# Presentation: 294953

## Aberrant Drug-taking Behaviors:What Do We Know?

***Steven D. Passik, PhD***
***Associate Attending Psychologist***
***Memorial Sloan Kettering Cancer Center***
***New York, NY***

## Where Will The Pendulum Stop?

_*Avoidance*_
- “Will not prescribe opioids for any reason”
- Driven by fear of regulatory action or being “burned”

_*Balance*_
- Rational pharmacology
- Driven by continued prescribing with close monitoring

_*Widespread Use*_
- “Less than 1% will ever become addicted”
- Prescribing without recognition of dangers

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

- Analgesia (pain relief)
- Activities of Daily Living (psychosocial functioning)
- Adverse effects (side effects)
- Aberrant drug taking (addiction-related outcomes)

- Passik & Weinreb, 1998

## Slide 4

## 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

## Slide 6

## Physician-Ranking of Aberrant Behaviors

- Passik S, Kirsh K, et al. *J Pain Palliat Care Pharmacother*.  2002;16(4):39-49.

## Aberrant Behaviors (n = 388)(Passik, Kirsh et al, 2005)

- (n = 215)

- (n = 98)

- (n = 33)

- (n = 26)

- (n = 16)

- Number of Behaviors Reported

## Aberrant Behaviors in Cancer and AIDS(Passik, Kirsh et al, 2005)

## 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%)

## Aberrant Behavior vs. Abuse

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

- Addiction (out of control, compulsive drug use)
*Compton et al number of behaviors and perception as self as addict*
- Pseudo-addiction (inadequate analgesia)
*Elander certain behaviors linked to pseudo-addiction in sickle cell patients*
- Other psychiatric diagnosis
- Organic Mental Syndrome (confused, stereotyped drug-taking)
- Personality Disorder (impulsive, entitled, chemical-coping behavior)
- Chemical Coping (drug overly central)
- Depression/Anxiety/Situational stressors (self-medication)
*Inflexxion data links aberrant behavior to psychiatirc comorbidity*
- Criminal Intent (diversion)
*Jung and Reidenberg: MDs cannot detect actors*

- (Passik & Portenoy 1996)

## Predictors of Opioid Misuse in Patients with Chronic Pain: A Prospective Cohort Study.Ives, et al., BMC Health Serv Res. 2006 Apr 4;6(1):46 

- Prospective, cohort study to examine one year prevalence of “opioid misuse” in chronic non-cancer pain pts (n=196)
- Opioid Misuse defined as:
- Negative urine toxicological screen for prescribed opioids;
- UTS positive for opioids or controlled substances not prescribed by our practice;
- Evidence of procurement of opioids from multiple providers;
- Diversion of opioids;
- Prescription forgery; or
- Stimulants (cocaine or amphetamines) on UTS

## Predictors of Opioid Misuse in Patients with Chronic Pain: A Prospective Cohort Study.Ives, et al., BMC Health Serv Res. 2006 Apr 4;6(1):46

- Mean patient age was 52 years, 55% were male, and 75% were white.
- Sixty-two of 196 (32%) patients committed opioid misuse.
- Detection of cocaine or amphetamines on UTS most common (40.3% of misusers).
- Misusers more likely than non-misusers
- Younger
- Male
- Past alcohol abuse
- Past cocaine abuse
- Previous drug or DUI conviction
- Race, income, education, depression score, disability score, pain score, and literacy not associated with misuse
- No relationship between pain scores and misuse

##  Surprise Urine Drug Test (Katz and Fanciullo, CJP, 2002)

| Issues--
UDT Results | Yes (%) | No (%) | Total (%) |
| --- | --- | --- | --- |
| + | 10 (8) | 26 (21) | 36 (29) |
| - | 17 (14) | 69 (57) | 86 (76) |
| Total | 27 (22) | 95 (78) | 121 |

- A total of 53 (43%) had a “problem” so identified

## 
Measures for Screening for Addiction Risk
STAR/SISAP
CAGE AIDD
- 	Opioid Risk Tool (Emerging Solutions in Pain)
SOAPP (see painedu.org) 
Psychiatric Interview Assessment of Risk
Chemical
Psychiatric
Social/Familial
Genetic
Spiritual

- Measures for Screening for Addiction Risk
- STAR/SISAP
- CAGE AIDD
- - 	Opioid Risk Tool (Emerging Solutions in Pain)
- SOAPP (see painedu.org)
- Psychiatric Interview Assessment of Risk
- Chemical
- Psychiatric
- Social/Familial
- Genetic
- Spiritual

**Assessment of Addiction Risk**

## Opioid Risk Tool (ORT)

**Webster & Webster. *****Pain Med.***** 2005;6:432.**

_**Scoring**_
-  **0-3: low risk (6%)**
** ****4-7: moderate risk (28%)**
** **_**>**_** 8: high risk (> 90%)**

_**Administration**_
-  **On initial visit**
** ****Prior to opioid therapy**

**Notes:**
1. Webster & Webster. Pain Med 2005;6:432-442.[p433]

## Screening Instrument for Substance Abuse Potential (SISAP)

**Coambs et al. *****Pain Res Manage.***** 1996;1:155.**

**Notes:**
1. Coambs et al. Pain Res Manage 1996;1:155-162.[ref did not arrive, theme of whole paper] 

## Screener and Opioid Assessment for Patients in Pain (SOAPP)

- 14-item, self-administered form, capturing the primary determinants of aberrant drug-related behavior
- Validated over a 6-month period in 175 chronic pain patients
- Adequate sensitivity and selectivity
- May not be representative of all patient groups
- A score of ≥ 7 identifies 91% of patients who are high risk

**Butler et al. *****Pain.***** 2004;112:65.**

**Notes:**
Butler et al. Pain 112;65-75.[p71, 72, 73]

## Smoking: Predictor of  Aberrant Drug Use?

- The SISAP and SOAPP include tobacco use as a factor in determining risk1,2
- Tobacco use is highly prevalent among substance misusers3
- Smoking increased desire to abuse drugs in an addict population (N = 160)3
- Smoking may be used as a form of substance replacement in those trying to abstain3,4

**1****Coambs et al. *****Pain Res Manage.***** 1996;1:155.**
**2****Butler et al. *****Pain.***** 2004;112:65.**
**3****Rohsenow et al. *****Addict Behav.***** 2005;30:629.**
**4****Conner et al. *****Exp Clin Psychopharmacol.***** 1999;7:64.**

**Notes:**
Coambs et al. Pain Res Manage 1996;1:155-162.[p]
Butler et al. Pain 112;65-75.[p70]
Rohsenow et al. Addict Behav 2005;30:629-641.[p630, 633, 635, 638]
Conner et al. Exp Clin Psychopharmacol 1999;7(1):64-71.[p67 - discussion]

## Smoking and Persistent Pain

- Chronic pain patients smoke at significantly higher rates than the general population
- Smoking is associated with nonspecific low back pain, fibromyalgia, and headache disorders.1-4
- Strong dose response relationship exists between cigarette consumption and persistent low back pain.5

**1****Jamison et al. *****Addictive Behaviors*****. 1991. 16: 103-10. **
**2****Hahn et al. 2006. Submitted.**
**3****Payne et al. *****Headache.***** 1991. 31: 329-32.  **
**4****Yunus et al. *****Scand J Rheumatol*****. 2002. 31: 301-5.**
**5****Porter  et al. *****J Am Acad Orthop Surg*****. 2001. 9: 9-17.**

## Smoking and Aberrant Drug-taking Behaviors

- Pseudo-addiction (inadequate analgesia)
- Smokers may require higher doses of opioids because of nicotine-opioid interactions
- Substance use disorders
- Smoking may be a more socially acceptable form of substance use or a proxy for other forms of substance use
- Chemical coping/self-medication of pain
- Smoking may be a means of self-medication for stressors related to persistent pain

**Dhingra and Passik,  Practical Pain Management (CME Supplement) 6(2) p A-D, 2006.**** **

## NIDA Study: Adherence Therapy for Opioid Abusing Pain Patients

- 40 Patients
- 2 sites in Virginia and New York
- Pain: evidence of efficacy of opioid therapy for diagnosis, > 6 months duration, and constant, moderate-severe intensity (VAS >7 despite daily opioids)
- Substance Abuse Co-morbidity: opioid abuse or dependence, > 2 on “problems with pain meds”, no current substance dependence, and lifetime dependence or current abuse permissible
- Psychiatric Co-Morbidity: no unstable major psychiatric disorders, current suicidal/homicidal ideation or medication dose considerations
- Medical Co-Morbidity: no unstable or very severe medical conditions or planned surgery within study period and not taking medications that interact with methadone

- Haller D. Adherence Therapy for Opioid Abusing Pain Patients “PROJECT PAIN”. NIDA (Grant #R01DA1369) Presented at 2006 CPDD Conference.

## NIDA Study: Adherence Therapy for Opioid Abusing Pain Patients

- Haller D. Adherence Therapy for Opioid Abusing Pain Patients “PROJECT PAIN”. NIDA (Grant #R01DA1369) Presented at 2006 CPDD Conference.

## Patient: Frequently Endorsed Aberrant Medication Taking Behaviors

- 64% increased dose without permission
- 64% continued to take opioid although relief was minimal
- 52% were concerned about use of pain medication
- 52% felt they were treated like addict
- 44% borrowed pain medication from others
- 40% frequently requested additional or stronger dose of medication
- 36% used pain medications to treat problems other than pain
- 36% argued with physician about medications
- 32% were overly concerned about access to pain medication
- 32% used pain medications not authorized by physician

- Haller D. Adherence Therapy for Opioid Abusing Pain Patients “PROJECT PAIN”. NIDA (Grant #R01DA1369) Presented at 2006 CPDD Conference.

## Physician: Frequently Endorsed Aberrant Medication Taking Behaviors

- 48% increased dose without permission
- 44% were overly concerned about access to opioids
- 40% argued with physician about pain medications
- 40% manipulated doctors to get more pain medications
- 40% went to ER to obtain pain medications
- 36% frequently requested additional or stronger dose of medication
- 36% use of pain medications is out of control
- 32% used recreational drugs
- 32% used more pain medications than warranted
- 32% felt they were treated like addict

- Haller D. Adherence Therapy for Opioid Abusing Pain Patients “PROJECT PAIN”. NIDA (Grant #R01DA1369) Presented at 2006 CPDD Conference.

## Decreases in Opioid Use**

**For methadone, opioids, and oxycodone **_**p**_**’s < .01**

## Trends in Non-Opioid Drug Use

## Summary

- Empirical data has been accruing on aberrant behaviors
- These studies are beginning to tell us:
- ADTBs are common
- Frequency of ADTBs relates to addiction risk in the sample
- ADTBs can be predicted; smoking a predictor?
- Not impacted by adequacy of pain control in the dual diagnosis group of patients(?)
- They can be managed with highly structured approaches