1 Treating Addiction in Chronic Pain Patients A Clinical Journey Brad Anderson, MD Chief, Department of Addiction Medicine Kaiser Permanente Northwest
2 Pain Addiction
3 Kaiser Permanente Northwest 480,000 members clinicians Portland Metro and Salem in Oregon Vancouver and Longview in Washington
4 Department of Addiction Medicine 40 counselors 5 medical staff 11 medical offices 6,000 patients per year Level I, II, III, adult & adolescent Inpatient and outpatient detox Codependency treatment Chronic Pain Addiction Group (CPAG)
5 Diagnoses at Intake Alcohol Amphetamine Cannabis No diagnosis Cocaine Opioid
6 Half of referrals to Addiction Medicine from primary and specialty care are due to concerns about opioid addiction. Is this addiction? If so, what do I do about it?
14 Contract for long-term opioid therapy for chronic nonmalignant pain Single prescriber Medicine, dose, refills Risk / benefit Reasons to discontinue
15 Contract for long-term opioid therapy for chronic nonmalignant pain Introduced the concept that addiction is not an absolute contraindication to prescribing opioids Challenged the idea that opioid therapy is only for end-of-life care Developed with cooperation of state BMEs
16 Evaluation for appropriateness of long-term opioid therapy from an addiction medicine standpoint What we found Concerning behaviors were often due to inadequately treated pain, not addiction Rarely resulted in recommendation to discontinue opioids Physical dependence and addiction often confused
17 Evaluation for appropriateness of long-term opioid therapy from an addiction medicine standpoint What we found Mainly short acting opioids being prescribed Poor utilization of non-opioid therapies Difficult to make addiction diagnosis Patients with addiction who were on opioids for pain didn t fit well into standard treatment
22 Cougalgia Chronic pain syndrome seen in Washington State Cougar fans Also known as Pullman-ary hypertension Associated with Depression Anxiety PTSD Delusional thinking
23 Cougalgia Predominantly genetic with some environmental influence Differential diagnosis Cubosis Mal-de-Mariner Beavertigo Overlap with addiction Continued viewing despite adverse consequences Loss of remote control Compulsive ESPN use
24 Cougalgia - Treatments Three 10 win seasons with top 10 rating Unanticipated side effects 3 Apple Cup losses Dobamine Seahawk substitution therapy Rose Bowl victory probably only hope
25 Chronic Pain / Addiction Group I Initially lead by staff from both the Dept of Addiction Medicine and Pain Clinic Pain management strategies predominated during group time Eventually discontinued as census decreased
26 Chronic Pain / Addiction Group II Lead by counselor and physician assistant from the Dept of Addiction Medicine For inclusion, patients must have, and agree with, the diagnoses of Addiction Chronic pain Most patients were on an opioid and had addiction treatment experience All patients had an assessment and treatment plan
27 Chronic Pain / Addiction Group II Goal of the group To learn how to live with pain and addiction on a daily basis.
28 Chronic Pain / Addiction Group II In other words Learn how to have to opioids be a medication for pain without being a drug of choice Keeping things black and white
29 Pain Addiction
30 Chronic Pain / Addiction Group II In other words Learn how to have to opioids be a medication for pain without being a drug of choice Keeping things black and white Stay on the analgesic curve
31 DOSE Analgesia Euphoria Pseudoaddiction Euphoria to Analgesia TIME
32 Name Your Treatment Column A Column B Column C New Step Program Change Direction House Life Point Group Turning Works Community Recovery Pathways System Health Day People Care Dawn Place Safe Roads Home Fresh Start Center
33 CPAG II Check In Name Substance of choice Sobriety date Number of meetings attended in past week Pain level Taking meds as prescribed? One word feeling today Do you need time in group today?
34 Chronic Pain / Addiction Group II To accomplish goals, coordination with the Primary Care Provider is key. Develop Opiate Therapy Plan Long acting opioids, scheduled, not PRN Eliminate short acting opioids Avoid benzodiazepines Random urine toxicology Referral to Pain Clinic and participation in pain management 8 week class
35 CPAG II Female 76% Male 24% 0
36 CPAG II Addiction Diagnoses Opioid 69% Alcohol 41% Marijuana 16% Amphetamine 10% Other 10%
37 CPAG II Pain Diagnoses Back/neck 60% Fibromyalgia 28% Headaches 17% Arthritis 8% Other 12%
38 CPAG II Psych Diagnoses Depression 72% Anxiety 28% PTSD 20% Axis II 10% Other 16%
39 CPAG II Long Acting Opioids Methadone 54% Sustained release morpine 37% 10 0 Oxycontin 6%
41 Chronic Pain / Addiction Group II What we found Most patients love the group Need to remind patients that this is an addiction group, not a pain group Need to remind patients to attend a pain group Strong interplay between psychological factors (stress, anxiety), pain and addiction Patients who left the group and relapsed, often returned
42 Chronic Pain / Addiction Group II What we found The group DID NOT significantly change the behavior of the patients Primary Care Provider! 1. Opiate therapy plans not consistently developed 2. Short acting opiates were prescribed again 3. Urine toxicology not done
43 Research Opportunities Identify barriers to PCP cooperation with Addiction Medicine recommendations Development of meaningful and measurable outcome measures to assess efficacy of chronic pain / addiction groups Identify patient characteristics which would predict good or poor outcomes with opioid therapy Evaluate use of case managers to improve functioning and decrease health care utilization
44 For more information, please contact us Lucile Gauger, PA-C Christine Finucane, LCSW Brad Anderson, MD
54 A Confusing Nomenclature Substance abuse Addiction Dependence Psychological dependence Chemical dependency Drug abuse
55 Opioid Dependence Physical dependence - a physiological state of adaptation to opioids Withdrawal syndrome with abstinence Relief of withdrawal with reintroduction As little as two weeks at therapeutic doses
56 Opioid Dependence Psychological dependence - subjective sense of need for opioids Positive effects Avoidance of negative effects associated with abstinence
57 Opioid Dependence Physical dependence does not equal psychological dependence. Physical dependence usually accompanies psychological dependence.
58 Addiction A primary, chronic disease with - genetic, - psychosocial and - environmental factors influencing its development and manifestations. It is often progressive, fatal and characterized by - impaired control, - preoccupation with use and - continued use despite adverse consequences. These symptoms may be continuous or periodic.
59 Addiction Latin for given over or awarded to, from ad - to + dicere - say, pronounce U2 - lifeless lifeline, running to stand still C.S. Lewis - an ever increasing craving for an ever diminishing pleasure.
60 Pain & Addiction Pain is often poorly treated in patients with addiction Fear of addicting patient Poor pain management skills Unfamiliarity with addiction Fear of regulatory sanctions
61 Pain & Addiction Patient concerns Fear of inadequately treated pain Fear of withdrawal Fear of relapse
62 Chronic Pain & Addiction Addiction - functioning decreases with increasing dose Pseudoaddiction - functioning increases with increasing dose
63 Common Recommendations Develop opiate therapy plan ( contract ) Use long acting / sustained release opiates Random urine toxicology Maximize non-opiate pharmacology Maximize non-pharmacologic modalities Pain clinic referral
64 Summary Pain & Addiction Demonstrate interest is in pain control, not medication (chronic pain treatment equation) Do everything through the front door Goal is pain control and increased functioning
65 Chronic Pain Treatment Equation chronic pain Tx = + other meds + physical therapy + relaxation opiates + ice/heat + education + etc
66 Chronic Pain & Addiction Treatment Goals Decrease pain Decrease associated symptoms anxiety depression insomnia Increase functioning Opioid remains a medication, not a drug of choice
67 Chronic Pain & Addiction To achieve these goals Addiction must be treated Use non-pharmacological modalities Use non-opioid medications If opioids are needed, use long acting or time released and take on scheduled basis Random urine toxicology
68 Chronic Pain & Addiction Opiate Therapy Plan Basic or Complex based upon addiction risk prescriber medication & dose amount & refill schedule patient s goals for therapy description of risks & responsibilities for patient signed by patient and prescriber
69 The 3 C s of Addiction Loss of CONTROL using month s meds in a few days or weeks early refills requests, obtaining meds from family, friends, Internet, street Adverse CONSEQUENCES sedation, OD, decrease functioning Preoccupation or COMPULSION reliance on opioids, poor compliance with other treatment modalities
70 Diagnosing Addiction Ask yourself Has this patient developed a relationship with this medication beyond what I prescribed it for? Does this patient go to lengths to get this medication that most of my patients don t?
71 Diagnosing Addiction Using supply before refills due Calling after hours, weekends, Friday at 5:00 Calling when PCP not available Multiple ER and UCC visits Calling provider at home Lost and/or stolen prescriptions Meds eaten by dog, fell in toilet, left in Seaside, picked up by ex-wife, etc...
72 Diagnosing Addiction Patient says med gives me energy Euphoria or sense of well-being Forging or changing scripts Borrowing or lending medications Obtaining meds from Internet or illegally Stockpiling medications Family/friends concerned about use Reported allergies to other analgesics
73 Diagnosing Addiction History of addictive disease Prior attempts to decrease or stop meds Annoyance at other s comments about use Guilt or embarrassment about use Use to treat non-targeted symptoms Use when no symptoms present Unsanctioned dosage increases