronic pelvic pain�. She has been prescribed Vicodin for her pain. She has been diagnosed with endometriosis and has had laser ablation and GnRH therapy, eventually a hysterectomy. All therapies work, only to fail later. Your exam shows diffuse pelvic tenderness without adnexal tenderness, mass, or other findings. She requests that you refill the Vicodin and Xanax that her previous OB Gyn has prescribed.

88. 88 Which one is the addict? A patient of your has been seeking treatment for severe back pain. His insurance coverage will pay only for office visits but not medication. He has been prescribed Vicodin and MS Contin by you for his pain. He reveals to you that he has started going to a methadone clinic and has been diagnosed with opioid dependency.

89. 89 Pseudoaddiction A patient of your has been seeking treatment for severe back pain. His insurance coverage will pay only for office visits but not medication. He has been prescribed Vicodin and MS Contin by you for his pain. He reveals to you that he has started going to a methadone clinic and has been diagnosed with opioid dependency.

90. 90 Which one is the addict? A patient sees you for pain medication. Three years ago, you referred him to residential treatment for alcoholism. He has apparently been sober since then, attending AA. He suffered a work related back injury three months ago. His MRI was negative. His use of pain medications is escalating; he now requests Dilaudid so he can �keep working�. When you express concern, he responds �I was an alcoholic. I�ve never had problem with pain pills!�

91. 91 Co existing CD and pain A patient sees you for pain medication. Three years ago, you referred him to residential treatment for alcoholism. He has apparently been sober since then, attending AA. He suffered a work related back injury three months ago. His MRI was negative. His use of pain medications is escalating; he now requests Dilaudid so he can �keep working�. When you express concern, he responds �I was an alcoholic. I�ve never had problem with pain pills!�