Chronic Pain Management: Opiate Prescribing vs. Over-Prescribing

Michael R. Clark, MD, MPH, MBA Vice Chair, Clinical Affairs

Director, Adolf Meyer Chronic Pain Treatment Programs

Department of Psychiatry and Behavioral Medicine

Johns Hopkins University School of Medicine

Baltimore, Maryland

Why be Concerned about Opioids?

• 35 million Americans have

used opioid analgesic for

non-medical purpose

• 7 million Americans misuse

or abuse prescription drugs

each month

• Prescription drug abuse

accounts for ~25%-30%

of all drug abuse

• Pain and addiction are

interrelated

0

1

2

3

4

5

6

People Abusing/

Misusing, millions

ACPM. http://www.acpm.org/?UseAbuseRxClinRef#Prevalence.

Passik SD, et. Al. Pallative Care and Supportive Oncology 2002 – fix ref

DAWN data – fix ref

Opioid Analgesia 1990s

• Old teaching

– All patients get addicted

to narcotics

– Side effects limit

effectiveness

– Save until pain is severe • Tolerance

– Pain is not life-

threatening

• New thoughts

– Almost no one gets

addicted to opioids

– Side effects can be

managed

– Treat pain early • Tolerance is exaggerated

– Pain kills

Hydrocodone/APAP Most Prescribed

Product in the United States

IMS NPA+, 2005

11

6

7

27

110

19

26

21

48

79

11

0 20 40 60 80 100 120

Other

F

O/C

C/C

T/C

Lipitor

Number of Prescriptions (in Millions)

0 20 40 60 80 100 120

Tramadol/Comb.

Propoxyphene/Comb.

Codeine/Comb.

Hydrocodone/Comb.

Oxycodone/Comb.

Oxycodone

Fentanyl

Morphine

Other Opioid

Lipitor

Amoxicillin

21

26

19

110

27

11

7

6

11

48

79

0 20 40 60 80 100 120

T/C

C/C

O/C

F

Other

Lipitor Highly Prescribed

Products in US

HYCD/APAP TRx

increased 8% each

year since 2001

Psychoactive Agents New Users, 1963-2000

0

500

1,000

1,500

2,000

2,500

1960 1965 1970 1975 1980 1985 1990 1995 2000

New

Use

rs, t

ho

usa

nd

s

Pain Relievers

Tranquilizers

Stimulants

Sedatives

NHSDA, 2002 – fix ref

Deaths from Unintentional Overdose 1999-2007

0

2

4

6

8

10

12

14

1999 2000 2001 2002 2003 2004 2005 2006 2007

Nu

mb

er o

f D

eath

s, t

ho

usa

nd

s

Opioid analgesic

Cocaine

Heroin

Center for Disease Control and Prevention – fix ref

Opioid Analgesia

2000-2012

• Old teaching

– All patients should be

given an opioid trial

– No ceiling effect for

opioids

– High pain level requires

opioid as first-line agent

– Even individuals with

SUD or addiction will do

well on opioid therapy

• New thoughts

– In some patients, risks

may be too high for

opioids

– As doses ↑, effects ↓

– Pain level alone does

not dictate opioid use

– Significant practice

issues in monitoring

patients on opioids

Chronic Pain Management PCP Uniquely Positioned

• Only providers able to cope

with large chronic pain

population

• Multiple, repeated

exposures to patient, family – Sees patients in crisis

– Aware of coping mechanisms

– Knows family members

• Familiar with chronic

disease management model 75 80 85 90 95 100

Asthma

Hypertension

Stroke

Diabetes

COPD

ASCVD

Primary Care Others

1996 Medical Expenditure Panel Surveys. Ann Family Med. 2004;2(suppl 1) – need full ref

Introducing Jack

Initial Presentation, History

• 52-year-old general contractor

– Married, 3 children

• Presents to PCP with acute

LBP that interferes with work,

family life

– Right lower back

– Radiating down right leg

to lateral foot

– Intensity rated 6/10

– Duration, 6 weeks

• History

– Recurrent minor past injuries

in same area

• Typically resolved with OTCs

– Anxiety, depression

• Even in childhood

– Experimented with alcohol,

marijuana when younger

• Helped anxiety but “I did not

like that illegal stuff”

• “Plus, my family got all

messed up on that stuff”

– Family history of depression

Jack

Initial Treatment

• Prescribed stretches, rest, ice, anti-inflammatory,

muscle relaxant

• 7 days off work due to physically demanding job – No availability of modified duty

• Follow-up appointment scheduled for 1 week

LBP Leading Cause of Job-Related Disability

• Most common reason for presentation to PCP

• Direct costs >$26 billion in the United States (1998) – 149 million lost work days

– 5% to 9% of workers’ comp claims, but 65% to 85% of costs annually

• In cases of acute radiating lumbar pain, rule out “red flag” conditions – Cauda equina syndrome

– Neoplasm

– Infection

– Fracture

• Only 4% of patients with acute lumbar pain, sciatica will have

detectable lumbar disk herniation on radiologic examination

CDC. MMWR Morb Mortal Wkly Rep. 2001;50:120-125; Chou R, et al. Ann Intern Med. 2007;147:478-491; Gregory DS, et al. Am

Fam Physician. 2008;78:835-842; Guo HR, et al. Am J Public Health. 1999;89:1029-1035; Hashemi L, et al. J Occup Environ Med.

1998;40:1110-1119; Luo X, et al. Spine. 2004;29:79-86; Pai S, et al. Orthop Clin North Am. 2004;35:1-5.

Pain Assessment

General Approaches

• Detailed history – Pain characteristics

– Review of medical records

• Prior diagnoses, therapies

• Physical, psychological

comorbidities

• Physical examination – Musculoskeletal

– Neurologic

• Work-up, diagnostic studies

• Clinical considerations – Pain etiologies, characteristics

– Effect on biopsychosocial

domains including risk for

addiction

• Challenges – Lack of a specific measurement

tool that can prove presence or

intensity of pain

– Inaccurate patient descriptions

• Degree of pain OR relief

AMA. http://www.ama-cmeonline.com/pain_mgmt/printversion/ama_painmgmt_m1.pdf; Argoff CE. J Am Osteopath Assoc.

2002;102(9 suppl 3):S21-S27; Sinatra R. J Am Board Fam Med. 2006;19:165-177.

Treatment based on initial assessment and regular reassessments

that are comprehensive, individualized, documented

Developing a Care Plan

• Working diagnosis – Pain etiology

– Pain syndrome

– Inferred pathophysiology

• Initial treatment – Individualized based on pain intensity, duration, disease, tolerance of AEs, risk

for aberrant behavior

– May be stepwise in nature

– May involve multidisciplinary team

– May include behavioral + nonpharmacologic + pharmacologic modalitites

– May include analgesics with different, complementary MOAs and agents to

reduce other symptoms (sleep disturbance, fatigue)

Zorba-Paster R. Expert Opin Pharmacother. 2010;11:1823-1833.

Nonpharmacologic Strategies

In Pain Management

Deardorff WW. http://behavioralhealthce.com/index.php/component/courses/?task=view&cid=67.

Physical Bandages, corsets

Topical analgesic cream

Exercise

Heat, cold

Body mechanics

Reactivation of deconditioning

Hydrotherapy

Massage

Physical devices

Physical, occupational therapies

Functional restoration

ROM interventions

Interventional Bracing

Injection, radiation therapy

Nerve blocks

Neurodestructive surgery

Spinal cord stimulation

TENS

Psychological Attention control, distraction

Biofeedback

CBT

Behavioral, operant interventions

Desensitization

EMDR

Family therapy

Goal-setting and pacing

Guided imagery

Hypnosis

Patient education

Psychotherapy

Pharmacologic Strategies

In Pain Management

REF

NSAIDs Aspirin, ibuprofen, naproxin, flurbiprofen

COX-2 Inhibitors Diclofenac, celecoxib, etoricoxib,

Opiates Bupenorphrine, tentanyl, hydrocodone, hydromorphone,

methadone, morphine, oxycodone, oxymorphone, tapentadol,

tramadol

Antidepressants Amitriptyline, duloxetine, milnacipran

Anticonvulsants Carbamazepine, gabapentin, pregabalin

Muscle Relaxers Cyclobenzoprine

Topical agents Capcaicin, lidocaine

Jack 1 Week later

• Pain not resolved

• New pain-related

symptoms – Sleep disruption

– Irritability

– ↓ ability to participate in

hobbies

• Treatment plan adjusted – More time off work

(2 weeks)

– Physical therapy

Pain

Sleep Mood

Acute ≠ Chronic Pain

Chronic pain: pain “uncoupled from a noxious stimulus or healing tissue”

American Geriatrics Society. J Am Geriatr Soc. 2009;57:1331-1346; American Medical Association.

www.ama-cmeonline.com/pain_mgmt/printversion/ama_painmgmt_m1.pdf; Woolf CJ.. Ann Intern Med. 2004;140:441-451.

Acute Pain (Good) Chronic Pain (Bad)

Recent onset

Short duration

Lasts >3-6 mo

Meets ≥1 of following

Persists ≥1 month beyond typical course of acute illness, normal healing

Is part of a chronic pathologic process

Recurs: days, weeks, months

Protective

Indicates potential

or actual injury

Maladaptive

Indicates damage to/abnormal operation of peripheral/central nervous system

Dysregulation, sensitization

Hyperalgesia: normally painful stimulus becomes more painful than usual

Allodynia: nonpainful stimulus becomes painful

Jack 3 Weeks Later

• Pain not resolved

• Related symptoms worsen – Sleeping <4 hours per night – ↑ irritability, anxiety – In danger of losing job due to time off

• PCP considers prescribing an opioid – Risk assessment

• Administers ORT, Jack classified as low-risk

– Opioid agreement

– Prescribes hydrocodone/APAP

Be aware of all

medications your

patient receives

for all conditions from

all prescribers

Assessment for Opioid Therapy and

Initiation of Opioid Trial

• Personal, family history

– Medical, psychological

– Prior treatment, compliance

• Including opioids

• Examination

• Risk assessment

– Consider risks and benefits of

long-term opioid therapy

• Evidence, guidelines, AEs

– Stratify patient according to

risk level

• Documentation

• Medication selection, dosing

– Start low, titrate ↑ in smallest

possible increment

– Increase dose until

• Pain remits

• Intolerable AEs persist

– SA as initial therapy?

• Shorter half-life

• May have ↓ risk for

unintentional overdose

Chou R, et al. J Pain. 2009;10:113-130; Passik SD, Lowery A. Pain Medicine. 2011;12.

Zacharoff KL, et al. Managing Chronic Pain with Opioids in Primary Care. Infelxxion, Inc: Newton, MA; 2010.

Individual, Interrelated Risk Factors

For Opioid Abuse

• Active alcohol or

substance abuse

• Personal or family history

of substance abuse

• Legal, disability issues

related to pain

• Younger age

• Male sex

• Previous DUI conviction

• Smoking

• Poor social support

• Adverse childhood events

• Preadolescent sexual

abuse

• Psychiatric, psychological

disorders

Dunbar SA, Katz NP. J Pain Symptom Manage. 1996;11:163-171; Ives TJ, et al. BMC Health Serv Res. 2006;6:46; Kendler KS, et al.

Arch Gen Psychiatry. 2000;57:953-959; Tsuang MT, et al. Am J Med Genet. 1966;67:473-477; Tsuang MT, et al. Arch Gen Psychiatry.

1998;55:967-972.

Risk Assessment and Screening Clinician-Administered Tools

1. Belgrade MJ, et al. J Pain. 2006;7:671-681; 2. Coambs RB, et all. Pain Res Manage. 1996;1:155-162;

3. Chabal C, et al. Clin J Pain. 1997;13:150-155; 4. Wu SM, et al. J Pain Symptom Manage. 2006;32:342-351.

Tool Items Goal

DIRE1 7 Assess whether long-term opioid therapy appropriate in patients with CNCP

SISAP2 5 Predict probability of developing aberrant behavior during opioid

therapy for CNCP by inquiring about alcohol, marijuana, cigarette use

POAC3 5 Assesses criteria that suggest prescription opioid abuse in chronic pain patients

ABC4 20 Track addiction behaviors related to prescription opioids

Risk Assessment and Screening Patient-Administered Tools

1. Webster LR, Webster RM. Pain Med. 2005;6:432-442; 2. Butler SF, et al. J Pain. 2008;9:360-372.3;

3. www.drtepp.com/pdf/substance_abuse.pdf; 4. Brown RL, Rounds LA. Wisconsin Medical Journal. 1995;94:135-140;

5. Li V, et al. Pain Medicine. 2001;2:2456; Adams LL, et al. J Pain Symptom Manage. 2004;27:440-459.

Tool Items Goal

ORT1 5 Predict, quantify potential for developing aberrant behavior during opioid therapy

SOAPP-R2 24 Predict potential opioid-related aberrant behavior

Determine appropriateness of long-term opioid therapy for patients with CNCP

DAST3 28 Quantify extent of problems associated with drug abuse

CAGE-AID4 4 Identify misuse/addiction

STAR5 14 Predict, identify patients with addiction + pain

PMQ6 26 Assess risk for opioid medication misuse

How Do Risk Measures Compare? A Retrospective Study

• N=48 patients

discharged from

Tennessee pain

practice

• Assessed accuracy

in predicting aberrant

drug-related behaviors

0% 20% 40% 60% 80% 100%

Semi-Structured Clinical Interviewa

SOAPP

ORT

DIRE

Accuracy Rate, %

a With a psychologist who could access all other test results.

Moore TM, et al. Pain Medicine, 2008;10:1426-1433.

Opioid Agreement

• Sets forth expectations

of patient, physician

– Rationale for, goals of opioid

therapy

– Responsibilities of physician in

prescribing opioids

– Responsibilities of patient in

using opioids

– Potential AEs

• Should be signed after

assessment, before starting

opioid trial

• Should reflect patient literacy

– Assessment of 162 English-

language opioid contracts

submitted by APS members

• Mean readability grade level

was 13.8

• Vocabulary not

conversational

– Low-literacy English-language

version developed, validated

• 7th-grade reading level

• Contains 26 statements,

12 clipart illustrations

Roskos SE, et al. J Pain. 2007;8:753-758; Wallace LS, et al. J Pain. 2007;8:759-766; Zacharoff KL, et al. Managing Chronic Pain

With Opioids in Primary Care. Inflexxion, Inc: Newton, MA; 2010.

Jack Return to PCP After Interventional Care

• Referred to physical medicine

specialist for imaging, potential

interventional treatment

– X-ray unremarkable

– MRI showed mild stenosis at

right L5-S1 disc

• Epidural steroid injection

– Did not help

• Medication adjusted

– Gabapentin 300 mg tid

– Increased dose of

hydrocodone/APAP

• 6 weeks later, returns to PCP

reporting continued pain

– 6/10, worsens with prolonged

standing, walking

• Poor functioning

– Sleep, mood

– Still unable to return to his

physically demanding job

• Ran out of medication early;

requests early refill or larger

supply

Reevaluation of Opioid-Treated Patients The 4 As

• Analgesia – Pain level

– 30% improvement?

• Activity – Functional level

– Progress toward

therapeutic goals

• AEs – Emergence, persistence

– Treatment

• Aberrant drug-related

behavior – Compliance monitoring

– Undertreatment vs. misuse

vs. abuse

– Need for referral

Chou R, et al. J Pain. 2009;10:113-130.

Jack Treatment Adjustment

• After determining that Jack is opioid-tolerant, PCP

recommends switch to long-acting morphine

Tolerance: state of adaptation in which exposure to a drug

induces diminution of ≥1 of the drug’s effects over time;

can be undesirable (tolerance to analgesia) or desirable

(tolerance to AEs)

SA vs LA Opioids

Sinatra R. J Am Board Fam Med. 2006;19:165-177; Von Korf, et al. Pain. 2011;152:1256-1262.

Pros Cons

SA Onset of effect 30-40 min Duration of action 2-4 hr

Decreased absorption after full meal

Affect limbic system rapidly (pleasure

center)

LA Duration of action 6-72 hr

Less effect on limbic system (except oxycontin [30% of dose

released in first 30-40 min])

More predictable serum levels, analgesic effect

Avoids mini-withdrawals

Easier to use; greater compliance, patient satisfaction

Less reinforcement of drug-taking behavior; may be more

appropriate if known or expected high risk

Patients report being in control of pain, tend not to dose-

escalate

Cost

Increased dosage for potential

diversion

Opioid Rotation

Principles and Fundamentals

• Appropriate in cases of poor

response, intolerable AEs

– Long-term opioid use, CNCP,

complex pain conditions

• Rate of use varies, 10%-40%

• Optimal choices unclear

• ↓ calculated dose of new agent

by 25% to 50% at initiation

• Manage potential effects

– Adjuvant analgesics during

conversion

– Specific treatment for AEs

Chou R, et al. J Pain. 2009;10(2):113-130; De Stoutz ND, et al. J Pain Symptom Manage. 1995;10:378-384; Grilo RM, et al. Joint Bone Spine.

2002;69:491-494; Inturrisi CE. Clin J Pain. 2002;18:S3-S13; Kloke M, et al. Support Care Cancer. 2000;8:479-486; Manchikanti L, et al. Pain

Physician. 2012;15:S67-S116; Quang-Cantagrel ND, et al. Anesth Analg. 2000;90:933-993; Sinatra R. J Am Board Fam Med. 2006;19:165-177.

Opioid rotation: switching from one

opioid to an another to ↑ analgesia,

compliance and ↓ AEs

Incomplete cross-tolerance:

tolerance to AEs of one opioid

does not imply same for another

Follow-Up During Dose Adjustments

• Monitor closely to evaluate effectiveness of analgesia,

tolerability of AEs

• Anticipate subsequent dose adjustments, rotations – ≥1 rotation often necessary; sometimes 3-4

• Recognize that dose ratios in conversion tables may be

more accurate for single-dose opioid administration than

chronic opioid dosing .

Cherny NJ, et al. Cancer. 1995;76:1283-1293; Cherny NJ, et al. Clin Oncol. 2001;19:2542-2554

Galer BS, et al. Pain. 1992;49:87-91; Quang-Cantagrel ND, et al. Anesth Analg. 2000;90:933-937.

A Call from Jack’s Wife

• After 4 weeks of doing well on

morphine, PCP hears concerns

about Jack – Lost his job

– Consumes alcohol excessively

at night

– Slurs speech

– Has fallen

– Verbally abusive

– Suspected marijuana use

• PCP has discussion with Jack – Revisits opioid agreement

– Refers for psychosocial

evaluation

– Orders UDT

• Jack reports continued pain – Medications help more with

anxiety, sleep than with pain

– Agrees to stop drinking

– Denies marijuana use

Chemical coping: pattern of maladaptive coping through

drug use; occasional misuse in times of stress

Compliance Monitoring Purpose and Techniques

• Purpose

– Identify previous, current drug

use

– Determine basis of treatment

– Eliminate drug abuse, misuse

– Implement adequate pain

management strategies

• Techniques

– Screening tests

– Controlled substance

agreements

– Patient education

– PDMPs

– Medication reconciliation

– UDT

– Combination of above

Manchikanti L, et al. Pain Physician. 2008;11:S155-S180.

Urinary Drug Testing Key Role in Safe Patient Management

• Detects presence or absence of drug class, agent,

metabolites – Confirms compliance with treatment plan

– Detects drug misuse as early as possible

– Advocates for patient to 3rd-party interests

• Insurers

• Law enforcement

Heit HA, Gourlay DL. J Pain Symptom Manage. 2004;27:260-267.

Make sure laboratory knows what you are looking for

Clinical Suspicion vs UDT

• Prospective study (N=414)

• Suspected misuse: clinicians

correct in 70% of cases

• NO suspected misuse:

clinicians correct in only 39%

of cases

• Overall, clinician accuracy in

identifying categorization only

slightly better than by chance. – Reinforces need for UDT for all

opioid-treated patients

Bronstein K, et al. Presented at: ?? meeting

Group A, not suspected misuse

Group B, suspected misuse

Group C, randomly selected

Urinary Drug Testing Pros and Cons

+ - Extensively validated (vs sweat, saliva, hair, nails)

Cannot be used to calculate amount of drug taken

Non-invasive Does not reflect time of last dose

Good sensitivity, specificity Does not reflect frequency of drug use

Cost Cannot indicate route of administration

Concentration of drug and metabolite stay in urine

May miss low levels of

appropriate use in fast metabolizers

Screening vs. Confirmatory Tests

Screening test Confirmatory test

Analysis Technique Immunoassay GS/MS or HPLC

Use Qualitative; detects drug class Quantitative; identifies specific drug

Power to detect synthetic/

semi-synthetic opioids

(fentanyl, buprenorphine,

hydrocodone, hydromorphone, methadone, oxycodone,)

Low/none High

Cost Inexpensive (FDA 5-drug testing kit ~ $1)

More expensive; may not be covered by insurance

Turnaround Rapid; 1-3 d Slow; >3 d

Other Intended for drug-free population; may not be useful in pain medicine

Legally defensible results

Positive or Negative UDT Results Potential Causes and Actions

Heit HA, Gourlay DL. J Pain Symptom Manage. 2004;27:260-267.

+ Prescribed Medication

+ Other Substance – Prescribed Medication

• Adherence

• Substance producing

same metabolite as

prescribed

• False positive

• Illicit or unprescribed drug, OTC

• Substance producing same

metabolite as illicit or

unprescribed drug, OTC

• False positive

• Diversion

• Irregular intake,

bingeing

• False negative

• Inability of lab to detect

desired substance

↓ ↓ ↓ • Confirm • Confirm, discuss, consider referral

• Discuss, ↑ vigilance via frequent follow-up, pill counts, smaller

supply, PDMP

Urine Drug Testing Results

N=230 patients on ≥60-day opioid therapy

– From 12 states (mostly Florida)

300 UDT results

– July 2007-July 2008

The Heritage News (Summit). Summer 2011.

All Patients Noncompliant

Compliant

Behaviors

Not taking prescribed pain medication

Taking other nonprescription controlled substances

Using illicit drugs

Response

Generated physician response: counseling, discontinuation of opioid medication, discharge from practice

No visible physician response (no notation in notes and no prescription adjustment),

No data(claim settlement, pt. no-show, etc.

Jack UDT Results

• Positive for non-prescribed drug, illicit drug – Oxycodone

– Marijuana

• PCP suspects doctor shopping or acquisition of

opioids from friend or family – Checks state PDMP to research prescribing records

– Calls Jack to schedule follow-up

Jack

Treatment Adjustment

• PCP discusses findings with Jack, who admits to

using a friend’s oxycodone when his morphine

“didn’t work” or he “couldn’t sleep” – Reviews opioid agreement again

– Reminds Jack that opioid use does not guarantee

complete pain relief, opioids not to be used for sleep

– Increases dose of hydrocodone/APAP for BTP

– Prescribes sleep agent (WHICH?)

• Refers Jack for psychological evaluation

Jack Psychological Evaluation

• After initial refusal, Jack agrees to evaluation,

shares information that he did not provide to PCP – “Medication isn’t working, but when I tried stopping it,

I felt even worse”

– Friend’s oxycodone the “only thing that helps”

– Describes “constant edginess and irritability”

– Feels “useless” without work

Physical dependence: state of adaptation manifested by rebound or withdrawal

symptoms produced by abrupt cessation or rapid dose reduction, decreasing

blood levels of drug, or administration of antagonist

Chronic LBP Beyond Physical Pain

• Patients with LBP 3 × more likely to self-report fair or poor

health, 4 × more likely to have serious psychological distress

NCHS. Health, United States, 2006, with chartbook on trends in the health of Americans. Hyattsville, MD: 2006.

Without LBP With LBP

In fair or poor health

Serious

psychological distress

Chronic LBP

Psychiatric Comorbidities

Patients with chronic back pain entering functional

restoration (N=200)

Major depression

Substance abuse

Anxiety disorder

Other

Polatin PB, et al. Spine (Phila Pa 1976). 1993;18:66-71.

1 psychiatric

diagnosis

Is Jack Addicted to Opioids?

• At psychologist’s urging, Jack shares his concerns

with the PCP – Still reluctant to stop opioid treatment

• Fears withdrawal

• Fears lack of options, lifetime of disability

Addiction

• Primary, chronic, neurobiologic

disease of the brain

– Reward

– Motivation

• Memory, related circuitry

• Multiple factors influencing

development, manifestations

– Genetic

– Psychosocial

– Environmental

Chou R, et al. J Pain. 2009;10:113-130. Savage SR, et al. J Pain Symptom Manag. 2003;26:655-667. AAPM, APS, ASAM.

www.painmed.org/Workarea/DownloadAsset.aspx?id=3204. ACPM. www.acpm.org/?UseAbuseRxClinRef#Resourcesdication time tool clinical

reference. Kahan M, et al. Can Fam Physician. 2006;52:1081-1087. Gilson AM, Kreis PG. Pain Med. 2009;10(suppl 2):S89-S100.

Addiction: ≥1 of the “4 Cs”

• Impaired control over use

• Compulsive use

• Continued use despite harm

• Craving

Pseudoaddiction: drug-seeking

behavior that mimics addiction

but subsides with effective

analgesic intervention

Pain Patients as Nonmedical Users

A Chart Review Study

• N=162 patients entering substance

abuse treatment for problems with

oxycodone SR

– 117 men, 45 women

– Mostly rural (n=148, 91.4%)

– Mean dose, 181.3 mg

– Mean duration, 19.7 months

• 160 (98.8%) bought on street

• 78 (48.1%) also used other opioids

(hydrocodone products/methadone)

• 48 (29.6%) obtained drug through

legitimate Rx

Hays L, et al. J Natl Compr Canc Netw. 2003;1:423-428.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Initial administration

Administration at admission

Pat

ien

ts, %

IV

Snorting

Oral

Pain Patients as Nonmedical Users

A Prospective Study

• N=109 patients entering

substance abuse treatment

– 75 men, 34 women

– Mean age 31 y

• 61% had chronic pain

• 84% received legitimate opioid

prescription for pain medication

at some point

• 91% purchased prescription

opioids from street dealer at

least once

• 80% altered delivery system of

prescription drug by chewing,

snorting, IV administration

• Most commonly abused drugs

– Hydrocodone (78%)

– Oxycodone (69%)

– Methadone (23%)

– Fentanyl (7%)

Passik SD, et al. J Pain Palliat Care Pharmacother. 2006;20:5-13.

Pain Patients as Nonmedical Users Aberrant Behaviors in a Prospective Study

0

25

50

75

0 1-2 3-4 5-7 8+

Pat

ien

ts E

xhib

itin

g B

ehav

iors

, %

Number of Aberrant Drug-Taking Behaviors

Passik SD, Kirsh KL. J Support Oncol. 2005;3:83-86.

215

98

33 26 16

Adherence Therapy for Opioid-Abusing Pain

Patients: the NIDA Study

• N=36 patients with pain >6-mo

duration, VAS >7 despite daily opioids

– Substance abuse comorbidity

permitted

• >2 on “problems with pain

meds”

• SCID-diagnosed opioid use

disorder (abuse, dependence)

– Other current substance use

disorder, lifetime dependence

not permitted

– Psychiatric, medical

comorbidities not permitted

• Interventions

– Adherence, motivational

adherence therapy

– Methadone therapy

• Outcomes

– ↑ methadone dose over time;

↓ all other opioids

– Trend level ↓ in misuse of

nonopioids

Haller D. Presented at 2006 College on Problems of Drug Dependence Annual Conference.

www.seiservices.com/blendingseattle/tue_pdfs/Session22_Haller.pdf.

0

5

10

15

20

25

30

35

40

45

50

Aberrant behavior resolved

Self-discharged Referred for addiction treatment

Consistently negative UDT

Aberrant Behavior Outcomes

The Opioid Renewal Clinic

Weidemer NL, et al. Pain Med. 2007;8:573-584.

Aberrant behavior (n=171)

No aberrant behavior (n=164)

Discontinuing Opioid Therapy Exit Strategies

• Warranted in certain cases

– Intolerable AEs

– Failure to progress to goals

– Lack of compliance

– Aberrant drug-related behavior

• Inadequate evidence to identify

optimal strategy, setting

– ↓ dose 10% to 50% per week

– Outpatient sufficient for

patients without substantial

medical or psychiatric

comorbidities

– Inpatient detox or outpatient

rehab useful for some patients

– Addiction treatment for those

whose aberrant drug-related

behavior is due to addiction

Chou R, et al. J Pain. 2009;10:113-130; Cowan DT, et al. Pain Med. 2005;6:113-121; Ralphs JA, et al. Pain. 1994;56:279-288;

Tennant FS Jr, et al. NIDA Res Monograph. 1983;43:315-321.

Symptoms of Opioid Withdrawal

Initial 1-2 wk ≤6 mo

Anxiety Anxiety

Shaking Poor sleep

Diarrhea Widespread paresthesia

“Goose bumps” Mood changes

Jack A Plan that Works

• Suspecting that untreated

depression underlies

Jack’s aberrant behavior,

PCP adjusts Jack’s

medications once again – Long-acting morphine xxx

– Hydrocodone/APAP xxx

prm

– Sleep agent xxx

– Venlafaxine 37.5 mg bid

• Compliance monitoring – Weekly opioid prescriptions

– Frequent UDT and PDMP

checks

• Co-management with

psychologist

• Documentation in medical

record

• Counseling

Summary

• Opioid medications are appropriate for some carefully selected

patients with chronic pain

• Visual inspection cannot determine a patient’s risk for aberrant drug-

related behavior with opioid therapy

• Every patient on long-term opioid treatment should be monitored for

development of misuse or abuse – Structured initial, follow-up assessments

– UDT, PDMP

– Treatment agreements

– Education, counseling

Potential benefits include improved patient care,

reduced stigma, overall risk containment