TREATING TWO DISEASES

1. TREATING TWO DISEASES CHRONIC PAIN SYNDROMES AND THE DISEASE OF ADDICTION Bruce C. Springer, M.D. Pine Rest Addiction Services

2. PAIN • Pain is an unpleasant sensory and emotional experience that is associated with potential or actual tissue injury or is described in terms of such injury. • (Int’l Assoc for the Study of Pain, 1979) • An experience influenced by: • culture, temperament

3. PAIN • past experience, memory • anticipation, beliefs • emotional factors, co-occurring health • cognitive factors, gender, age • The experience of pain is different from individual to individual and within the same person at different times

4. PAIN • The pain signal is transmitted from nociceptors along peripheral nerves to the dorsal root ganglion and then to the dorsal horn of the spinal cord. • The spinothalamic tract carries the impulse up to the thalamus and to the somato- sensory cortex and limbic system to be experienced and interpreted.

5. CHRONIC PAIN • Tissue damage releases chemicals which sensitize nerve fibers and alter gene expression. • Regeneration of nerve fibers into a neuroma which generates pain signals. • Injury to and degeneration of pain inhibitory pathways. • Sleeplessness, anxiety and depression trigger more pain

6. PAIN MODULATION • Descending pathways originating in the ventral medulla, periaqueductaland periventricular gray matter are stimulated by endogenous and exogenous opioids.

7. PAIN MODULATION • These pathways interact with sensory spinal neurons inhibiting pain impulse transmission. This involves numerous chemicals and neurotransmitters, including endorphins, GABA, norepinepherine, serotonin, enkephalins, and oxytocin.

8. PAIN MODULATION • Increases in inhibitory input on sensory neurons in the spinal cord is in response to opioid binding to receptors on neurons in the midbrain and medulla. • This gives us insight into how opiates function in the CNS to alleviate pain.

9. PAIN MODULATION • This pain modulation system may not work well in patients with the disease of addiction to opiates. • Indeed addicted patients may well have a more intense pain experience.

10. ADDICTION • A DISEASE • primary • neurophysiologic • chronic • FACTORS • genetic • psychosocial • environmental

11. ADDICTION • Affects about one in ten Americans • Loss of control over a substance or behavior and inability to stop despite negative consequences • Mesolimbic dopamine system is home to the reward and reinforcement of behaviors essential to survival

12. WWW.DRUGABUSE.GOV

13. ADDICTION • Opiates bind to mu receptors in the periaqueductal gray and other areas described above and help modulate pain. • They also bind to mu receptors in the VTA and increase dopamine release in the NA.

14. ADDICTION • Thus opiates are rewarding and reinforcing. • Tolerance produced by neuroadaptation to a substance where the individual must use more to achieve the desired result or no longer benefits from the original effective dose.

15. ADDICTION • Physical Dependence is a result of neuro-adaptation where there is experienced a characteristic abstinence syndrome when the drug is stopped, decreased abruptly or when an antagonist of this drug is given. • Patients can develop both of these and not have the disease of addiction.

16. CONSEQUENCES • More people die from prescription drug overdoses than in car accidents in Michigan. • In 2007 someone died of an overdose every 19 minutes. • Prescription drug abuse is the fastest growing substance abuse problem in the U.S. • For every OD death, 9 people are admitted to treatment facilities, 35 visit ER’s, 161 report abuse or addiction and 461 report non medical use of opiates.

17. PAIN IN ADDICTED PATIENTS • Increased pain sensitivity in opiate addicted patients on methadone maintenance. • Evidence supports an opiate-induced hyperalgesia. • This hypersensitive state improves with opiate detoxification.

18. PAIN IN ADDICTED PATIENTS • Addiction may serve to facilitate the pain experience • Inability to experience pleasure • Chaotic lifestyle • Sleep disorders • Anxiety, irritability, • Loss of social support, interpersonal conflicts • Noncompliance with past treatment plans

19. PAIN IN ADDICTED PATIENT • Addicted patients alternate between intoxication and withdrawal states thus activating the neurochemical stress response, chronic negative emotional state and increasing the pain experience • Anhedonia • Irritability • Dysphoria

20. PAIN IN ADDICTED PATIENTS • Dopamine depletion and perhaps decreased dopamine receptors in reward pathways. • Depression. • Pain assessment in patients with substance use disorders is complicated.

21. ASSESSMENT of PATIENTS • Look for a recent history of substance use disorder, • prescription abuse, problems with opiates • non involvement in AA or NA, • little or no family support or too much support • Allergies to multiple opiate and non-opiate analgesics

22. ASSESSMENT of PATIENTS • Be aware of patients at higher risk for addiction: • family history of addiction, • smokers, • current problems with drugs, • other compulsive behaviors, • gambling addiction • cannabis use “legal” vs. illicit

23. ASSESSMENT of PATIENTS • The addicted patient (vs. the legitimate chronic pain patient) will: • crave drugs, use opiates compulsively, • increase the dose on their own, • have social and relational problems, • severe withdrawal symptoms, be intoxicated,

24. ASSESSMENT of PATIENTS • use other substances, • often use higher doses • seek early refills • shun personal responsibilities.

25. ASSESSMENT of PATIENTS • Decreasing function and increased complaints of pain despite medication titration • Persistent negative affective states, anxiety, depression and irritability

26. RED FLAGS • Reports of lost or stolen prescriptions • Appearance at office without appointment and in distress • Frequent visits to ERs to request drugs • Family reports overuse or intoxication • Failure to comply with non-drug pain therapies • Fails to keep appointments

27. RED FLAGS • Not interested in rehabilitation • Reports no effect of non-opiate interventions • Seeks prescriptions from other providers • In Michigan you may use the MAPS form to get prescription information from the MI Dept. of Community Health

28. PAIN PATIENT • History and physical; rule out a worsening organic lesion as the cause of worsening pain. • Look for pain facilitating problems such as sleep disturbance, mood disorders, disability, stress, drug addiction or abuse. • What studies are needed? • Get as many old records as possible. • Communicate with previous health care providers.

29. PAIN PATIENT • Rule out a worsening organic lesion as the cause of worsening pain. • Be open to potential signals of addiction or pseudo-addiction. • Substance abusing patients may over report pain out of fear or desire to divert drugs. • Recovering addicted patients may under report pain over fear of relapse

30. APPROACHING the ADDICTED PATIENTS • Be matter-of-fact in your questions about your “worried about your relationship with some of these medications and what it is doing to your life and your pain treatment.” • Ask about nicotine, caffeine then alcohol next before asking more about opiates, etc.

31. APPROACHING the ADDICTED PATIENT • “Honest answers are vital for us to make a good treatment plan for your pain and your life better.” • “You did not volunteer for chronic pain and you did not volunteer to lose control over these drugs.” • “I hope you will volunteer to treat both.”

32. SOAPE GLOSSARY Summary Reinforce the patient-physician relationship in the midst of this chronic illness. • “We need to work together on this.” • “This requires a team effort and you and I are two members of the team.”

33. SOAPE GLOSSARY Optimism Remember the patient may well expect failure • “People with these diseases can’t do all this by themselves.” • “… with help you will do well…” • “… no one deserves the pain and humiliation these diseases bring…” • “… treatment works…” • “… you can expect improvement in most areas of your life…”

34. SOAPE GLOSSARY Absolution Guilt, shame and weakness are paralyzing and can lessen the patients ability to take on sobriety. • “Your pain and addiction problem are not your fault. They are diseases and it is our responsibility to work together toward your recovery from both.” • “Recovery is likely.”

35. Plan cont… • “What do you think you can do at this point” • “There are many things we can do to pursue recovery from addiction and pain” What will their insurance cover? What is the patient ready for?

36. SOAPE GLOSSARY Explanatory Model • Ask the patient, “What is your idea of a person with addiction?” • Try to understand what the patient understands about addiction. • “This is an illness that responds to medical intervention and treatment, but not to willpower alone.”

37. PAIN PATIENT • Patient must sign release forms to other care providers including PT/OT, counselors, psychologists, psychiatrists, pain specialists and PCP etc. • Encourage free exchange of information among all providers and with the patient.

38. PAIN PATIENT • Establish clear treatment goals • Analgesia • Improvement in other symptoms • Restoration of function

39. ADDICTION • The diagnosis of addictive disease is made by yourself or another provider. • It is a prospective diagnosis made over time • It is important for the patient to realize that without treating addiction their pain will never be adequately treated.

40. ADDICTION • Institute a Recovery Program • Discuss with an addiction specialist • Introduce to a treatment program • Keep a list of local NA meetings • Be willing to stay engaged with the patient • Formulate a treatment agreement with the patient that has at its core the patients continued steadfast recovery from addiction while pain is treated.

41. ADDICTION RECOVERY and PAIN TREATMENT AGREEMENT • Treatment agreement • Pill counts • Urine drug screens • One provider for opiates (if needed) • One pharmacy • No missed appointments • No lost scripts. • Attendance of 12-step meetings

42. ADDICTION RECOVERY and PAIN TREATMENT AGREEMENT • Complete cooperation with non pharmacologic treatment and non opiate treatments. • Cooperation with counseling, physical therapy, treatment of mood disorders. • Complete abstinence from other addictive substances. • Strict use of meds as prescribed and no use of other peoples meds.

43. ADDICTION RECOVERY • The patient must consent to be held accountable by a team of people including possibly a Narcotics Anonymous sponsor.

44. 12-STEP PROGRAMS • Founded in 1935 by two hopeless alcoholics Bill Wilson and Robert Smith M.D. • Discovered that by talking to others with the same disease they could stay sober. • AA meetings found in most countries. • AA Big Book published in many languages.

45. PSYCHOLOGICAL INTERVENTIONS • Deep relaxation • Biofeedback • CBT • Guided Imagery • Treat mood disorders, antidepressants tx • Family/Relationship therapy • Functional Rehabilitation

46. ON GOING CARE • The goal should be to remain engaged with the patient regarding pain while continuing to encourage and support their recovery from addiction. • Must constantly reinforce the patients active role in their treatment. • Move gently to eliminate unnecessary dependence on medications: tapering, replace opiates with buprenorphine, detox.

47. DISCONTINUING OPIATES • Pain has resolved. • Side effects are unmanageable. • Opiates are not stabilizing the patient or improving function. • Patient loses control over the opiate pain med. • Patient using other substances such as ETOH, benzodiazepines, cannabis, etc. • Patient is diverting the opiates.

48. Dysphoria Insomnia Severe craving Irritability Lacrimation Dilated pupils Rhinorrhea Nausea and vomiting Diarrhea Cramping abdominal pain Joint aching Muscle cramping Hot and cold flashes WITHDRAWAL SIGNS AND SYMPTOMS

49. Sweating Goose flesh Yawning Elevations of blood pressure Tachycardia Mild fever WITHDRAWAL SIGNS AND SYMPTOMS

50. PAIN IN ADDICTED PATIENTS OPIATE INDUCED HYPERALGESIA • Increased pain sensitivity in opiate addicted patients on methadone maintenance. • Evidence supports an opiate-induced hyperalgesia. • This hypersensitive state improves with opiate detoxification.