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
Numbers (in Millions) of Lifetime Nonmedical
Users of Selected Pain Relievers among Persons
Aged 12 or Older 2002 and 2003
10
Past Month Illicit Drug Use, by Age 2003
11
Maine opioid problem
12
Maine opioid problem
Maine Office of Substance Abuse Treatment Data
System
13
Maine opioid problem - young adults
14
Maine opioid problem - HCV
15
Pain

• The awareness of nociception
• An unpleasant sensory and emotional experience
  associated with actual or potential tissue damage
  or described in terms of such damage IASP

16
Pain

• Pain is a subjective experience that has both
  sensory and affective components
• Four distinct components transduction,
  transmission, modulation, and perception

17
Pain system

• Interneuron-spinal
• Thalamus
• Sensory neuron- peripheral
• Cortex

18
Neural modulation of pain

• Substance P
• NMDA
• Both excitatory and inhibitory systems
• Opioids

• On-off cells
• Serotonin
• Norepinephrine
• Cannabinoids

19
Neural plasticity

• Changes in the peripheral and central nervous
  system that occur as the result of a nociceptive
  injury
• Produces changes in both structure and function
• Effects transduction, modulation and perception
  of pain

20
Neural plasticity

• Changes in genes, peptides and transmitters at
  levels of spinal cord, drg, nerve and skin,
  leading to spontaneous ectopic activity (Na
  channel changes).
• Loss of opioid receptors pre and post
  synaptically.
• Damaged nerves produce large amounts of substance
  P

21
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

22
Definitions

• Allodynia pain due to a normally non-painful
  stimulus
• Central pain pain initiated or caused by a
  primary lesion or dysfunction in the central
  nervous system

23
Definitions-

• Hyperalgesia
• An increased response to a stimulus which is
  normally painful.
• hyperalgesia is a consequence of perturbation of
  the nociceptive system with peripheral or central
  sensitization, or both

24
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

25
WHO analgesic ladder

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

26
Opioids

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

27
Pain-opioid spiral

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

28
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.

29
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.

30
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

31
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

32
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.

33
Drug misuse

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

34
Drug abuse

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

35
Addiction

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

36
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.

37
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

38
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

39
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

40
Addictive behavior vs Medical dependence
Stimmel, 1997

• Primary purpose euphoria
• Rapid dose escalation as tolerance develops
• Abstinence unlikely to be maintained despite
  frequent attempts

• 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

41
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

42
Addictive behavior vs Medical dependence
Stimmel, 1997

• 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

43
Oliver Wendell Holmes

• If the whole materia medica, as now used, could
  be sunk to the bottom of the sea, it would be all
  the better for mankind, and all the worse for the
  fishes.

44
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.

45
Physician, regarding chloral hydrate, 1870

• It is wrong to claim for it a harmlessness
  which belongs to no active remedy yet
  discovered.

46
Physician, 1871

• With their characteristic anxiety for dosing
  themselves, Americans would overuse all new
  remedies.

47
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.

48
Parke Davis Catalog, 1885

• If these claims are substantiated by more mature
  observation, and cocaine should prove to be the
  long sought for specific for the opiate habit,
  the reliable antidote in poisoning by opiate
  preparation, and the invaluable tonic in
  alcoholism, it will indeed be the most important
  therapeutic discovery of the age, the benefit of
  which to humanity will be simply incalculable.

49
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.

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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.

51
Screening

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

52
Physician issues

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

53
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

54
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

55
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.

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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.

57
Some suggestions

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

58
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.

59
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.

60
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.

61
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.

62
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.

63
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.

64
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

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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.