Title: Addiction
1Addiction
A primary, chronic, neurobiological disease,
with genetic, psychosocial, and environmental
factors influencing its development and
manifestations.
2Prevalence of Addictive Disorders
- General population 3-18
- Chronic pain population
- 3.2-18 1
- 24 2
- 27 3
- Hospitalized population 20-26 4,5
- Trauma population 40-62 6-9
- Cancer-related pain 27 10
1Fishbain DA, et al. Clin J Pain. 1992877-85.
2Hoffman HG, et al. Int J Addict.
199530919-927. 3Chabaln C, et al. Clin J Pain.
199713150-155. 4Regier DA, et al. Arch Gen
Psychiatry. 198441934-958. 5Graham AW. Arch
Intern Med. 1991151958-964. 6Heinemann A, et
al. Arch Phys Med Rehab. 198869619-624.
7Honkanen R, et al. J Stud Alcohol.
198344231-245. 8Reyna TM, et al. Ann Surg.
1985201194-197. 9Brown RL, et al. Wisc Med J.
199594135-140. 10Bruera E, et al. Acta
Oncologica. 199837749-757.
3Addiction
- Addiction can hide in the fabric of normal
- Seen through the rear-view mirror
- Addiction is not a disease of using, but one of
thinking and behavior. - Barry Rosen, MD
4Denial With Chronic Pain
- I only take meds as prescribed
- I only take meds because Im in pain
- Im not addicted
- Im different from others who have addiction
- I never got medications from the street
- I never shoot my drugs
- Im a good citizen
5Addiction
- Physiological, cognitive, and behavioral
symptoms characterized by - Loss of control (compulsive use)
- Continuation of use despite adverse consequences
(family, legal, job, health, social, etc.) - Preoccupation with obtaining and using the
- drug despite the presence of adequate analgesia
- Urge to rediscover high, which diminishes,
leaving - user in a less than normal feeling state
(dysphoria)
6Addiction 5 Cs
Chronic Compulsive use, not assoc. with
willpower Control-impaired--unable to limit
intake Craving--desire for the drug when it is
absent Continued use despite harmirrational
pursuit of mood change/high at expense of
family, job, emotional well-being, and health
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8The Action of Opioids
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11Opiate Receptors
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13Substance Dependence
DSM-IV Criteria
A problematic pattern of substance use, leading
to significant clinical impairment as manifested
by three or more of the following, occurring at
any time in a 12-month period.
14Substance Dependence
DSM-IV Criteria
5. Great deal of time procuring
hunter and gatherermultiple docs, driving
long distances 6. Important activities
given up 7. Continued use despite knowledge of
harm
- Tolerance
- Withdrawal
- Use of larger amounts over longer period
- Unsuccessful efforts to cut down or control
- substance
15Tolerance
- A state of adaptation in which exposure to a
drug induces changes that result in a
diminution of one or more of the drugs effects
over time. - Higher dose required to achieve effect.
- Variable over time with patient-to-patient
variability. - Tolerance to side effects desirable.
- Not necessarily addiction.
16Physical Dependence
- A state of neuroadaptation to the
- presence of a drug, in which a
- withdrawal syndrome emerges on
- abrupt cessation of the drug or rapid
- reduction of dose.
- Organism functions normally only in the
- presence of the drug.
- Natural physiologic reaction to ongoing
- exposure to certain drug classes.
- Interaction of frequency/duration/dose.
17Aberrant Drug Related Behaviors (Less Predictive)
- Aggressive complaining about the need for higher
doses - Drug hoarding during periods of reduced symptoms
- Requesting specific drugs
- Prescriptions from other physicians
- Unsanctioned dose escalation
- Reporting mood altering effect not intended by
the physician - Passik and Portenoy, 2003
18Aberrant Drug Related Behaviors (More Predictive)
- Stealing or Borrowing drugs from another
patient - Obtaining Rx drugs from non-medical people
- Prescription forgery
- Selling prescription drugs
- Concurrent abuse of related illicit drugs
- Multiple unsanctioned dose escalations
- Repeated episodes of lost prescriptions
- Injecting oral formulations
- Passik and Portenoy
19Negative Consequences
- Pain no better, or only marginal improvement
- Function no better or worse
- Increasing pain complaints
- Cognitive Impairment/Intoxication
- Emotional ability
- Falls/MVAs
20Loss of Control
- Earlier requests for medications
- Unscheduled urgent office visits
- Emergency room visits for Rx
- Prescriptions stolen/lost/the dog ate it
- S.O. reports overuse/abuse intoxication
- Where are the unused pills/used patches?
- Reason for use to relieve emotional symptoms.
21Compulsion
- Preoccupation with meds
- Interested only in pain relief not in other
rehabilitation activities - Not interested in non-opioid modalities
- Will end up needing to see other docs
- Failure to comply with non-drug Rxs
22Pain and Addiction
23Pain and Addiction
- Dual diagnosis
- Each feeds on the other if both present
- Negative consequences interrelated
24Seddon Savage, M.D.
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26Sleep Disturbance
Secondary Discomforts
Drug Dependence
Addiction
Pain
Functional Disability
Depression
Anxiety
Increased Stresses
Seddon Savage, M.D.
27Addiction-Pain Syndrome
Addiction- Pain Syndrome
Addictive Disorder
Pain Disorder
28Potential Train Wrecks???
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31Cognitive/Behavioral Therapies Are Effective for
the Treatment of Chronic Pain
- Meta-analysis by Morley et al, 1999 Pain 80
1-13. Based on 25 controlled trials. - Cognitive behavioral treatments for chronic pain
reduce pain experience, behavioral expression of
pain, and increase positive coping. - More evidence of effectiveness of these therapies
than there are for analgesic medications for
treatment of chronic pain syndrome.
32Conditioning Learning that Pain Can Elicit
Reward
- A noxious stimulation in the presence of
solicitous spouse - Compared pain intensity and cingulate
activation by EEG in the presence and
absence of the spouse. - The presence of the solicitous spouse (doting
and overprotecting when pt. complains of pain)
increased pain intensity and more than doubled
cingulate activation from the electrical
stimulus. Flor et al., 2003. - Society for Neuroscience Annual meeting
33Conditioning Increases Pain in the Presence of
Cues Predicting Reward
- Social reward can reinforce the experience of
pain ENABLING. - Being regularly rewarded for experiencing pain
will increase the amount of pain one
experiences. - This is especially important for patients who
gain from their pain disability, e.g., receiving
benefits for having pain can make the pain more
intense and frequent. - Physiological learning process
- Involves no conscious deceit or exaggeration on
the part of the patient. - Patients truly experience more pain if they are
being rewarded for it.
34Reward
- Rewarding pain will increase pain.
- Rewarding functioning will increase functioning.
- Clinically, we want to reward non-pain behavior
and pay less attention to pain behavior.
and the winner is
35The Presenting Complaint is Delivered by the
Patient
- What is a Good patient?
- Severity of symptoms correlates with an overtly
diagnosable disorder - Emotionally intact
- Compliant and doesnt challenge
- Grateful
- i.e. a good patient is a good fit with the
acute medical model
Oresckovich
36Clarify Clinician Role in Treating Pain
- We are treating Pain Behaviornot just Pain!
- Acute Pain is totally different from Chronic
Pain! - Chronic Pain is a totally different disease.
- Chronic Pain patients have totally different
needs. - Chronic Pain needs a totally different model
- Curative Model
- vs.
- Rehabilitative/Restorative Model
- Paul Farnum, MD
- Physician Health Program, BC
37The CNCP Package
- Duration
- Diagnostic Dilemma
- Dramatization
- Drugs/Dont work
- Dependence
- Disuse/Deconditioning
- Disturbed Sleep
- Depression/Despair (x2!)
- Dysfunction Major!
38At Risk Patient
- Past history of SUD
- Emotionally traumatized
- Dysfunctional/alcoholic family
- Lacks effective coping skills
- Dependent traits
- Stimulus augmentersdeficit in hedonic tone
- Paul Farnum, MD
- Physician Health Program, BC
39Clinician/Physician at Risk Treating the Patient
with Chronic Pain
- Obsessive-Compulsive controlling style
- Perfectionist
- Exaggerated sense of responsibility
- Equate self-worth with success
- Care-aholic
- Strong relationship with patient
- Paul Farnum, MD
- Physician Health Program, BC
40Clinician/Physician at Risk
- Family of origin issues
- A strong and deep need to help
- Orientation toward immediate symptom relief that
overshadows a consideration of long- term
consequences - A touch of grandiosity and omnipotence Only I
statements - Inability to handle own feelings if requested
treatment is withheld - Paul Farnum, MD
- Physician Health Program, BC
41 42Control
- Perceived control
- Gave patients a joystick and told them they could
lessen the duration of a noxious thermal
stimulus by making a quick response to a cuethe
joystick actually did nothing - Reduced pain intensity
- Reduced activation of the insular and cingulate
cortices by noxious stimuli - Therefore, the more patients take control of
their situation, the less pain they perceive. - Salomons et al., 2004. J Neurosci 24 7199-7203
43Attention
- Looked at pain from a noxious thermal stimulus
during an interference task - The interference task decreased pain intensity
and activation of the insula. - Therefore, the less patients focuses on their
pain, the less the pain is perceived/
experienced. -
- Bantick et al., 2002. Brain 125 310-319
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46A Behavioral Therapy Graded Exposure for
Pain-related Fear
- Patient identifies activities he/she fear will
worsen his/her pain or injury - Therapist exposes patient to these activities
then compares pain expectation to actual pain
experience during tasks
47Daily Log of Exposure Therapy
Daily measures of pain-related fear and pain of
Mr. A during baseline (A-B) and
exposure treatment (B-C).
Vlaeyen et al., 2002. In Psychological Approaches
to Pain management. (Turk Gatchel, eds.)