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Addiction in Pain Management
Steven D. Passik, PhDKenneth L. Kirsh, PhD
T
remendous progress has been made in the study and treatment of pain in the past two decades (1,2). Efforts have been undertaken to make pain assessment and treatment a priority of medical care and to utilize all of the weapons in our armamentarium to bring relief to the millions of people with chronic pain, including opioid therapy for nonma-lignant pain (3,4). Hundreds of thousands of pain patients have benefited from increased willingness to prescribe opioids. Unfortunately, the rhetoric of the pain community has tended to trivialize the complexities of treat-ment (5). The growing problem of prescription drug abuse has forced the field to take a new look at opioid prescribing and to seek balance in its risks and benefits. Although the rhetoric should be replaced with scientifi-cally based approaches to clinical management, we should not abandon use of opioids: the dramatically expanded use of opioids was undertaken with a paucity of long-term data to justify it, but complete avoidance of opioids is equally unsupported.When the president of the American Medical Association wrote fa-mously in a 1941 editorial that “the use of narcotics in the terminal cancer [patient] is to be condemned if it can possibly be avoided...[because one] of the unfortunate [side] effects is addiction,” he was voicing an extreme view on opioids with little basis in science (6). Today, all practitioners involved in pain management have the dual mission of relieving suffering without contributing to drug abuse. By understanding the principles of addiction medicine as they apply to pain management, health care providers can safely provide pain management to all who need it. Adequate assessment of aberrant behavior is key to mastering these principles.
Although initial reports were optimistic that the increasing production and use of opioids was not accompanied by increased abuse and diversion
of these drugs, during the past 10 years the problem has become obvious (7). The media spectacle that accompanied the misuse of sustained-release oxycodone was only the most visible of a multitude of opioid abuses by well-known celebrities and other public figures (8). There is no doubt that much reporting of prescription drug abuse in the popular press has been inaccurate, sensationalized, unbalanced, and distasteful. As a result, many physicians were initially dismissive of the problem because its seriousness was actually obscured for them by the media circus. However, it has become abundantly clear, regardless of what index one uses to gauge the problem (e.g., the Drug Awareness Warning Network, the Household Survey), that prescription drug abuse is on the rise (9-11).
The national problem of prescription drug abuse is only part of the issue, however. Prescribers must also know what drugs are being abused locally, be aware of local trends, and prescribe specific medications care-fully, especially if they happen to be locally “hot.” For example, in a retro-spective and ongoing proretro-spective study in central and southeastern Kentucky, where the vast majority of our patients reside, we have learned a great deal about abuse of “hot” pain medications such as oxycodone and less popular ones such as fentanyl, and which patients are at particular risk for abuse or diversion (12). This understanding affects our work with fellow physicians when deciding which drugs to prescribe and strategies for prescribing the riskier agents. We have a duty to assess and treat our patients as individuals, but we must also assess and treat them in the con-text of existing drug abuse in their community.
Treatment and Good Practice
As physicians identify and treat patients with pain and comorbid aberrant drug-taking behaviors, they must remember the basic tenets of good chronic pain management, which will aide the care of complicated pa-tients. For instance, any medications chosen to treat the patient should be titrated to effect or toxicity, following the “start low, go slow” principle. Also, patient self-report should be respected, even if the patient has been found to be a questionable source. We must not naively accept completely the patient’s words, but neither should we dismiss them out of hand. Furthermore, any pain patient must abide by the rules of therapy and make a good faith effort to achieve a successful outcome. Finally, it is important for the clinician to have an ongoing assessment and thorough documenta-tion of the patient’s funcdocumenta-tioning according to several key domains.
The Four A’s
Passik and Weinreb described the “4 A’s” of pain management outcomes: analgesia (pain relief), activities of daily living (psychosocial functioning),
adverse side effects (side effects), and aberrant drug-taking behaviors (ad-diction-related outcomes), as a shorthand for the domains that should be assessed and discussed at every return visit for patients on chronic opioid therapy (13). Doing so in a detailed manner is time consuming, and a tool would certainly help to upgrade most physicians’ documentation.
Differential Diagnosis
Various definitions of abuse that include the phenomena related to physical dependence or tolerance are not applicable to patients who receive poten-tially abusable drugs for legitimate medical purposes (14). A differential di-agnosis should be explored if questionable behaviors occur during pain treatment (Table 12-1). A true addiction is only one of several possible ex-planations but is more likely when behaviors such as multiple unsanc-tioned dose escalations and obtaining opioids from multiple prescribers occur.
The diagnosis of pseudoaddiction must also be considered if the pa-tient is reporting distress related to unrelieved symptoms. Behaviors such as aggressively complaining about the need for higher doses or occasional unilateral drug escalations that appear to be addiction on the surface may be indications that the patient’s pain is under-medicated. Indeed, one of the most perplexing aspects of differential diagnosis is the distinction be-tween addiction (the behavior is out of control, continues despite harm)
Table 12-1 Differential Diagnosis Considerations for Assessing Aberrant Drug-Taking Behaviors
Differential Diagnoses Patient Behavior
Addiction Out-of-control behavior; compulsive, harmful drug use Pseudoaddiction Under-treated pain leads to desperate acting out;
patients may turn to alcohol, street drugs, or doctor-shopping; these behaviors subside once pain is adequately treated
Organic mental syndrome Patients often confused and have stereotyped drug-taking behavior
Personality disorder Patients impulsive, have sense of entitlement, and may engage in chemical-coping behaviors
Chemical coping Patients place excessive emphasis on meaning of their medications and are overly drug focused
Depression, anxiety, and Patients marked by desire to self-medicate their mood situational stressors disorder or current life stress
Criminal intent Subset of criminals intent on diverting medications for profit
and pseudoaddiction (the behavior is driven by inadequate analgesia, re-solves when analgesia is improved) (15). No behavior is universally linked to addiction or pseudoaddiction, despite how aberrant it might appear (we have reported, for example, a case of prescription forgery that was linked to anxiety related to the caregiver’s vacation and had nothing to do with abuse/diversion) (16). Generally, patients will describe uncontrolled pain rather than loss of control. Thus, before clinching a diagnosis, clinicians often have to “walk the line” between the two possibilities by imposing limits while titrating drugs upward until the behavior comes under control or escalates further. There is no doubt that the notion of pseudoaddiction was an important step forward in pain management: a recognition of the desperation set in motion by unrelieved pain and a somber realization that patients can be pushed to uncharacteristic ways of behaving driven by our failure to optimally treat them. However, it is also crucial to recognize that pseudoaddiction is not an empirically validated notion. The initial paper on the subject was a small case series (15).
Impulsive drug use may also indicate the existence of another psychi-atric disorder, diagnosis of which may have therapeutic implications. For example, patients with borderline personality disorder may be categorized as exhibiting aberrant drug-taking behaviors if utilizing prescription med-ications to express fear and anger or to relieve chronic boredom. Similarly, patients who use opioids to self-medicate symptoms of anxiety or depres-sion, insomnia, or problems of adjustment may be classified as aberrant drug takers. Occasionally, aberrant drug-related behaviors appear to be causally related to mild encephalopathy, with confusion regarding the ap-propriate therapeutic regimen. Problematic behaviors rarely imply criminal intent, such as when patients report pain but intend to sell or divert med-ications. These diagnoses are not mutually exclusive, and a thorough psy-chiatric assessment is vitally important in categorizing questionable behaviors properly in the population without a prior history of substance abuse and in the population of known substance abusers who have a higher incidence of psychiatric comorbidity (17,18).
Understanding Street Values
It is important for clinicians who treat chronic pain patients to be aware of the street value of the medications they prescribe. National trends exist, but local and practice-specific variations are significant. To learn about the street values of various opioid analgesics, Brookoff asked 130 hospital patients who admitted to abusing medications about their behaviors (19). He discovered that, in general, controlled-release preparations of opioids had less value than other opioids and even some non-opioid formulations. For example, hydromorphone, a short-acting opioid, had a mean value of $47 per pill (4 mg strength) compared with $3 per pill for slow-release morphine.
More recently, our team has undertaken a prospective study of addicts entering a treatment facility for prescription opioid abuse. Designed as a follow-up to an earlier chart review to explore OxyContin abuse in rural Appalachia, addicts are questioned about their prescription opioids of choice, how they abuse the medication, and how much they paid for the medication (12). Patients seeking drug rehabilitation for prescription opi-oids in our rural Appalachian sample still prefer OxyContin (64% abused it), followed by Lortab (35%) and Percocet (15%) (not mutually exclusive). All of these medications were purchased for roughly $1 per milligram. Interestingly, related to the Brookoff study, hydromorphone was valued at approximately $10 per milligram (19). This shows initial evidence that street pricing for drugs has some stability regionally and during more than a decade.
The Drug Abuse Warning Network provides national data on overdoses in emergency rooms, which reveal that hydrocodone combinations are ac-countable for most overdoses, followed closely by oxycodone combina-tions (20). Methadone and fentanyl combinacombina-tions are typically lower but have occasional fluctuations. Clearly then, it is important to monitor na-tional and local trends in street drugs.
Tailoring the Approach
Clinicians should plan treatment according to their assessment results and diagnoses. Categories of patients (Uncomplicated Patient, Patient with Comorbid Psychiatric and Coping Difficulties, and Patient with Addiction) and recommendations for providers qualified to treat them are listed in Table 12-2. Hubris about the ability to treat anyone under any circum-stances needs to be replaced by a sober assessment of who a particular practitioner can treat in his or her practice setting given the practitioner’s time, expertise in complex psychiatric issues, and resources. Learning which patients to treat independently, which patients to treat with help, and which patients to refer is crucial for safe pain management. Therefore, health care providers should obtain consultations as needed. Furthermore, drug therapy should be based on informed consent of the risks and bene-fits of all medicines prescribed. Health care providers should discuss with their patients realistic expectations and functional goals for rational phar-macology. Helping the patient understand how success or failure is to be measured, in terms of pain control (hopefully a meaningful reduction in pain intensity), in terms of function (stabilized or improved), toxicities (manageable or none), and regarding aberrant behaviors (few or none) is crucial for compliance and understanding of therapy goals.
When prescribing, the health care provider must be consistent with state and federal regulations. With this in mind, what does the physician owe the patient/community where initiation of an opioid trial is concerned? The physician must perform a thorough assessment of the patient’s risk for
Table 12-2 Categories of Chronic Pain Patients and Treatment Requirements
Patient Category Treatment Requirements
Uncomplicated patient (has • Minimally monitored drug-only therapy no documented comorbid • Routine medical management
psychiatric problems or • 30-day supply of medications with liberal rescue-connections to drug dose policy
subculture) • Monthly follow-ups
• Monitoring by primary care physician
Patient with comorbid • Structure, psychiatric input, and drug treatments that psychiatric and coping decentralize pain medication from patient coping difficulties (addictive techniques
behavior with central • Decentralization/reduction of meaning of focus on obtaining drugs) medications and of conditioning and socialization
surrounding drug
• Pain-related psychotherapy
• Monitoring by primary care physician in conjunction with physical therapist, occupational therapist, social worker, and/or psychologist/psychiatrist
Patient with addiction • High-level structure that includes frequent visits (active abuser; in drug- • Limited supply of medications
free recovery or in • Long-acting opioids with little street value methadone maintenance) • Judiciously offered rescues only
• Urine toxicology screening and follow-up • Active recovery programs or psychotherapy • Monitoring by specialists (unless primary care
physician has training in treating addiction)
aberrant behavior and match it to a level of appropriate opioid treatment. If a patient is at high risk, multiple precautions can be employed to mitigate risk without categorically denying opioid therapy to the patient. However, if a given practice cannot provide the appropriate structured therapy, refer-ral to a more specialized setting may be necessary.
Interdisciplinary Treatment
A multidisciplinary team approach with an interdisciplinary focus (i.e., col-laborative, holistic, and embodying tenets of biopsychosocial model) is rec-ommended for the management of substance abuse and misuse in the medical setting (21-24). Mental health professionals with specialization in the area of addiction are usually instrumental given their expertise in devel-oping and executing strategies for behavioral management and treatment compliance. Unfortunately, they are not often readily available to clinicians working in private practice or other medical agencies. Therefore, clinicians in independent practice should establish a collective of complementary
practitioners in their area to whom they can refer patients for supplemen-tary pain control services and team-based support.
Clinicians practicing in isolation can quickly become angry, defensive, and frustrated when treating patients with chronic pain, which can uninten-tionally compromise quality of care and cause the patient to feel alienated, hopeless, and rejected. Structured, interdisciplinary treatment (addiction and behavioral medicine, rehabilitation, social work, and/or psychiatry) is the most effective way to facilitate staff understanding of patient needs. It pro-vides a forum for necessary venting and strategizing and helps develop and administer efficacious, empathetic pain control and substance abuse ther-apy. Regular staff meetings can also help establish patient-specific and team-based treatment goals, facilitate consistency and confidence in treatment, foster patient compliance, and maximize potential for meeting clinical goals.
Conclusion
The health care provider involved in pain management must recognize that prescription drug misuse is not simply media hype and that it is not con-fined to remote areas (12). The particular sociology of such locations may have made places like Appalachia especially vulnerable, but prescription drug misuse is a widespread problem.
Before prescribing a controlled substance, the health care provider should medically evaluate the patient for pain and for vulnerability to misuse and aberrant drug-related behavior: understanding of risk factors for chemical dependency and psychiatric co-morbidities, social and familial situation, genetic loadings, and spirituality must be reached. The results of this assessment should not be used to categorically exclude patients from opioid therapy but can guide agreed-upon boundaries required to effec-tively manage an at-risk patient.
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