when is your pain patient addicted?

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When is your pain patient addicted? When is your pain patient addicted? Richard L. Stieg, M.D., MHS Richard L. Stieg, M.D., MHS www.centen.net www.centen.net www.richardlstiegmd.com www.richardlstiegmd.com May 16, 2012 May 16, 2012 Centennial Rehabilitation Associates Chronic Pain Specialists

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When is your pain patient addicted?. Richard L. Stieg, M.D., MHS www.centen.net www.richardlstiegmd.com May 16, 2012. Centennial Rehabilitation Associates Chronic Pain Specialists. Dr. Richard Stieg, MD MHS and Centennial Rehabilitation Associates. - PowerPoint PPT Presentation

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Page 1: When is your pain patient addicted?

When is your pain patient addicted?When is your pain patient addicted?

Richard L. Stieg, M.D., MHSRichard L. Stieg, M.D., MHS

www.centen.netwww.centen.net

www.richardlstiegmd.comwww.richardlstiegmd.com

May 16, 2012May 16, 2012

Centennial Rehabilitation Associates Chronic Pain Specialists

Page 2: When is your pain patient addicted?

Dr. Richard Stieg, MD MHS and Centennial Rehabilitation Associates

One of the founders of the field of Pain Medicine and instrumental in training fellows President of the American Academy of Pain Medicine (1990-present) President of the Colorado Society of Clinical Neurologists (1979-1980) President Western USA Pain Society (1983-1984) Board certified in Neurology and Pain Medicine, holds a Specialty Certificate in Addiction

Medicine Level II physician with the Colorado Division of Workers' Compensation Medical Director, Pinnacol Assurance (1994-2001) Associate Medical Director of Centennial Rehabilitation Associates since 2002

Centennial Rehabilitation Associates provides a multidisciplinary approach to chronic pain treatment that is unique to Colorado and the surrounding area. Based on the “gold standard” set by the Colorado Division of Workers’ Compensation, our program is designed to address both the physical and behavioral components of chronic pain.

Page 3: When is your pain patient addicted?

Outline

Part I

Definitions and incidence of chronic pain and addiction in America

Dual diagnosis patients: introduction to problems in evaluation and treatment

Part II Treatment options Use of prescription drugs Standards of care Buprenorphine and Methadone Solutions

Page 4: When is your pain patient addicted?

Chronic PainChronic Pain

Any pain which is unremitting or lasts beyond expected Any pain which is unremitting or lasts beyond expected healing time, when associated with disease or injury. May healing time, when associated with disease or injury. May defy easy explanation.defy easy explanation.

The patient usually expresses the problem in terms of an The patient usually expresses the problem in terms of an injured or diseased body part.injured or diseased body part.

There is now evidence that for some people it is a chronic There is now evidence that for some people it is a chronic diseasedisease characterized by physiological changes in the characterized by physiological changes in the central nervous system that may be altered by biological, central nervous system that may be altered by biological, social and spiritual factors.social and spiritual factors.

Page 5: When is your pain patient addicted?

Pain Disorder, Chronic (DSM-IV)

Pain in one or more area, sufficient to need clinical attention

Pain causes distress or impairment in social, occupational or other functional areas

Psychological factors playing an important role in the severity, exacerbation or maintenance of pain

The symptoms are not being intentionally produced or feigned (as in Malingering)

The pain is not better accounted for by a Mood, Anxiety or Psychotic disorder

Page 6: When is your pain patient addicted?

The estimated prevalence of chronic pain in the US is ~70 million

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Addiction -- ASAM/AAPM/APS

A primary, chronic, neurobiological disease with genetic, psychosocial and environmental

factors influencing its development and manifestations. It is characterized by behaviors

that include one or more of the following: impaired control over use, compulsive use, continued use despite harm and craving.

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A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12 month period:

- A failure to fulfill major role obligations at work, school or home (e.g. repeated absences, truancy, child neglect) - Recurrent use in situations in which it is physically

hazardous (e.g. driving while impaired) - Recurrent substance-related legal problems

- Continued substance use despite having persistent or

recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

The symptoms have never met the criteria for “Substance Dependence” for this class of substance

Substance Abuse (DSM-IV )

Page 9: When is your pain patient addicted?

A syndrome characterized by a maladaptive pattern of substance abuse, leading to clinically significant impairment or distress, as manifested by 3 or more of the following, occurring in the same 12 month period:

– Withdrawal– Tolerance– Substance is taken in larger amounts or for longer than Rx– Persistent desire or unsuccessful efforts to cut down or

control– A great deal of time spent in activities to obtain substance– Important social, occupational or recreational activities

are given up or reduced because of substance use– Use continues despite the user’s knowledge that he/she

has a persistent or recurrent problem that is caused by or exacerbated by the substance

Substance Dependence (DSM-IV)

Page 10: When is your pain patient addicted?

Marijuana: 15,706 - 110,512 (up 604%) Heroin: 33,884 - 94,804 (up 180%) Cocaine: 80,000 - 180,000 (up 125%) Methamphetamine/speed varied

between 15,000 - 19,000 (n/c)

Prescription drugs: sedative-hypnotics, benzodiazepines, narcotics, stimulants

Incidence of illicit drug usefrom DAWN (Drug Abuse Warning Network) from 1990-2001

Page 11: When is your pain patient addicted?
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18 million have Serious Mental Illness/ 4 million with associated alcohol and/or drug problem

34% mental illness rx only 2% addiction rx 12% dual rx 52% no rx

20 million need alcohol or drug rx 14% received it

Dual Diagnoses----Who Gets Treatment?(U.S. Government study)

Page 13: When is your pain patient addicted?

• Inadequate training of healthcare professionals

• Poor public and professional knowledge• Public fear of narcotics• Charlatanism in pain treatment• Few outcomes-based practice standards• Roadblocks to access

Reasons for inadequate care of pain patients in the United States

Page 14: When is your pain patient addicted?

MMWR / August 20,2010 / Vol. 59 / No. 32

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Page 15: When is your pain patient addicted?

Published rates of abuse/addiction in chronic pain population are ~ 10% (3-18%)

– This suggests that known risk factors for– abuse or addiction in the general population

would be good predictors for problematic prescription opioid use:

– > History of early substance use– > Personal/family history of substance abuse

> Co-morbid psychiatric disorders

Page 16: When is your pain patient addicted?

Is the pain “real”?

Physiological Pain Non-organic factors contributing to pain Factitious or malingering? The use of pain medications to manage

emotions

Page 17: When is your pain patient addicted?

Tolerance

Need for more drug for same effect

Diminished effect with same amount of drug

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Withdrawal

Physiological and psychological consequences of decreased dose

Use of substance to avoid withdrawal

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Behavioral Indicators of Medication Use Problems

Runs out of medications early Has multiple prescribers Obtains medications from others Has difficulty functioning due to over-medication Watches the clock for next dose Takes medication for other than pain relief Gradually increasing dose to manage pain Poor pain control with medication

Page 20: When is your pain patient addicted?

Appropriate use of narcotics

Psychological assessment does not suggest substance abuse problem

Patient has physiological pain Patient has a pain disorder

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Half-Time Q&A

Centennial Rehabilitation Associates

Chronic Pain Specialists

Page 22: When is your pain patient addicted?

Addiction and Chronic PainAddiction and Chronic Pain

Distinct biological entitiesDistinct biological entities May coexistMay coexist Pharmacologic treatment is differentPharmacologic treatment is different Physical treatment is differentPhysical treatment is different Psychosocial treatment shares some common Psychosocial treatment shares some common

elements (e.g. learning to cope, 12-step tx.) elements (e.g. learning to cope, 12-step tx.)

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Traditional treatment doesn’t address both pain and addiction – important to treat both the pain and the addiction

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Who is best qualified to evaluate and treat dual diagnosis patients?

There are many good addiction programs: almost all emphasize abstinence as part of treatment

The literature strongly supports the use of multidisciplinary pain programs as the gold standard, but these have largely disappeared

Today’s pain specialists emphasize interventional strategies: most have no interest in treating addiction

There are very few dual programs or practitioners

Page 25: When is your pain patient addicted?

The use of prescription drugs in dual diagnosis patients

This is the major public health issue

How has the problem evolved?

What are the solutions?

Page 26: When is your pain patient addicted?

Treating the dual diagnosis patient

Non-pharmacological treatment is the ideal The ideal is rarely accomplished The reasons: lack of funding, lack of

specialists, persistent disease (e.g. chronic pain requiring opioid management or opioid addiction requiring maintenance)

Presence of psychiatric disease confounding care

Page 27: When is your pain patient addicted?

Why use opioids for chronic non-malignant Why use opioids for chronic non-malignant pain before end-of-life care?pain before end-of-life care?

The drugs may adequately control painThe drugs may adequately control pain

They may help to maintain physical and They may help to maintain physical and emotional functionalityemotional functionality

They may be the only treatment availableThey may be the only treatment available

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Important questions about usageImportant questions about usage

Who are appropriate candidates for chronic Who are appropriate candidates for chronic opioid therapy?opioid therapy?

When is it time to remove narcotics?When is it time to remove narcotics? How should “breakthrough pain” be treated?How should “breakthrough pain” be treated? What is the “downside” of lifetime use?What is the “downside” of lifetime use? How will government regulatory agencies How will government regulatory agencies

continue to deal with users and dispensers of continue to deal with users and dispensers of these drugs?these drugs?

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Important questions (continued)

How many problem drug users are we creating?

How can we best identify the problem drug user?

How is problem drug use treated/does it always require opioid withdrawal?

Is Buprenorphine the “dream medication” for opioid withdrawal/opioid maintenance?

Page 30: When is your pain patient addicted?

What do we know about standards of care in evaluating and treating patients with drugs that can be abused?

1. Numerous published guidelines by state medical boards and medical specialty organizations

2. An abundant literature in peer-reviewed publications, trade journals and the lay press about the dangers involved

3. Availability of prescription drug monitoring programs

Page 31: When is your pain patient addicted?

Common themes in published guidelines

1. Careful history and physical exam with attention to risk factors associated with potential substance abuse 2. Periodic reassessment of risk factors, drug efficacy, need for continued use of specific drugs3. Utilization of less risky treatment when available4. Proper utilization of specialty consultations5. Attention to drug interactions, signs of overdosing, abusing, diverting, use of drug monitoring programs and urine drug testing6. Written documentation of drugs dispensed and all of the standards listed above

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Drug TestingDrug Testing

Should be used to manage care---not to punishShould be used to manage care---not to punish Should be consensual with honest explanation to patientShould be consensual with honest explanation to patient Provides objective evidence of compliance with a mutually Provides objective evidence of compliance with a mutually

agreed-upon treatment planagreed-upon treatment plan Aids in diagnosis and treatment of all disorders presentAids in diagnosis and treatment of all disorders present Can be an advocate for patient in family and social issuesCan be an advocate for patient in family and social issues Assesses Assesses only only the presence of a drug class or a particular drug the presence of a drug class or a particular drug

in a specific concentration at a moment in time in a specific concentration at a moment in time It does It does not not diagnose drug abuse, dependency or addictiondiagnose drug abuse, dependency or addiction Clinical judgment should dictate useClinical judgment should dictate use

Page 33: When is your pain patient addicted?

BuprenorphineBuprenorphine

Binds tightly to the opioid receptor (“high Binds tightly to the opioid receptor (“high affinity”)affinity”)

Long half-life (30 hours)Long half-life (30 hours) Partial agonist (70 percent activity)Partial agonist (70 percent activity)

– Produces little or no euphoriaProduces little or no euphoria– Generally has fewer untoward reactionsGenerally has fewer untoward reactions– Requires special DEA licenseRequires special DEA license

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Buprenorphine plus NaloxoneBuprenorphine plus Naloxone

Subutex Buprenorphine 2 mg or 8 mgSubutex Buprenorphine 2 mg or 8 mg Suboxone Buprenorphine with Naloxone Suboxone Buprenorphine with Naloxone

2.0mgm/0.5mgm 8.0mgm/2.0mgm2.0mgm/0.5mgm 8.0mgm/2.0mgm

– Buprenorphine 2 mg with naloxone 0.5 mgBuprenorphine 2 mg with naloxone 0.5 mg– Buprenorphine 8 mg with naloxone 2 mgBuprenorphine 8 mg with naloxone 2 mg The only purpose of the naloxone is to prevent people from crushing and injecting the tablet The only purpose of the naloxone is to prevent people from crushing and injecting the tablet

- naloxone is not absorbed from the mouth- naloxone is not absorbed from the mouth

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Why use Buprenorphine for Chronic pain?Why use Buprenorphine for Chronic pain?

Crossover from short acting opioidsCrossover from short acting opioids Presence of suspected or known opioid Presence of suspected or known opioid

dependency/addictiondependency/addiction Safety profile/ “ceiling effect”Safety profile/ “ceiling effect” Convenience of administrationConvenience of administration Withdrawal usually mildWithdrawal usually mild Analgesia less than morphineAnalgesia less than morphine

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Methadone for the treatment of opioid Methadone for the treatment of opioid addiction and chronic painaddiction and chronic pain

Only licensed clinics can treat addictionOnly licensed clinics can treat addiction Any provider can write for pain treatment, but Any provider can write for pain treatment, but

few have the requisite expertisefew have the requisite expertise An excellent drug for central neuropathic pain An excellent drug for central neuropathic pain

with unique pharmacological propertieswith unique pharmacological properties Extremely dangerous if used improperly/rising Extremely dangerous if used improperly/rising

death rate in the U.S. and modern countriesdeath rate in the U.S. and modern countries Very inexpensive ($30-$40/month for pain tx)Very inexpensive ($30-$40/month for pain tx)

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References

1. Savage,S. Long-term Opioid Therapy:Assessment of Consequences and Risks. J.Pain and Symptom Management:11(5).274-286, 1996.

2. Webster,L. & Fine,P. Approaches to Improve Pain While MinimizingOpioid Abuse Liability. The Journal of Pain: 11(7). 602-611,2010

3. Becker,WC et al. Nonmedical Use of Opioid Analgesics Obtained Directly From Physicians: Prevalence and Correlates. Arch.Intern.Med. 171(11). 1034-1036, 2011

4. Radley Balko. The War Over Prescription Painkillers. http://www.huffingtonpost.com/radley-

balko/prescription-painkillers_b_1240722.html?ici...

5. Institute of Medicine 2011 Report. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Resear

Page 38: When is your pain patient addicted?

Website References

1.American Pain Society : www.ampainsoc.org

2.AAPM: www.painmed.org

3.American Chronic Pain Assoc:http://theacpa.org

4. [email protected]

5.http://www.uspainfoundation.org

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Next Webinar

Wednesday, June 20th from 12-1pm (MT)

“Behavioral Interventions with Chronic Pain Patients” Presented by Beverly Noyes, PhD

This program has been submitted to The Commission for Case Manager Certification

for approval to provide board-certified case managers with 1 clock hour.

To register, go to www.centen.net

Centennial Rehabilitation Associates

Chronic Pain Specialists