9/23/2015. Chronic Pain and Addiction: Too Close for Comfort? Disclosures. Objectives. 45 y.o. Female Nurse. Question #1.

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1 Disclosures Chronic Pain and Addiction: Too Close for Comfort? Marc J. Myer, MD ABAM Director, Health Care Professionals Program I have no financial disclosures to report. Objectives 45 y.o. Female Nurse Describe the problem Provide a brief description of the neurobiology of addiction Describe the significance of this problem Describe means of identifying addiction Examine prevention in your practice L4-L5 "slipped disc" or herniation when moving a patient on a medical/surgical floor History of alcoholism, in remission for 10 years prior to injury (no longer active in AA) Hydrocodone provided for chronic neck pain after multiple nonopioid treatment failures Within 3 months is drug seeking and doctor shopping Diversion from the workplace, termination, nursing license suspension Question #1 The Predicament Opioid prescribing in my practice is best described as: a. No problem b. An intermittent problem c. An ongoing, regular hassle d. One of the worst aspects of my practice Addiction treatment requires abstinence Pain treatment often relies on opioids Addiction treatment programs may exclude those with chronic pain Pain programs may exclude those with addiction Accurate addiction assessment is difficult in those with opioid use for pain Pain assessment is undermined by drug seeking behaviors 1

2 The Predicament Physicians Quandary Related to Pain and Addiction Pain relief is an expectation The Joint Commission, the World Health Organization, pharmaceutical companies and pain specialists promote aggressive pharmacologic pain management with opioids Addiction and pain have co-existing psychiatric disorders We have little training in addiction and we have little training in pain. Yet pain is the most common reason for a primary care visit, and addiction is one of the most common illnesses seen in primary care. Addiction is a Disease of the Limbic System Brain Neurophysiology Addiction usurps neural mechanisms of learning and memory that under normal circumstances serve to shape survival behaviors. Vulnerability/Risk for Addiction Vulnerability/Risk for Addiction Estimated genetic risk 40-60% Age at first use Co-occurring psychiatric illness History of sexual or physical trauma History of previous substance use disorder Nicotine use 293 patients receiving a new Rx for an opioid painkiller (e.g., oxycodone, hydrocodone, morphine) in % progressed to long-term use (prescriptions lasting 3-4 months); 6% ended up with more than a 4-month supply Nicotine use and substance use highest predictors Hooten, et al. Mayo Clinic Proceedings 2015 Repeated prescriptions for opioids in Norway higher for those with history of smoking Odds Ratio (OR) 3.1 (95% CI, ) for daily smokers; 1.8 (95% CI, ) or previous heavy smokers Skurtveit, et al. Ann Epidemiol

3 Numbers in Thousands 9/23/2015 Relapse Among Physicians Annual Numbers of New Nonmedical Users of Psychotherapeutics: Factors that increase risk Positive family history Co-occurring psychiatric illness Parenteral opioid use Domino, et al. JAMA National Household Survey on Drug Abuse A Frightening Trend: Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older, Emergency Department Visits DAWN Data Results for SAMHSA the 2013 National NSDUH Survey 2010 on Drug Use and Health: Summary of National Findings Rates* of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold: United States, Prescription Opioids Drive Increase in Drug Overdose Deaths * Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and crude rates per 10,000 population for kilograms of OPR sold. Total Drug Overdose Deaths Prescription Opioid Overdose Deaths ,849 38,329 4,030 15,597 16,651 In 2010, 60% of drug overdose deaths (22,134) involved prescribed medications CDC Website: 02/20/2013 3

4 Percent of Person Years Odds Ratio 9/23/2015 Overdose Risk and Opioid Dose Accidental Overdose Deaths Heroin ~ 3,000 Cocaine ~ 5,100 Prescription Opioids ~ 15, Opioid Dosage (mg/d) Percent Use CDC Website Dunn KM, et al. Ann Intern Med The Problem The Problem billion prescriptions filled in U.S.; sales = $307 billion 20-40% of adults report chronic pain, opioids are the primary treatment Prescription opioid dependence: The fastest growing addiction in the U.S : 4 fold increase in treatment admissions (18-24: 8 fold) Overdose deaths: 1999 (3,000) 2008 (15,000) The number 1 accidental cause of death (CDC: epidemic) America Loves Opioids America Loves Opioids Americans are 4.6% of the world s population, but we consume: 80% of the global opioid supply 99% of the global hydrocodone supply 2/3 of the world s illegal drugs Hydrocodone continues to be the number one prescribed drug in the United States (levothyroxine is #2) Enough opioid pain relievers were prescribed last year to medicate every American adult with a standard pain treatment dose of hydrocodone 5 mg taken every 4 hours for a month Machikanti 2007 A bottle of Bayer s heroin. Between 1890 and 1910 heroin was sold as a non-addictive substitute for morphine. It was also used to treat children with a strong cough. Is this why my grandmother had fond recollections of childhood? 4

5 America Loves Opioids Question #2 I think % of my chronic pain patients have addiction. a. Under 10% b % c % d % Who Prescribes Opioids The One Doctor Source for Prescription Drugs According to CDC data: 40% of opioid prescriptions come from primary care physicians 39% come from emergency department physicians According to NSDUH 2008 data, only 1 in 20 nonmedical users (4.3%) of prescription pain relievers got them from a drug dealer. In most cases, prescription drugs obtained for nonmedical purposes originated from a single doctor rather than from multiple sources. CDC Data Use and Source Diversion in KY: $$ per 100 Pills (2006) Sources of prescription opioids in 586 street drug users in New York City For euphoria: Dealer 62.5%; Doctor or Pharmacy 38% For pain relief: Dealer 33%; Doctor or Pharmacy 83% For withdrawal: Dealer 70%, Doctor or Pharmacy 50% Davis & Johnson, 2008 David Kan, MD 5

6 Question # 3 Chronic Pain Impact Statistics on substance Use and chronic pain in the United states (SAMHSA TIP 54, Exhibit 1-1) Category Chronic pain patients who may have addictive disorders Statistic 32% (Chelminski et al., 2005) I have identified patients with opioid addiction in the past year. a. One to Ten b. Ten to Twenty c. Twenty to Thirty d. Over Thirty People ages 20 and older who report pain that lasted more than 3 months People experiencing disabling pain in the previous year People ages 65 and older who experience pain that has lasted more than 12 months Civilian, noninstitutionalized U.S. residents ages 12 and older who report nonmedical use* of pain relievers in past year People ages 12 and older who report that they initiated illegal drug use with pain relievers People with opioid addiction who report chronic pain 56% (National Center for Health Statistics, 2006) 36% (Portenoy, Ugarte, Fuller, & Haas, 2004) 57% (National Center for Health Statistics, 2006) 5% (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007) 19% (SAMHSA, 2008) 29 60% (Peles, Schreiber, Gordon, & Adelson, 2005; Potter, Shiffman, & Weiss, 2008; Rosenblum et al., 2003; Sheu et al., 2008) Acute Pain vs. Chronic Pain Acute Pain Sudden onset, usually sharp in quality Serves as a warning of disease or a threat to the body Multiple causes: Broken bones, cuts, burns, surgery, infection Chronic Pain Persists, lasting longer than 3 months Serves no useful purpose; may continue after healing of an injury Assumes control of the individual Chronic Pain by the Numbers Do Opioids Work for Chronic Pain? The Jury is Out. 116 million people in the U.S. suffer from chronic pain Low back pain is the most common type, affecting 28% of the population Knee pain is second at 20% of the population Markell 2007: Systematic review failed to conclude that opioids provide effective relief of chronic pain Ballantyne 2007: Directly compared efficacy of different opioids, and determined a non-significant reduction in pain compared to baseline Chou 2003: Concluded there was insufficient and poor evidence to prove the safety or effectiveness of any opioids Kaslo 2004: Found a mean decrease in pain of at least 30%, and at least 44% of people continued treatment Furlan 2006: Strong opioids were better, but drop-out rate of 33% on average Eriksen 2006: Denmark study demonstrated worse pain, higher healthcare utilization, and lower activity levels with opioids IOM Relieving Pain in America 6

7 Pain Physiology: A Complication Medication Adherence in a Chronic Pain Population A retrospective analysis of 938,586 urine drug tests by Ameritox, Ltd. 1/06-1/09 (Pop. Health Mgmt Vol. 12, #4, 2009) 75% unlikely to be using medications consistent with prescription 38% no detectable level of prescribed medication 29% non-prescribed meds present 27% drug level higher than expected 15% drug level lower than expected 11% illicit drugs detected Basbaum 2009 USCF Aberrant Drug-Related Behaviors Physicians Role in Addiction More Predictive Selling Prescription Drugs Prescription forgery Stealing or borrowing drugs from another patient Injecting oral formulations Obtaining prescription drugs from nonmedical sources Concurrent abuse of related illicit drugs Multiple, unsanctioned dose escalations Repeated episodes of lost prescriptions 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 Unapproved use of a drug Reporting psychic effects not intended by the physician Portenoy 1996 Nearly 94% of physicians failed to accurately diagnose an alcohol problem in adults in the CASA National Survey of Primary Care Physicians and Patients on Substance Abuse. April 2000 Physicians Role in Addiction Screening for Substance Use Disorders Substance Use Disorder? A Rand study published in the June 26, 2003 New England Journal of Medicine stated that doctors treating 280 people with evidence of alcohol problems followed recommended procedures only 11% of the time. They suggested specific treatment only 5% of the time. This was the least standardized care of all health conditions studied. Case: Palliative medicine consultation service asked to see a 34 yearold man in SICU for uncontrolled pain. Man had been admitted electively for an operation to convert an ileal pouch to an ileostomy. Pt. had a h/o Crohn s disease with multiple abdominal operations in a 3- year period. He had a poorly defined chronic abdominal pain syndrome and chronic anxiety. He had been seeing a chronic pain specialist and psychiatrist as an outpatient and was taking the equivalent of 2000 mg oral morphine daily. He didn t tell his surgeon about this because on previous admissions, he had been accused of being an addict. Other PMH and medications were not significant. 7

8 Screening for Substance Use Disorders Substance Use Disorder? Case (cont.): Initial palliative care consult was on POD #1. On exam: patient awake and writhing in bed with abdominal and rectal pain. He was diaphoretic, anxious, had widely dilated pupils and was tachycardic (pulse 130) with BP 160/90. Abdomen was diffusely tender, but bowel sounds were present. Pain medications at the time were morphine PCA at 2 mg/hr basal rate with 1 mg Q 15 min prn. He was also receiving lorazepam 1-2 mg Q2h prn for anxiety. The patient demanded that meperidine be used. The attending surgeon told the patient and family that he needed to be off all opioids because of addiction. There was no documentation in the chart by either doctors or nurses suggesting addiction. Screening for Substance Use Disorders Tools To screen for substance Use Disorders (SAMHSA TIP 54, Exhibit 2-8) Tool Alcohol, Smoking, and Substance Involvement Screening Test Alcohol Use Disorders Identification Test (AUDIT) Format 1 item for lifetime use, 6 items for each of 10 sub-stances used, and 1 item on injection use 10-item screening questionnaire Administration/ Scoring Time Depends on number of substances used 2 minutes to administer/ 1 minute to score AUDIT-C 3-item screening questionnaire Less than 1 minute to administer and score CAGE Adapted To Include Drugs Drug Abuse Screening Test Michigan Alcoholism Screening Test (MAST) (MAST-G for older adults) 4 yes/no questions Less than 1 minute/ not scored 20 yes/no questions 1 2 minutes to administer/ not scored 24 yes/no questions 10 minutes to administer/ 5 minutes to score Training Required Yes Yes Yes No No No Screening For Opioid Misuse Among Those with Chronic Pain ORT: Opioid Risk Tool Designed for adult patients in primary care 5 item screening tool for initial risk Self report Stratifies risk Validated Screening for Opioid Misuse Among Those with Chronic Pain SOAPP-R: Screener and Opioid Assessment for Patients with Pain (Revised) Designed for adults Multiple versions (from 5-24 items) Can be used to monitor for misuse over the course of treatment Stratifies risk Validated Referring for Further Assessment Category Screening Elements of screening, Brief Intervention, and referral to Treatment (SAMHSA TIP 54, Exhibit 2-9) Description Identifies individuals with problems related to substance use. Screening can be through interview and self-report. Physicians Can Do Their Part Brief Intervention Brief Treatment Referral to Treatment Follows a screening result indicating a moderate risk. A successful brief intervention encompasses support of the patient s ability to make behavioral change. Follows a screening result of moderate to high risk. Brief treatment includes assessment, education, solving problems, introducing coping mechanisms, and building a supportive social environment. Follows a screening result indicating a substance use disorder. This process facilitates access to care for individuals requiring more extensive treatment than SBIRT provides and ensures access to the appropriate level of care for all who are screened. Narcotic Contracts Medication Call-backs Blister Packing Prescription Drug Monitoring Programs Urine toxicology screening Universal Precautions 8

9 Universal Precautions in Chronic Pain Treatment Universal Precautions in Chronic Pain Treatment 1. Diagnosis with reasonable differential 2. Detailed psychological assessment, including risk of addiction 3. Rational non-opioid therapeutic trial 4. Pre-trial assessment of pain and function 5. Informed consent (verbal and written-signed) 6. Treatment agreement (verbal and written/signed) 7. Careful, time limited trial of opioid therapy 8. Reassessment of pain, function and diagnosis 9. Regular assessment of aberrant behavior 10. DOCUMENT! Gourlay 2004 Primary Care Triage of Chronic Pain Patients Primary Care No history of substance use disorder No major psychiatric comorbidity Primary Care with Consultation Increased risk patient: In recovery, family history, aberrant behavior, current psychiatric disorder Referral to Tertiary Care (Addiction Medicine Specialist) Active addiction Major untreated psychiatric disorder CDC Agenda Prescription Drug Monitoring Programs (PDMP) Support and Develop Surveillance Systems (PDMP s) Educate Patients, the Public and Medical Providers Policy Change The National All Schedules Prescription Electronic Reporting (NASPER) Act, was signed into law on August 11, 2005 The Department of Justice and SAMHSA continue to fund grants PDMPs can identify individuals, physicians, or pharmacies that have unusual patterns suggesting drug diversion, abuse, or doctor shopping In 1992 only 10 states had PDMPs Now over 40 states have operational PDMPs in place Only 3 states Kentucky, Nevada & Utah routinely provide their information proactively to physicians There is a new emphasis on sharing data across state lines and having the information available on all patients in the electronic health record 9

10 Federal Response What Will You Do? Please Commit to Action! Training Tracking and Monitoring (PDMP s) Proper Medication Disposal Enforcement Epidemic: Responding to America s Prescription drug Crisis 2011 (ONDCP) Screen for addiction and alcoholism Examine your prescribing practices Use prescription monitoring programs Intervene and Treat those with addiction Refer to an addiction specialist just like any other medical specialty Thank you 10