# Presentation: 030706

## Treatment of Pain in Patients with Substance Abuse

**Sidney H. Schnoll, M.D.,  Ph.D.**

## Physicians prescribe medications about which they know little for diseases about which they know less for patients about whom they know nothing.				Voltaire	

## Addiction

**A primary, chronic, neurobiologic 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 drug use;**
**compulsive use; continued use despite harm;**
**and craving.**

**AAPM, APS, ASAM - 2001**

## Neuroadaptation

**Physical dependence**
**A state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.**
**Tolerance**
**A state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of  the drug’s effects over time.**

**AAPM, APS, ASAM - 2001**

## Scope of the Problem

**Equal opportunity disorder**
**25-40% of all hospital admissions**
**10-16% of outpatients seen in general medical practice**
**Primary care physician is often the first to see the problem**
**All physicians must be able to recognize and initiate treatment**

## Economic Costs of Smoking, Drinking and Drug Abuse

**McGinnis, JAMA, 1993   *Purdue Pharma, L.P., 2002   **CDC, 2003**

**Cost in billions of dollars**

## Annual Cost Per Drug Addict

**2.722**

**3.5**

**12.46**

**16.69**

**39.6**

**43.2**

**Cost in thousands of dollars**

## State Substance Abuse Spending

**Justice, education, health, child/family assistance,**
**mental health/developmentally disabled, public**
**safety, and state workforce (95.8%)**

**Regulation and compliance**
**(0.5%)**

**Prevention,**
**treatment and**
**research (3.7%)**

**CASA, 2001**

## Federal Substance Abuse Spending

**Supply side reduction**

**Demand reduction**
**Treatment, research, prevention**

## Relationship Between Drug Use and Drug Problems

**Drug Use **

**Drug Problems**

**None**

**Light**

**Moderate**

**Moderate**

**Heavy**

**None**

**Small**

**Severe**

**Low Risk**

**At Risk**

**Problem**

**Addicted**

## Recognizing the Drug Abuser

**If you don’t think about it, you won’t recognize it**
**Screen as part of your routine examination**
**Be nonjudgmental in your approach**
**Use simple nonthreatening screening tools**

**CAGE Questions**
**Have you ever tried to ****C****ut down  on your alcohol or drug use**
**Do you get ****A****nnoyed when people comment about your drinking or drug use**
**Do you feel ****G****uilty about things you have done while drinking or using drugs**
**Do you need an ****E****ye-opener **

**Recognizing the Drug Abuser**

**Trauma test**
**Since your 18th birthday have you:**
**had any fracture or dislocations of your bones or joints (excluding sports injuries)**
**been injured in a traffic accident**
**injured your head (excluding sports injuries)**
**been in a fight or been assaulted while intoxicated**
**been injured while intoxicated**
**2 or more positive responses or 2 or more accidents**

**Recognizing the Drug Abuser**

**CRAFFT questions for teens**
**Have you ridden in a ****C****ar with someone who is drinking or high, or have you driven in a car when drinking or high?**
**Do you drink or get high to ****R****elax or feel more sociable?**
**Do you ever drink or get high ****A****lone?**
**Do you ever ****F****orget things that happen when you are drinking or get high?**
**Are your ****F****amily or ****F****riends concerned about your drinking or drug use?**
**Have you gotten into ****T****rouble because of your drinking or drug use?**

**Recognizing the Drug Abuser**

**Complaints of sexual dysfunction with no other cause found**
**Sexually and needle transmitted infections**
**endocarditis**
**hepatitis**
**HIV/AIDS**
**TB**
**Needle marks and/or tracks**
**Atrophy or perforated nasal septum**

**Recognizing the Drug Abuser**

**Laboratory findings**
**elevated MCV**
**abnormal liver enzymes**
**positive urine toxicology screen**
**positive tests for needle and sexually transmitted diseases**

**Recognizing the Drug Abuser**

**Most predictive**
**Selling prescription drugs**
**Prescription forgery**
**Stealing or borrowing drugs from another patient**
**Injecting oral formulations**

**Most predictive**
**Obtaining prescription drugs from nonmedical sources**
**Concurrent abuse of related illicit drugs**
**Multiple unsanctioned dose escalations**
**Repeated episodes of lost and/or stolen prescriptions**

**Recognizing the Drug  Abuser**
***Behaviors***

**Less predictive**
**Aggressive complaining about the need for higher doses**
**Hoarding drug during periods of reduced symptoms**
**Requesting specific drugs**
**Obtaining prescriptions from multiple physicians**

**Less predictive**
**Unsanctioned dose escalation**
**Unapproved use of the drug**
**Reported psychic effects not intended by the physician**
**Use of multiple pharmacies**

**Recognizing the Drug  Abuser**
***Behaviors***

## Readiness for Change

**Precontemplation**
**Contemplation**
**Preparation**
**Action**
**Maintenance**

## OPIOPHOBIA

## Pseudoaddiction

**Seeks more medication for appropriate treatment of pain**
**Watches clock because medication prescribed at inappropriate dosing intervals**
**Does not respond to what physician feels is maximum dose**
**To avoid these problems - trust patient**

## Reasons for Undertreament of Pain

**Lack of knowledge of modern pain treatment**
**Difficulty in addressing psychological aspects of pain**
**Inadequate training in treating chronic diseases**
**Fear of prescribing opioid medication**

## Myths About Opioids and Pain

**Opioids cause addiction in pain patients**
**Opioids cause relapse in recovering patients**
**Give pain medication prn to reduce abuse**
**Give lowest possible dose at longest possible interval to reduce addiction**
**Tolerance leads to continual increase in doses**

## Effects of Regulations

**Physicians don’t understand CSA**
**don’t know what the schedules mean**
**agree that it causes undertreatment of problems (70%)**
**86% treat less aggressively because of**
**hassle**
**government oversight**
**fear of addiction**

**Adams**

## Prescription Drug AbuseWhat do we know?

**Very few prospective studies**
**Most data are inferred**
**Is the problem overprescribing or underprescribing**
**Physicians are taught very little about prescribing controlled substances**

## Existing Studies

**Addiction rare in acute and chronic cancer  pain treatment  ****Kanner and Foley, Chapman and Hill**
**Boston Collaborative Project – 11,882 patients with no prior history of addiction, 4 cases of addiction  ****Porter and Jick**
**Few problems when treating chronic non-malignant pain, no dose escalations       ****Jamison et al, Portenoy**
**10,000 burn unit patients who  received  opioids,  no  problems ****Perry and Hedrick**

**Review of 24 papers**
**Only 7 used adequate diagnostic criteria**
**Incidence of abuse, physical dependence and addiction ranged from 3.2-18.9%**
**Conclusion:  addictive behavior not common in general chronic pain population**

**Existing Studies**

**Fishbain et al,  1992**

**Study of patients on opioids for pain**
**Chart review of 59 patients**
**Mean follow up **
**36 months**
**34% complete relief**
**69% developed tolerance**
**56% abused opioids (used more than prescribed)**
**24% diagnosed as addicts**
**Criteria for diagnosis of addiction not specified**

**Existing Studies**

**Bouckoms et al, 1992**

## Medication Compliance is Not Addiction

**Most surveys use illicit abuse model to determine rates of prescription abuse**
**DSM designed for illicit drug abuse not prescription abuse**
**Criteria can easily be misapplied to prescription drug users.**

**Prescription Drug Abuse**

## Modified-Release vs Short-Acting Analgesics

**Adherence rates better for ATC analgesics than PRN  ****Miaskowski et al, JCO, 2001**
**Improved pain management with MRA vs SAA ****Ferrell et al, Onc. Nurs. Forum, 1989**
**CRA vs SAA provide equal analgesia with lower side effects with CRA ****Caldwell et al, J. Rheumot, 1999**
**CRA improve mood without impairment of cognitive function ****Haythornthwaite et al, JPSM, 1998**

## Slide 32

**Give enough medication plus rescue doses**
**Ask patient to bring in all original medication bottles with or without medication.**
**date filled**
**pharmacy**
**prescribing physician**
**number of pills dispensed**
**number of remaining pills**

**Guidelines to Prescribing Drugs with Abuse Liability**

**Monitor for lost or stolen prescriptions**
**Obtain random urine screens.  Know the drugs for which the laboratory screens.**
**Use adjunctive medications as necessary**
**Document, document, document**

**Guidelines to Prescribing Drugs with Abuse Liability**

**See the patient as frequently as needed**
**Work with significant others**
**Know how to withdraw the patient from the medication**
**Know the pharmacology of the drugs being prescribed**
**duration of action**
**parenteral to oral conversion ratio**

**Guidelines to Prescribing Drugs with Abuse Liability**

**Bring patient in for unscheduled visits**
**Obtain release to contact other health care  providers**
**Limit prn medications since this promotes drug seeking behavior**
**Adequately treat the condition to avoid problems of pseudoaddiction**

**Guidelines to Prescribing Drugs with Abuse Liability**

## ... the  physician should not treat the disease, but the patient who is suffering from it.

**	****	****	****	****Maimonides**