# Presentation: 294948

##  Aberrant Drug-taking Behaviors in Medically Ill Pain Patients

- Steven D. Passik, PhD
- Director, Symptom Management and Palliative Care Program - Markey Cancer Center
- Associate Professor of Medicine and Behavioral Sciences
- University of Kentucky
- Lexington, KY
- APA, NYC, 05/03/04

## Indiana/UK Studies on Aberrant Drug-taking in Pain Management 

- Attitudes and behaviors in cancer patients and women with AIDS, Passik, et al., JPSM,1998
- UTS in pain management, Passik et al, JPSM, 1998
- Survey of clinicians’ perceptions of ADTB, Passik et al, JPSMPC, 2002
- Development of a tool to assess pain outcomes in chronic opioid therapy, Passik et al submitted
- Aberrant drug taking in cancer and AIDS patients, Passik et al, in prep
- Retrospective Characterization of abusers of OxyContin seeking drug treatment in Kentucky, Hays, et al., JNCCN, 2003; Preliminary prospective data

## Aberrant Drug-taking Behaviors: The Model

- Probably more predictive
- Selling prescription drugs
- Prescription forgery
- Stealing or borrowing another patient’s drugs
- Injecting oral formulation
- Obtaining prescription drugs from non-medical sources
- Concurrent abuse of related illicit drugs
- Multiple unsanctioned dose escalations
- Recurrent prescription losses

- Probably less predictive
- Aggressive complaining about need for higher doses
- Drug hoarding during periods of reduced symptoms
- Requesting specific drugs
- Acquisition of similar drugs from other medical sources
- Unsanctioned dose escalation 1 – 2 times
- Unapproved use of the drug to treat another symptom
- Reporting psychic effects not intended by the clinician

- Passik and Portenoy, 1998

## Differential Diagnosis of Aberrant Drug-Taking Attitudes and Behavior

- Addiction
- Pseudo-addiction (inadequate analgesia)
- Other psychiatric diagnosis
- Encephalopathy
- Borderline personality disorder
- Depression
- Anxiety
- Criminal Intent

- (Passik & Portenoy 1996)

## Physician-Ranking of Ab. Behs.(Passik, Kirsh, et al, J Pain Pall Care Pharm, 2002)

| Rank | Aberrant Behavior: | Mean (SD) |
| --- | --- | --- |
| 1 | Selling prescription drugs | 4.0 (3.5) |
| 2 | Forging Prescriptions | 4.4 (3.6) |
| 3 | Altering route or drug delivery system (i.e., crushing sustained release tablets for snorting or injecting) | 4.7 (3.6) |
| 4 | Concurrent abuse of related illicit drugs | 5.1 (2.9) |
| 5 | Stealing or borrowing medications from others | 5.2 (2.9) |
| 6 | Obtaining drug from non-medical source | 5.8 (3.0) |
| 7 | Frequent Prescription losses | 6.2 (2.7) |
| 8 | Multiple unsanctioned dosing | 7.4 (2.9) |
| 9 | Aggressive demand for more drug | 7.6 (3.4) |
| 10 | Unapproved use of drug to treat non-pain symptoms | 7.7 (3.1) |
| 11 | Drug hoarding | 8.6 (3.3) |
| 12 | Unsanctioned dose escalation once or twice | 9.8 (3.6) |
| 13 | Unkempt appearance | 11.0 (3.2) |

## Aberrant drug-taking in cancer and AIDS 

- 73 patients with AIDS -  100%  with reported past or current history of substance abuse  (42% of total sample)
- 100 patients with cancer -18% reported past or current history of substance abuse (58% of total sample)
- 101 men (58% ),  72 women (42%)
- 118 Caucasian (68%),  50 African-American  (29%)  5 “Other” (3%); Mean age = 51.6 (SD = 15.2)

## Measures

- SCID – substance abuse module
- Brief Pain Inventory
- Pain Management Index
- Brief Symptom Inventory
- Memorial Symptom Inventory
- Marlowe Crowne Social Desirability
- Aberrant Behavior Interview

## Results

- Compared to cancer patients , patients with AIDS were significantly more likely to :	-Be single
- 		-Be male
- 		-Be of a minority ethnic group
- 		-Be younger
- 		-Report past or present psychiatric problems
- 		-Report being inadequately medicated for pain

## Aberrant Behaviors Reported

- 					Total Sample	Cancer patients	AIDS patients
- 					(n = 173)		(n= 100)		(n = 73)
- Total # aberrant behaviors	590		 142		   448
- 					(100%)	 	(24%)		(76%)
- Average # of aberrant behavior	3.41		1.42		6.14
- Total #  of “aberrant behaviors 	 423		122		301
- “probably less predictive of 	(72%)		(86%)		(67%)
- addiction”
- Total # aberrant behaviors 	167		20		147
- “probably more predictive 	(23%)		(14%)		(33%)
- of addiction”

## Numbers of Aberrant Behaviors

## Most Frequently Reported Aberrant Behaviors

- _Aberrant Behavior_		       _Cancer patients_			_AIDS patients_
- 				            (n= 100)	      	    	(n = 73)
- 				         Freq.         %			Freq.    	%
- Expressed anxiety or	        27	        27			37           51
- desperation over
- recurrent symptoms
- Hoarded medications	       22	        22			28          39
- Taken someone else’s	        11	        11			36          50
- pain medicine
- Aggressively complained 	        13	        13			29          40
- to doctor for more drugs
- Requested a specific drug	        18	        18			24          33.3

## Least Frequently Reported Aberrant Behaviors

- _Aberrant Behavior_		_Cancer patients_		_AIDS patients_
- 				        	     (n= 100)	                   (n = 73)
- 			        		Freq.        %		Freq.         %
- Prescription forgery		   0	  0		1	<1
- Prostituted others for drugs		   0	   0		4	6
- Sold prescription drugs      	   	   0	   0		6	8
- Stolen drugs from others 		   0	   0		7	10
- Performed sex for		        	   0	   0		7	10
- money to obtain drugs

## Reported Pain Relief

-  						Cancer		             AIDS
- 						_patients_		_patients_
- 						(n =100)		(n =73)
- Percent of pain relief 			76%			37%
- Adequate pain relief	(PMI)		92	     		49				      		(92%)		           (67%)
- Inadequate pain relief	(PMI)		8			 24
- 						(8%)			 (33%)

## AIDS Patients and Aberrant Behaviors

- 						Adequate		Inadequate
- 						_Analgesia_		_Analgesia_
- 						 (n = 49)			(n = 24)
- _Total # aberrant behaviors_			305			152						(6.2)			(6.3)
- Aberrant behaviors “probably		239			116
- less predictive of addiction	“		(78%)			(74%)
- Aberrant behaviors “probably		66			40
- more predictive of addiction”		(22%)			(26%)

## Slide 15

## The Four “A’s” of Pain Treatment Outcomes

- Analgesia – modest but meaningful
- Activities of Daily Living (psychosocial functioning) – 80% rated as improved overall
- Adverse effects (side effects) – common but tolerable
- Aberrant drug taking (addiction-related outcomes)

- Passik & Weinreb, 1998

## Aberrant Behaviors (Passik, Kirsh et al, in prep, 2004)

- (n = 215)

- (n = 98)

- (n = 33)

- (n = 26)

- (n = 16)

- Number of Behaviors Reported

## Characterization of OxyContin abusers seeking drug abuse treatment in KY

- Chart review survey of admissions to drug treatment center in Lexington at height of media coverage of the epidemic
- 195 admissions for OxyContin abuse
- SCID diagnoses and other medical/demographic data recorded

## Characterization of OxyContin abusers seeking drug abuse treatment in KY

- OxyContin abusers were:
- Using on average, 180mgs per day
- History of other DSM IV, nonsubstance abuse Dx
- History of poly-substance abuse
- History of other prescription drug abuse
- OxyContin abusers compared to other opioid abusers:
- Younger
- Male
- Rural

## Characterization of OxyContin abusers seeking drug abuse treatment in KY

- The 60 patients who ostensibly began using in pain treatment
- Treated mainly by primary care and other non pain experts
- Similar med/demos to other OxyContin abusers
- Equally likely to alter route of administration, with 13% reporting crushing and injecting

## Characterization of OxyContin abusers seeking drug abuse treatment in KY

- The 60 patients who ostensibly began using in pain treatment
- Treated mainly by primary care and other non pain experts
- Similar med/demos to other OxyContin abusers
- Equally likely to alter route of administration, with 13% reporting crushing and injecting

## Rx Drug Abusers Entering Treatment(Passik, Kirsh, et al, in process)

| Drug | # of instances (of n = 89) | Got from Street Dealer?* | Amount of $ per mg/mcg |
| --- | --- | --- | --- |
| OxyContin | 57 (64%) | 46 (81%) | $0.50-1.25/mg |
| Lortab | 31 (35%) | 18 (58%) | $0.40-1.20/mg |
| Percocet | 13 (15%) | 6 (46%) | $0.20-1.60/mg |
| Morphine | 4 (4%) | 1 (25%) | $0.25-0.40/mg |
| Methadone | 3 (3%) | 1 (33%) | $1.00/mg |
| Dilaudid | 2 (2%) | 2 (100%) | $7.50-12.50/mg |
| Duragesic | 2 (2%) | 0 (0%) | $1.00/mcg |

- * At least once

## Rx Drug Abusers Entering Treatment(Passik, Kirsh, et al, in process)

| Drug | Altered delivery | Snort* | Crush* | I.V.* |
| --- | --- | --- | --- | --- |
| OxyContin | 55/57 | 53 | 27 | 14 |
| Lortab | 17/31 | 15 | 9 | 4 |
| Percocet | 11/13 | 10 | 4 | 3 |
| Morphine | 4/4 | 2 | 1 | 3 |
| Methadone | 1/3 | 1 | 0 | 0 |
| Dilaudid | 2/2 | 1 | 1 | 2 |
| Duragesic | 0/2 | 0 | 0 | 0 |

- * Not mutually exclusive

## Conclusions 

- Patients of all types engage in some ambiguous drug-taking behavior
- Substance abuse history is associated with increased number of aberrant behaviors and types of aberrant behaviors
-  Provision of adequate analgesia may not be enough to limit aberrant behaviors in complex patients who have a history of drug abuse
- Assessment should be multimodal – 4A’s