Addiction Issues in Chronic

Pain Management
 Learning Objectives
 Epidemiology of addiction and drug abuse

 Discuss appropriate definitions related to abuse and

addiction

 Pathophysiology of addiction

 Understand the differential diagnosis of ambiguous

medication-related behaviours

 Treatment issues of chronic pain with addiction

 Relevant underwriting concerns

 Statistics
 Base rate of addictive disease in general
population:
 Alcohol – 15%
 Cocaine/Heroin -- 5%

 10% of adults in US have genetic

susceptibility to addiction
 Statistics
 In 2003, 4.7 million Americans used
prescription drugs non-medically:

 2.5 million – analgesics

 1.4 million – sedatives/tranquilizers

 761 000 – stimulants

 Statistics
 Vicodin: Most commonly prescribed
prescription analgesic in US

 Vicodin: Most prescribed medication of

any category (>100 million Rx’s)
 Statistics
 >50 million Americans suffer from chronic pain

 Overall rate of prescription analgesic

abuse/addiction in pain patients = 3.3%

 0.19% without a past or current substance

abuse disorder experienced problems with
opioids for pain

 Overall rate of concurrent addiction (all

substances) in chronic pain patients is the same
as in general population 6-10%
Proper definitions are
important!
 Basic Terminology

 Abuse = Abnormal use, non-therapeutic

 Addiction is a form of abuse

 Addiction = Drug Abuse

 Drug Abuse  Addiction, but can imply it

 The 4 C’s of Addiction

 Loss of Control

 Compulsive Use

 Craving

 Consequences (Use Despite Harm)

Definitions related to the use of opioids for the treatment of pain. A

Consensus Statement on Pain and OpioidsASAM, APS, AAPM, April 2001
http://www.painmed.org/productpub/statements/pdfs/definition.pdf
 In a Patient With Pain on
Opioids…

Physical Dependence  Addiction

Tolerance  Addiction
High dose  Addiction

RD Jovey, J Ennis, J Gardner-Nix, B Goldman, H Hays, M Lynch, D Moulin. Use of opioid analgesics for the treatment of chronic
noncancer pain – A consenus statement and
guidelines from the Canadian Pain Society, 2002. Pain Res Manage 2003;8(Suppl A):3A-14A.
DSM-IV-TR Substance Dependence

1. Tolerance
2. Physical dependence/withdrawal
3. Used in greater amounts or longer than intended
4. Unsuccessful attempts to cut down or discontinue
5. Much time spent pursuing or recovering from use
6. Important activities reduced or given up
7. Continued use despite knowledge of persistent
physical or psychological harm

3/7 required for diagnosis

4/7 common in non-addicted pain patients
Sees and Clark, J Pafter Savage, 2004
 DSM-IV-TR Substance Abuse

1. Recurrent use affecting daily participation in

major obligations at work, school or home
2. Recurrent use in physically hazardous settings
(driving)
3. Recurrent substance-related legal issues
4. Continued use despite recurrent or persistent
social or interpersonal consequences

1/4 required for diagnosis

Exclusionary for substance dependence
Sees and Clark, J Pafter Savage, 2004
 Addiction:
A Biopsychosocial Illness
Environment
Psychology Availability
& Milieu

*Manifestation of
the disease of

* Drug addiction
Neurobiology
Genetics
Acquired

Reinforcement
Adapted from JD Haddox, DDS, MD.
13
 Brain Circuits of Addiction

Prefrontal
Planning, cortex
Judgment frontal
cortex

Nucleus
accumbens
Medial forebrain
Reward bundle
Ventral tegmental
area

Emotions,
conditioned effects Amygdala

Tomkin & Sellers, CMAJ, 2001

Pain Patient vs. Opioid Abuser
 Controls meds
 Meds improve QOL
 Complains of side effects
 Concerned re: risk of
addiction
 Follows agreed upon
treatment plan
 Left over meds, does not
run out of or lose meds
 Can’t control meds
 Meds decrease QOL
 Wants meds despite S/E
 Denies possibility of
addiction
 Does not follow
treatment plan
 Seldom has meds left
over – excuses for lost
meds
Schnoll, J Law Med Ethics.1994
Heit, Eur J Pain 2001
 Ambiguous drug behaviours
– More suggestive of addiction
 Rx drug: selling, stealing, forgery
 Injecting oral formulations
 Obtaining Rx drugs from the street
 Concurrent abuse of ETOH or illicit drugs
 Repeated non-compliance despite warnings
 Double doctoring
 Drug-related deterioration in function
 Resistance to change in therapy despite evidence of
adverse drug effects

Passik, Portenoy, 2004

 Ambiguous drug behaviours
– Less suggestive of addiction
 Asking for more pain meds or specific meds
 Drug hoarding
 Openly getting meds from other MDs
 Occasional dose escalation or other non-compliance
 Treating another symptom with opioids
 Unintentional psychic effects
 Resistance to change in therapy that is working
 Intense anxiety about recurrent symptoms

Passik, Portenoy, 2004

 Pseudotolerance

 Occurs when a patient with chronic pain treated with

opioids increases activity levels resulting in more pain
OR
there is a worsening of the underlying pain condition

 This pain is relieved when the dose of opioid is increased

 Tends to occur during the initial titration phase or at a time that
the patient undergoes a significant change in activity level or
disease activity

Jackson KC, 2003

Heit H, 2005
 Pseudoaddiction
 An iatrogenic misinterpretation caused by
undertreatment of pain that is misidentified
by the clinician as inappropriate drug-
seeking behaviour
 Behaviour ceases when adequate pain relief
is provided
 Not a diagnosis, rather a description of a
clinical interaction

Weissman DE, Haddox JD. Pain. 1989;36:363-6.

19
 Addiction versus
Pseudoaddiction
 Addiction
Dx made prospectively:
 Patient’s behavior and compliance with
treatment agreement becomes aberrant
despite “Rational Pharmacotherapy.”

 Pseudoaddiction
Dx made retrorespectively
 Patient’s behavior and compliance with the
treatment agreement normalizes with
“Rational Pharmacotherapy.”
Gourlay, 2005
 Concurrent Pain & Addiction

 Both pain and addiction can co-exist in the

same patient

 Addiction can be to prescription medications,

illicit narcotics and/or alcohol

 This does not necessarily preclude the use of

opioid therapy, but does require more attention
(and time)
 Treatment of Pain & Opioid
Addiction
 Inpatient

 Outpatient
 Substitution
 Methadone
 Suboxone (buprenorphine/naloxone)
 Discontinuation
 Tapering (Rapid vs Gradual)

 Narcanon/Counselling
 Treatment of Pain & Opioid
Addiction
 Methadone: 2 indications
 Treating heroin/opioid addiction
 Treating chronic pain with or without addiction

 Suboxone:
 Addiction treatment as a substitute for Methadone
 Safer with less substitute-addiction potential
 Underwriting Points
 Differentiate between abuse and addiction as there
are different outcome implications
 Use of cocaine recreationally constitutes abuse
 Habitual use of marijuana likely constitutes addiction (as
with tobacco)

 Abuse (illicit substances) without addiction has

legal/criminal ramifications

 Addiction has more health related consequences

 Underwriting Points
 Consider comorbidities, specifically
psychiatric/psychological (depression/anxiety)

 Watch for unusual health outcomes (CVA, MI,

COPD) not associated with risk factors and
outside age-appropriate ranges for occurrence

 Frequent ER visits for unspecified diagnoses

(chest pains)
 Underwriting Points
 If there is chronic pain with a history of
substance abuse/addiction

 Determine past treatment history

 Assess current status

 UDT’s in APS
 Underwriting Points
 Virtually any prescription drug can be
misused/abused but psychotropic drugs are the
focus of concern especially with addiction

 Trends temporally and geographically

 Media biases
 Underwriting Points
 Opioids of choice:
 Hydrocodone
 Oxycodone
 Methadone

 Benzodiazepines of choice:
 Alprazolam
 Clonazepam
END