Goals! Compassionate and Appropriate Use of Narcotics in Addiction! David Martorano, M.D.! Addiction Vs! Dependence! The best laid If a tree falls!

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1 Goals! Screening for Addiction and Dependence! Compassionate and Appropriate Use of Narcotics in Addiction! David Martorano, M.D.! Implementing a Pain Contract! Narcotics & Pain Management in Addiction! 7/17/14! Addiction Vs! Dependence! Pain! All patients treated for chronic pain will demonstrate signs of dependence, including tolerance and withdrawal! Dopamine! Gain! Addiction may precede treatment or develop as a consequence of pain management! Courtesy of NIDA! Receptors and Transmitters in Pain & Reward! Pain and Gain! The best laid plans! If a tree falls! Fortunately, Morphine binds to areas involved in the pain pathway (including the thalamus, brainstem, and spinal cord)! Unfortunately, Morphine binds to opiate receptors that are concentrated in areas within the reward pathway (including the VTA, nucleus accumbens, and cortex)! The endorphin pathways associated with behavioral reinforcement are susceptible to inadvertent corruption by the administration of exogenous opiates! You can t treat what you don t know about! Urine/Saliva Drug Screens! Dash-10! 1!

2 To Screen or Not to Screen! Drug Tests! Pros - generates revenue, keeps patients on their toes, finds drug use, often required by third parties in pain management, & supports patients in maintaining sobriety and compliance! Cons - easily thwarted, false positives, adds costs to care, can alienate patients.! Urine- most common, cheap for initial screening, mass spectroscopy and more advanced immunochemistry are accurate but expensive and time consuming.! Blood- mostly used in forensics! Saliva- easiest, hard to cheat, patient is observed during collection of specimen! Skin- can provide continuous monitoring, but rather invasive! Addicts Lie! DAST-10! 1. Have you used drugs other than those required for medical reasons?! 2. Do you abuse more than one drug at a time?! 3. Are you always able to stop using drugs when you want to?! 4. Have you had blackouts or flashbacks as a result of drug use?! proper surveillance ensures compliance and reduces diversion.! people go to extraordinary means to get drugs! 5. Do you ever feel bad or guilty about your drug use?! 6. Does your spouse (or parent) ever complain about your involvement with drugs?! 7. Have you neglected your family because of your use of drugs?! 8. Have you engaged in illegal activities in order to obtain drugs?! 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?! 10. Have you had medical problems as a result of your drug use! DAST-10! What to do with a Positive Screen! Brief Motivational Interventions! Referral! Increased Surveillance! Pain Contracts! Tighter Prescribing of narcotics! 2!

3 Pain Contracts! Establishing Care! Similar to screening support patients but also create a potentially oppositional relationship with their provider.! Are increasingly required! Facililitate care! Must be customized to care delivery setting! Pain history! Review of diagnostic workups! Pain generator! Alternative pain management! Risk Benefit Discussion! Long Term Plan!? Pain Contract! Key Points to a Successful Pain Management Relationship! Chronic Pain! All controlled substances must come from one physician or group! Choose single point of distribution! Original containers of medications should be brought in to each office visit.! Medications may not be replaced if they are lost, get wet, are destroyed, are left on an airplane, etc.! Early refill requests may increase the frequency of care required! Renewals are contingent on keeping scheduled appointments! Any pain management treatment is initially a trial, and that continued prescription is contingent on evidence of benefit.! Goal is a 5/10 on subjective scale! Opiate rotation! Long acting over short acting! Partial agonists! Long Acting Full Agonists! Long Acting! MS-Contin and OxyContin dissolve more slowly! BID dosing is a bad idea! Half-life is less than 4 hours! 100! 75! 50! 25! Half-Life is only 2 hours longer, and pharmacokinetics are identical for short and long-acting in terms of metabolism! Longer time to action can result in risks of unintentional overdose! Longer time to action may reduce risk of addiction by diminishing pairing of conditioned stimulus and response! Need to consider AUC in terms of converting dosage from short acting! 0! 0! 1! 2! 3! 4! 5! 6! 7! Flatter curve means less euphoria! Best for people who have round the clock pain.! 3!

4 Methadone! Buprenorphine! Very long half-life! Demonstrated harm reduction benefits in addiction! May not be prescribed for addiction except in special circumstances! Very long time to action and gradual onset = increased accidental overdose! LAM was taken off market! Subutex (SL) Addiction Induction Q4-Q6H! Suboxone (SL) Addiction Maintenance QD-TID! Butrans (TD) Pain QW! Buprenex (IM/IV) Pain Q6-Q8H! QT prolongation - EKG monitoring for higher doses! Butrans! Ultram / Tramadol! Useful in chronic pain management with minimal or no opiate dependence! Useful in chronic pain management in moderate buprenorphine dependence! Only buprenorphine-based treatment currently covered by Medicaid/Workman s Comp! Effective for pain! Partial Central Opiod Agonist + Serotonin / NE! Q6 dosing! Partial agonist may decrease dependence! Seizures and Serotonin Syndrome! Exalgo - Once Daily Hydromorphone! Fentanyl! Expensive! Scary! Works! Limited utility at present! Induce at fractions of daily dose over many days (if total daily dose dilaudid = 24mg, start exalgo 8mg and reduce dilaudid dosing by 1/3)! I don t use in addiction! People eat patches! People sell patches! Hard to switch to other medications! 4!

5 Advice! Learn to love pain management! Don t get mad about non-compliance and deception! Support your clients in success and honesty! A well-managed pain patient is reliable and committed. They work hard to maintain compliance! 5!