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Exploring the Controversy of Pain and Addiction

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Is there a problem with prescription drugs? ... Physician mis-prescription. Patient misunderstanding. Drug abuse. Deliberate misuse of a drug. ... – PowerPoint PPT presentation

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Title: Exploring the Controversy of Pain and Addiction


1
Exploring the Controversy of Pain and Addiction
  • Mark Publicker, MD FASAM
  • Medical Director
  • Mercy Recovery Center

2
Is there a problem?
Newsweek While the pharmaceutical market
doubled to 145 billion between 1996 and 2000,
the painkiller market tripled to 1.8 billion
over the same period.
3
Is there a problem with prescription drugs?
  • Source Office of Applied Studies, Substance
    Abuse and Mental Health Services Administration.
  • National Household Survey on Drug Abuse, 1999.

4
Is there a problem?
5
DAWN 1990-1996
  • Morphine prescriptions increased by 60
  • DAWN mentions 3 increase
  • Oxycodone prescriptions increased by 23
  • DAWN mentions 30 decrease
  • Fentanyl prescriptions increased by 1100
  • DAWN 60 decrease

6
DAWN report
  • Prescription opioids, ED mentions
  • 1988 28,371
  • 2002 61,433
  • From 1994 to 2002, benzodiazepines increased more
    than 40 percent
  • Opiates/opioids, including narcotic analgesics,
    increased 2.7 times.

7
DAWN report
  • 2002, the benzodiazepines and opiates/opioids
    were each as frequent as heroin or marijuana

8
Drug Abuse Warning Network - 2000 report
  • Oxycodone increased 68 6879 to 10825
  • Hydrocodone increased 31 14639 to 19221
  • Note that DAWN does not register brand products

9
Maine opioid problem
10
Maine opioid problem
Maine Office of Substance Abuse Treatment Data
System
11
Maine opioid problem - young adults
12
Neurophysiological conundrums
  • Opioid-induced hyperalgesia
  • Fields withdrawal leads to activation of pain
    enhancing ascending pathways and inhibition of
    suppressing descending pathways
  • Mu opioid receptor variable responsiveness to
    opioid analgesics

13
WHO analgesic ladder
  • The who analgesic ladder matches the patient's
    report of pain intensity to specific types of
    analgesics.
  • Mild to moderate non-opioid analgesics

14
WHO analgesic ladder
  • Moderate to severe oral opioids plus non-opioid
    /- an adjuvant around the clock
  • Severe opioids /- non-opioid /- adjuvant
    around the clock

15
Opioids
  • Modulate pain mostly through descending systems
  • Evidence for peripheral effects as well

16
Pain-opioid spiral
  • Common with short-acting opioids
  • Repeated cycles of pain-contingent dosing leads
    to both tolerance and dependence

17
Tolerance
  • The need for an increased dosage of a drug to
    produce the same level of analgesia that
    previously existed. Tolerance also occurs when a
    reduced effect is observed with constant dose.
    Analgesic tolerance is not always evident during
    opioid treatment and is not addiction.

18
Pseudotolerance
  • The need to increase dosage due to other factors
    such as
  • Disease progression, new disease, increased
    physical activity, lack of compliance, change in
    medication, drug interaction, addiction, and
    deviant behavior.

19
Physical dependence
  • Indicated by the occurrence of withdrawal
    symptoms after opioid use is stopped or quickly
    decreased without titration, or if an antagonist
    is administered
  • Can be avoided by warning patients not to
    abruptly stop the medication and by using a
    tapering regimen
  • Physical dependence is not addiction

20
Pseudoaddiction
  • Drug-seeking behavior that seems similar to
    addiction, but is due to unrelieved pain. This
    behavior stops once that pain is relieved, often
    through an increase in the opioid dose.
  • Leads to inappropriately stigmatizing the patient
    with the label 'addict'.
  • Prn dosing, short-acting opioids

21
Pseudoaddiction
  • In the setting of unrelieved pain, the request
    for increases in drug dose requires careful
    assessment, renewed efforts to manage pain and
    avoidance of stigmatizing labels.

22
Drug misuse
  • Unintentional consumption of a drug in other than
    the commonly accepted manner.
  • Physician mis-prescription
  • Patient misunderstanding

23
Drug abuse
  • Deliberate misuse of a drug.
  • Self-medication of painful feelings and/or
    reality
  • To get high

24
Addiction
  • Compulsive use
  • Loss of control
  • Use despite known harm
  • Non-medical use
  • Aberrant drug behaviors

25
Addiction
  • Psychological dependence on the use of substances
    for their psychic effects and is characterized by
    compulsive use.
  • Addiction should be considered if patients no
    longer have control over drug use and continue to
    use drugs despite harm.

26
Addiction
  • Addiction is a cycle of spiraling dysregulation
    of brain reward systems that progressively
    increases, resulting in compulsive drug use and a
    loss of control over drug taking George Koob

27
Medication overuse vs addiction
  • Co-occurring personality disorders and poor
    coping skills can make these distinctions
    difficult
  • The percentage of rebound patients with addictive
    disorders is actually low
  • The patients willingness to collaborate with the
    physician is a good indicator that addiction is
    not present

28
Distinguish between an addict and a patient with
pain?
  • Patients with active addictions with painful
    conditions
  • Recovering patients with painful conditions
  • Patients who misuse
  • Patients who abuse to get high
  • Patients who abuse to self-medicate

29
Addictive behavior vs Medical dependence
Stimmel, 1997
  • Relief of pain
  • Constant dose and frequency with slow increases
    for tolerance
  • Usually able to abruptly stop or if wd develops
    can be successfully managed
  • Primary purpose euphoria
  • Rapid dose escalation as tolerance develops
  • Abstinence unlikely to be maintained despite
    frequent attempts

30
Addictive behavior vs Medical dependence
Stimmel, 1997
  • Function frequent intoxication
  • Behavior focus on drug-seeking to exclusion of
    socially productive activities
  • Able to function productively in acute pain
    states slight sedation may occur
  • Able to engage in productive activity due to
    relief of pain

31
Addictive behavior vs Medical dependence
  • Side effects common due to dose and routes of
    administration continued use despite
    complications
  • Polydrug use frequent
  • Mild, manageable side effects
  • Polydrug use rare unless prescribed by physician

32
Physician, 1894
  • We have an army of women I America dying from
    the opiate habit _ larger than our standing army.
    The profession (medicine) is wholly responsible
    for the loose and indiscriminate use of the
    drug.

33
Physician, regarding chloral hydrate, 1870
  • It is wrong to claim for it a harmlessness
    which belongs to no active remedy yet
    discovered.

34
North Carolina Physician, 1880
  • On one patient I have use the hypodermic
    syringe between 2500 and 3000 times in a period
    of eighteen months, and so far see no signs of
    the opium habit.

35
Dr. Paul Doctor, Alcoholic, Addict. AA Big Book
  • I never in my life took a tranquilizer, sedative
    or pep pill because I was a pill head. I always
    took it because I had the symptom that only that
    pill would relieve. Therefore, every pill was
    medically indicated at the time it was taken.

36
Dr Paul, continued
  • For me, pills dont produce the desire to
    swallow a pill they produce the symptoms that
    require that the pill be taken for relief. I had
    a pill for every ill, and I was sick a lot.

37
Screening
  • No good research-validated instruments
  • High risk
  • Prescription forgery, theft, alterations
  • Pattern of repeated lost, stolen, damaged
    prescriptions
  • Intoxication
  • Stories

38
Physician issues
  • Knowledge, skills and experience in the treatment
    of pain and in the use of opioid analgesics
  • Attitudes towards pain and addiction

39
Universal pain treatment system problems
  • Gaps in primary care knowledge of treatment and
    of referral criteria
  • Significant variation in the availability of
    basic or advanced assessment and/or treatment
    options
  • Lack of planning, direction, and coordination

40
Pain system treatment needs
  • Primary care education and responsibility for the
    care of mild to moderate acute and chronic pain
  • Ensure a specialty referral program exists which
    provides a multidisciplinary approach to
    assessment, diagnosis and creation of a
    coordinated treatment plan for complex chronic
    pain patients

41
Federation of State Medical Boards Model
Guidelines
  • The board recognizes that controlled substances,
    including opioid analgesics, may be essential in
    the treatment of acute pain due to trauma or
    surgery and chronic pain, whether due to cancer
    or non-cancer origins.

42
Model Guidelines, continued
  • Pain should be assessed and treated promptly,
    and the quantity and frequency of doses should be
    adjusted according to the intensity and duration
    of the pain.
  • Physicians should recognize that tolerance and
    physical dependence are normal consequences of
    sustained use of opioid analgesics and are not
    synonymous with addiction.

43
Some suggestions
  • When in doubt, ask for help
  • Dont rely on medication alone
  • Everyone gets one good story
  • Review the pharmacy record each time

44
Conclusions
  • There is a role for opiates in the management of
    some patients with chronic non-malignant pain
  • These patients need to be carefully selected, and
    the risks, benefits and alternatives to long-term
    opiate use explained.

45
Conclusions
  • For some pain syndromes, such as migraines, there
    is a clear consensus that chronic or frequent
    acute opiate use is contraindicated
  • and can worsen the pain disorder, rendering it
    intractable to acute and prophylactic treatment.

46
Conclusions
  • When long-term opiates (LTOs) are found to be
    necessary for the management of CNMP,
    short-acting opiates should be avoided.
  • Patients should be carefully screened for
    histories of alcoholism and other drug
    dependencies.

47
Conclusions
  • Patients being considered for LTOs should have a
    well-defined stimulus which is not reversible, or
    for which definitive treatment is medically or
    surgicaly contraindicated.
  • Physicians should consider obtaining
    consultations regarding the appropriateness of
    LTOs.

48
Conclusions
  • At least once a year, the physician should obtain
    a letter from the relevant specialist stating
    that
  • the underlying disease state causing the pain is
    unchanged or worse and
  • no new treatment methods have emerged in the
    interim which could otherwise treat the
    underlying disorder.

49
Conclusions
  • Patients should be referred for treatment of
    primary or secondary depression or other
    psychiatric disorders.
  • Utilize empathetic confrontation and intervention
    when addressing suspected substance abuse
    problems.

50
Oxycontin - Art van Zee, MDAnnals of Internal
Medicine April 6, 2004
  • It might have been easier
  • if OxyContin swallowed the mountains, and took
  • the promises of tens of thousands of young lives,
  • Slowly, like ever-encroaching kudzu.
  • Instead,it engulfed us,
  • gently as napalm would a school-yard

51
Oxycontin - Art van Zee, MD
  • Mama said
  • As hard as it was to bury Papa
  • after the top fell
  • in the mine up Caney Creek,
  • it was harder yet
  • to find Sis that morning
  • cold and blue,
  • with a needle stuck up her arm.
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