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Long-Term Opioid Therapy for Pain: Dependent or Addicted?!!A clinical Conundrum

Ajay Manhapra MDVA Inter-professional Fellow In Addiction MedicineDepartment of Psychiatry and Internal Medicine

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Clinical case: Long term opioid therapy (LtOT) with complications • 63 yr old WM with COPD on home O2, CHF, OSA refuses

CPAP, and continues to smoke – C/C R knee pain and “pain all over”, Limited mobility – Prescribed opioids from 42 years of age: Was on Morphine

SA 45 mg TID + Oxycodone 5 mg Q 6hrs prn, Got extra from outside physician to Morphine SA to 60 TID

• Admitted to hospital twice in past few months1. Fall with intracranial bleed, respiratory failure

2. Respiratory failure requiring naloxone drip and intubation– Patient firmly believes that opioids have no connection with

his hospitalizations. “Its all due to my pain”

• After hospitalizations, Morphine SA reduced to 30 mg TID.

• Referral to Opioid Reassessment Clinic (ORC)– Patient refuses to decrease opioids further and wants an

increase

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Key Question

63 yr old patient with serious medical comorbidities who wants to continue on LtOT for CNCP, even after two recent

life threatening events.

Is this patient just physically dependent or addicted?

• First examine the end results of long term opioid use• Then try to answer the key question: dependent or

addicted?

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Why do we treat opioid addiction with OAT?

Hser Y et al./ Arch Gen Psychiatry. 2001;58:503-508

On 33-year follow-up of opioid addicts In California, ≅50% died, many of them due to chronic disease in addition to overdose and accidents.

Overall goal of OAT is to reduce morbidity and mortality including that related to chronic disease

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Long term opioid therapy for pain: What is the outcome over years?

• Over years, long term opioid therapy (LtOT) for pain

associated with:

– Poor efficacy in pain control

– Significant disability and poor QOL beyond that of chronic pain

patients

– “Overdose” complications that are likely to be only the tip of the

iceberg

– Excess multi-system morbidity and mortality, especially in older

patients

– Accelerated chronic disease morbidity and mortality

– Excess psychiatric comorbidity

Emerging literature suggests that LtOT is associated with excess morbidity and mortality comparable to illicit opioid use, but with less

“overdose”

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Opioid Use Disorder by DSM-5 criteria Vs. Pain literature guided criteria

PAIN: CLINICAL UPDATES • DECEMBER 2013

All of this can be attributed to pain rather

than addiction!!! Very contextual!!

?Nearly impossible to meet th

is criteria in

pain patients on LtOT, especially older

ones

?

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Opioids

Illicit means

Prescribed

Intermittent to

Chronic use

Opioid induced

neuroadaptive changes

Reward: Pain relief

Reward: Hedonic

Distinct associative memories leads to specific learned

behavior

Distinct associative memories leads to specific learned

behavior

Opioid induced systemic adaptatio

n

Long term Medical Effects• Overdose • Opioid

related morbidity & mortality

• Systemic morbidity & mortality

Opioid abuse/misu

se

Addiction

Dependence Tolerance WithdrawalAnhedonia

Dependence Tolerance WithdrawalAnhedonia

Opioid dependence Vs. Addiction:A Distinction Without a Difference?

Dependence, whether or not part of a drug use disorder, is a powerful driver of opioid-seeking behavior

Distinct long term psycho-social effects

Distinct long term psycho-social effects

Concept adapted from: Ballantyne et al: ARCH INTERN MED/VOL 172 (NO. 17), SEP 24, 2012 & PAIN: CLINICAL UPDATES • DECEMBER 2013

If the end result and pathophysiology is similar, does a distinction between Dependence and Addiction really matter?

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Just physically dependent or Addicted?

• Probably not Opioid Use Disorder by DSM-5• He has significant tolerance and dependence that seems

to be driving opioid use• It is reasonable to assume that he has neuroadaptation

similar to any chronic opioid user• Although different from an illicit user, he has behavior

that can be characterized as opioid seeking• This is some thing more than simple “physical

dependence” – It appears to be associated with higher morbidity and

mortality risk– And this risk is playing out now with a high cost

Opioid Dependence vs. Addiction: Does A Distinction Matter?

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“If this not addiction, I have to call this something! This is bad!!” – Will Becker MD

– Borrowing from Ballantyne et al, may be:• “Complex Persistent Dependence” to prescribed

opioids

– Insistence/Need to continue using opioids for pain despite caution regarding

• Minimal or no efficacy• Complex behavioral and social patterns around opioids (what is

characterized as opioid seeking, misuse/abuse, etc.)• Increased “opioid related morbidity and mortality”• Increased psychiatric morbidity• Increased overall morbidity and mortality

Concept adapted from: Ballantyne et al: ARCH INTERN MED/VOL 172 (NO. 17), SEP 24, 2012 & PAIN: CLINICAL UPDATES • DECEMBER 2013

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What are the viable options for this patient with complex persistent dependence to opioids?

Continue LtOT in a safe manner Wean off opioids✔ Opioid Agonist Treatment

✖ MethadoneBuprenorphine

Reasoning for OAT similar as in opioid use disorder

We felt methadone was unsafe

We felt Buprenorphine is probably the best bet given his complex dependence and pain

✖✖

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Discontinuing long term opioids for pain

• Video describing patient perspective on discontinuing LtOT for pain

• Video not inserted due to email restriction from file size

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Conclusion

• We can make very little distinction between physical

dependence and addiction in LtOT for non-cancer pain

• Insistence on a diagnosis of addiction adds little value to

treatment

• Over years, many patients on LtOT seems to develop

“Chronic Persistent Dependence” to opioids associated

with varying degrees of excess morbidity and mortality

comparable to that with illicit opioids.

• Knowledge regarding management of Chronic Persistent

Dependence to prescribed opioids is evolving.