# Presentation: 699532

## Substance Abuse Issues in Chronic Pain Management

***Steven D. Passik, PhD***
***Director, Oncology Symptom ***
***Control and Research***
***Community Cancer Care, Inc. ***
***Indianapolis, IN***
***ALSAC, FDA***
***1/30/02***

## 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

## The 4 A’s: Analgesia

**The 4 A’s: Analgesia**

- Using a scale of 0 to 10, in which 0 means no pain and 10 means the worst pain imaginable, please rank the following:

- What was your pain level on average during the past week?

- What was your pain level at its worst during the past week?

- Compare your average pain during the past week with the average pain you had before you were treated with your current pain relievers.  What percentage of your pain has been relieved?

*Selected Questions*

- 5.3				±2.0 SD

- 8.5				±6.6 SD

- 57.8%				±26.1% SD

## The 4 A’s: Analgesia

- Is the amount of pain relief you are now obtaining from your current pain relievers enough to make a real difference in your life?

- (To doctor) Is the pain relief clinically significant?

*Selected Questions*

## The 4 A’s: Activities of Daily Living

- PhysicalFunctioning

- Mood

- FamilyRelationships

- SocialRelationships

- SleepPatterns

- OverallFunctioning

- 20

- 40

- 60

- 80

- 100

- 0

- 80.8

- 15.6

- 3.6

- 25.2

- 4.7

- 70.1

- 42.1

- 3.2

- 54.7

- 47.7

- 4.0

- 48.8

- 33.6

- 6.5

- 59.9

- 19.3

- 2.5

- 78.2

- Patients Reporting(%)

- Better
- Same
- Worse

## The 4 A’s: Adverse Side Effects

- Are you able to tolerate your current pain relievers?

- Are you experiencing any side effects from your current pain relievers?

*Selected Questions*

## The 4 A’s: Adverse Side Effects

**The 4 A’s: Adverse Side Effects**

- (To doctor) Are the side effects tolerable for the patient?

## 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

## Creating a Checklist for Monitoring Outcome During Long-term Opioid Therapy

- Steven D. Passik, PhDCommunity Cancer Care, Inc.Indianapolis, Indiana

## 4th “A” - Aberrant Drug-related BehaviorAdverse consequences possibly resulting from drug use

- Purposeful over sedation	241 (89.6)
- Negative mood Change	252 (92.6)
- Decline in psychological function	255 (94.1)
- Decline in social function	259 (94.9)
- Appearing intoxicated	260 (95.6)
- Decline in physical function	262 (96.0)
- Increasingly unkempt or impaired	266 (97.8)
- Worrisome drug effects (“Getting High”)	267 (98.2)
- Involvement in MVA	267 (98.5)
- Engages in sale of sex to obtain drugs	229 (100*)

- Frequency of behavior=0
-                                                                            n 	(%)

- * No answer: 53

## 4th “A” - Aberrant Drug-related BehaviorPossible loss of control or diversion of medications

- Requests frequent early renewals	220 (81.8)
- Increases dose without authorization	235 (86.7)
- Reports lost or stolen prescriptions	246 (90.8)
- Requests higher doses in worrisome manner	248 (91.2)
- Attempts to obtain prescriptions from other doctors	255 (94.4)
- Uses medication for purpose other than described (to help sleep)	255 (95.2)
- Engages in staff splitting	223 (97.8)
- Changes route of administration	269 (98.5)

- Frequency of behavior=0
-                                                                            n 	(%)

## 4th “A” - Aberrant Drug-related Behavior Preoccupation with opioids or other drugs

- Asks for medication by name	238 (89.8)
- Does not comply with other recommended treatments	253 (93.0)
- Reports no effects of other medications	255 (94.4)
- Misses appointments except for medication renewal	256 (94.5)
- Contact with street culture	258 (97.0)
- Abusing alcohol and street drugs	265 (98.1)
- Hording of medication	267 (98.9)

- Frequency of behavior=0
-                                                                            n 	(%)

## 4th “A” - Aberrant Drug-related BehaviorOther occurrences of potential concern

- Patient arrested or detained by police	266 (97.8)
- Patient a victim of abuse	269 (98.5)
- Associate(s) arrested or detained by police	269 (98.5)

- Frequency of behavior=0
-                                                                            n	 (%)

## 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)

## Defining the Problems

- Difficulties in assessing the risk of aberrant behavior and addiction
- Misunderstandings about what addiction is and the shortcomings of present definitions when applied to the clinical pain management situation
- The absence of well-articulated management strategies for patients with different substance abuse-related problems and aberrant behavior

## What is the Risk of Addiction and Aberrant Behavior?

- Boston Collaborative Drug Surveillance Project: Porter and Jick, 1980. *NEJM.*
- 4 cases of addiction in 11,882 patients with no prior history of abuse who received opioids during inpatient hospitalization
- Dunbar and Katz, 1996.  *JPSM*.
- 20 patients with ***both*** chronic pain and substance abuse problems on chronic opioid therapy
- Nine out of 20 abused medication
- Of the 11 who did not abuse the medications, all were active in recovery programs with good family support

## Spectrum of Risk of Addiction or Aberrant Behavior

- <1%

- ~ 45%

***LOW***
- Short-term
- exposure to
- opioids in
- non-addicts
- Porter and Jick

***HIGH***
- Long-term
- exposure to
- opioids in
- addicts,
- Dunbar and Katz

***Where is your patient?***

## Addiction or aberrant behavior results from a combination of
Chemical
Psychiatric
Social/Familial
Genetic
Spiritual

- Chemical
- Psychiatric
- Social/Familial
- Genetic
- Spiritual

- Influences

## “Pseudo-Addiction”

- Pattern of drug seeking behavior of pain patients receiving inadequate pain management that can be mistaken for addiction
- Cravings and aberrant behavior
- Concerns about availability
- “Clock-watching”
- Unsanctioned dose escalation
- Resolves with reestablishing analgesia

- Weissman DE, Haddox JD. Oploid pseudo addiction- an iatrogenic syndrome. *Pain* 1989;36:363.

## Consider the Risk of Not Treating Pain in Addicts

- Passik, et al. 2001.
- Study comparing addicts with AIDS to cancer patients and their response to under-treatment
- Aberrant behavior is set in motion by under-treatment

## The Non-Addicted Pain Patient Who Is a “Chemical Coper”

- Bears resemblance to addiction with regard to the “centrality” of the drug and drug procurement to the patient
- CCs need structure, psych input, and drug treatments that ***decentralize*** the pain medicine to their coping
- Decentralize pain medication: reduce its meaning, undo conditioning, undo socialization – accomplished through pain-related psychotherapy and prudent drug selection

## Tailoring The Approach 

- The uncomplicated patient – minimal structure
- The patient with comorbid psychiatric and coping difficulties – moderate structure and heavy psych/rehab input
- Addicted patients – highly structured
- The actively abusing
- The patient in drug free recovery
- The patient on methadone maintenance

## Summary

- There is a difference between addiction and the complex issues of noncompliance and aberrant behavior during pain management that has been poorly articulated
- The pain population is diverse – the application of opioid therapy to this diverse population requires careful assessment and tailored approaches that recognizes this diversity

## Redefining Addiction for the Chronic Pain Setting

## What Addiction Isn’t:  Physical Dependence

- Pharmacologic effect characteristic of opioids
- Withdrawal or abstinence syndrome manifest on abrupt discontinuation of medication or administration of antagonist
- Assumed to be present with regular opioid use for days-to-weeks
- Becomes a problem if:
- Opioids not tapered when pain resolves
- Opioids are inappropriately withheld

## What Addiction Isn’t: Tolerance

- Pharmacologic effect characteristic of opioids
- Need to increase dose to achieve the same effect or diminished effect from same dose
- Tolerance to various opioid effects occurs at differential rates
- Tolerance to non-analgesic effects often beneficial to patients (sedation, respiratory depression)
- Analgesic tolerance is rarely the dominant factor in the need for opioid dose escalation
- Patients requiring dose escalation most often have a change in pain stimulus (disease progression, infection, etc.)

- (Foley, 1991)

## DSM-IV Substance Use Disorder and the Typical Pain Patient on Opioids

- Need for markedly increased doses to achieve effect
- Diminished effect with same dose
- Withdrawal syndrome
- Taking substance to relieve or avoid withdrawal symptoms
- Dose escalation or prolonged use
- Persistent desire or unsuccessful efforts to cut down or control substance use
*Excessive time spent obtaining, using or recovering from use of the substance*
*Activities abandoned because of substance use*
*Use despite harm*

- A _maladaptive_ pattern of substance use leading to significant _impairment or distress_ as manifested by 3 or more of the following 9 symptoms:

## Behaviors That Raise the Suspicion of Addiction

- 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

- After Portenoy, in press.

## Summary

- Substance abuse issues are complex during pain management and they defy simple solutions
- These issues require tactical and humane approaches that combine thoughtful diagnosis, structure and a team approach