CNCP and Addiction. Disclosures 17/02/2015. CPSNS CPSNL Atlantic Mentorship Network P&A. John Fraser February 18, 2015

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1 CNCP and Addiction John Fraser February 18, 2015 Disclosures CPSNS CPSNL Atlantic Mentorship Network P&A "Your eyes are fine. It s just that on some eye charts the type is too small." 1

2 CNCP with history of addiction CNCP with active addiction CNCP with? addiction Chronic Pain in MMT patients Secondary analysis of Drug Abuse Treatment Outcome Study (DATOS) n Any CNCP Moderate to severe CNCP All SUD 7, % 23.9% MMT 1, % Potter et al, 2008, Am J Addict Pain in MMT patients Factors associated with moderate to severe CNCP in patients with SUD (n=7876) Adjusted OR (95%CI) p Functional disability 4.3 ( ) <.001 Health problems 1.5 ( ) <.001 Depression 1.3 ( ) <.001 Potter et al, 2008, Am J Addict 2

3 Prevalence of Addiction in CNCP Boscarino (2010) n=765 26% Hojsted (2010) n=253 19% Hojsted et al, 2010, Eur J Pain; Boscarino et al, 2010, Addiction Process of CNCP management Non- Pharma Trial Assessment Pain and Risk Functional goals Non- Opioid Trial Opioid Trial Outcomes Monitoring/ Reassessment Pain and Function Identification and Management of Problems Canadian Guideline for Safe and Effective Use of Opioids for CNCP 24 recommendations Deciding to initiate opioid therapy Conducting a trial of opioid therapy Monitoring long term opioid therapy Treating specific populations with long-term opioid therapy Managing opioid misuse and addiction in patients with chronic pain Includes many tools and practical information Furlan et al, 2010, CMAJ 3

4 Universal Precautions Clear diagnosis Identify patients at risk substance use history (personal and family) screening tools Collateral information Prescription Monitoring Program Pharmacist Previous prescriber Adequate trial of non-opioid therapy before opioids Gourlay et al, 2005, Pain Med Universal Precautions Treatment agreement Informed consent Use long acting opioids with fixed dosing Avoid higher risk opioids in high risk patients oxycodone, hydromorphone Appropriate dispensing (daily/weekly) Gourlay et al, 2005, Pain Med Universal Precautions Monitor and document 5 A s Activity Analgesia Adverse effects Affect Aberrant behaviours Urine drug testing Pill counts/patch returns Gourlay et al, 2005, Pain Med 4

5 Boundaries Clear and transparent communication Expectations Treatment agreement readable reasonable flexible Choices Red pajamas, Blue pajamas Sympathy vs Empathy Chronic vs Acute 5

6 Opioid Trial (watchful dose) CNCP with history of addiction CNCP with active addiction CNCP with? addiction CNCP with History of Addiction Risks Personal history of addiction Family history of addiction Mental illness Childhood abuse or trauma Smoking History of involvement with the law Age 6

7 CNCP with History of Addiction Tighter boundaries more frequent visits shorter dispensing intervals (weekly, daily) more frequent urine drug testing pill counts, patch returns more vigilant monitoring and responding to aberrant behaviours CNCP with history of addiction CNCP with active addiction CNCP with? addiction CNCP with Active Addiction Depressants (alcohol, benzodiazepines) Maximize non-opioid therapy Addiction services No opioid therapy until full remission 7

8 CNCP with Active Addiction Stimulants (cocaine, amphetamines) Maximize non-opioid therapy Addiction services Close monitoring (UDT) No opioid until full remission or can consider very controlled opioid therapy daily witnessed 24 hour morphine CNCP with Opioid Addiction inadequate analgesia drug seeking behaviour to reduce pain risk of addiction relapse Adequate pain control can prevent relapse Opioid therapy can effectively reduce symptoms of both diseases pain relief and withdrawal prevention CNCP with Opioid Addiction Multidisciplinary team addiction treatment centre MMT clinic Clear treatment goals Addiction: harm reduction CNCP: functional improvement Concurrent therapy Opioid addiction (methadone/buprenorphine) Non-opioid pain management 8

9 CNCP with Opioid Addiction Maximize non-opioid therapy Opioid therapy Methadone q8h Buprenorphine q8h Must be stable enough for take-home dosing Higher than expected doses due to tolerance, hyperalgesia CNCP with history of addiction CNCP with active addiction CNCP with? addiction CNCP with? Addiction DSM V criteria for addiction Taking the substance in larger amounts or for longer than the you meant to Wanting to cut down or stop using the substance but not managing to Spending a lot of time getting, using, or recovering from use of the substance Cravings and urges to use the substance Not managing to do what you should at work, home or school, because of substance use Continuing to use, even when it causes problems in relationships Giving up important social, occupational or recreational activities because of substance use Using substances again and again, even when it puts the you in danger Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance Needing more of the substance to get the effect you want (tolerance) Development of withdrawal symptoms, which can be relieved by taking more of the substance. 9

10 CNCP with? Addiction DSM V criteria for addiction Taking the substance in larger amounts or for longer than the you meant to Wanting to cut down or stop using the substance but not managing to Spending a lot of time getting, using, or recovering from use of the substance Cravings and urges to use the substance Not managing to do what you should at work, home or school, because of substance use Continuing to use, even when it causes problems in relationships Giving up important social, occupational or recreational activities because of substance use Using substances again and again, even when it puts the you in danger Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance Needing more of the substance to get the effect you want (tolerance) Development of withdrawal symptoms, which can be relieved by taking more of the substance. Aberrant Drug Related Behaviours serious Selling drugs Stealing drugs Forging prescription Injecting oral drug Double doctoring Drugs from street/friends Illicit drug use Presents intoxicated Frequent requests for early refills Drug binging Multiple unsanctioned dose increases Recurrent lost prescriptions Deterioration in function Resistance to change in therapy in spite of adverse effects Drug-related crime Involved with drug culture Refuses UDT Portenoy, 1994, in "Progress in Pain Research and Management" Aberrant Drug Related Behaviours less serious Multiple requests for dose Drug hoarding Openly getting opioids from pharmacy or other MD Requesting specific opioids (short acting) Concern from family/friends Requests for faxed Rx or fitin appointments Requests for Rx for travel Multiple injuries/accidents Requests for early refills Using opioid for other sx Occasional dose increases Unintended psychic effects Non adherence/intolerance to other treatments Missed appointments Presents sedated Opioid withdrawal symptoms Non-prescribed opioid in UDT Portenoy, 1994, in "Progress in Pain Research and Management" 10

11 Differential Diagnosis of Aberrant Behaviours Inadequate pain management Inadequate analgesia in stable condition (pseudoaddiction) Progression of disease Exacerbation of symptoms (pseudotolerance) New disease Medication interactions Opioid tolerance Opioid-induced hyperalgesia Opioid-resistant pain Inability to adhere to treatment Cognitive impairment Psychiatric disorder Self medication Sleep Acute trauma Depression, anxiety, stress (chemical coping) Opioid Withdrawal Diversion Analgesia for others Profit Savage, 2002, Clin J Pain Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion 11

12 Pseudoaddiction Under treated pain resulting in drug seeking behaviour which is misinterpreted as inappropriate Behaviour ceases when adequate pain relief provided Aberrant Behaviours Suggestive of Pseudoaddiction Requests for increased dose Seeks opioids from other sources (ER, pharmacy) Drug hoarding Requests for specific opioid Preoccupation with opioid Unsanctioned dose increases Requests for early refills Schnoll et al, 2003, Am J Addiction Pseudoaddiction Treatment Trial of dose increase Increase monitoring 12

13 Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Opioid Tolerance Repeated exposure results in decreased therapeutic effect or need for higher dose to maintain the same effect tolerance to analgesic effects of opioids develops slowly not a common clinically significant problem tolerance to euphoric effects of opioids develops rapidly Chang et al, 2007, Med Clin N Am Opioid Tolerance Treatment Trial of dose increase Increase monitoring 13

14 Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Pseudotolerance adequate pain relief increased activities increased pain request for increased dose of opioid Pseudotolerance Treatment Review pacing strategies Review functional expectations Pain self management program Consider a dose increase 14

15 Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Opioid Induced Hyperalgesia Increased sensitivity to pain resulting from opioid exposure hyperalgesia, allodynia diffuse, poorly defined pain beyond the preexisting pain distribution not explained by disease progression Chang et al, 2007, Med Clin N Am Opioid Induced Hyperalgesia Treatment Opioid taper Opioid rotation methadone, buprenorphine Ramasubbu et al, 2011, J Pain Palliat Care Pharmacol Lee et al, 2011, Pain Phys 15

16 Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Failed opioid trial Not all pains are opioid responsive Watchful dose: 200 mg morphine equivalent Indicators of failed trial No significant functional improvement No significant pain reduction Complications (sleep apnea, cognitive dysfunction, sedation, addiction, OIH) Intolerable side effects Failed Opioid Trial Treatment Taper opioid to last effective dose or to zero Consider opioid rotation 16

17 Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Opioid Withdrawal Reduction of occupied μ receptors due to decreasing opioid blood levels Dosing interval too long withdrawal 3 0 dose Opioid Withdrawal Diffuse pain beyond pre-existing pain distribution bone pain, joint pain or total body pain focused in legs exacerbation of pre-existing chronic pain Other withdrawal symptoms present early: restlessness, agitation, insomnia, sweats late: nausea, vomiting, diarrhea, abdominal cramps Usually with immediate release preparations, but can occur with sustained release 17

18 Opioid Withdrawal Treatment immediate release opioid: switch to sustained release sustained release opioid: q8h dosing Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Chemical coping Maladaptive coping using self medication for non-pain problems Insomnia Depression Anxiety Stress Effects of dose increase lasts 3 to 4 months Aberrant behaviours, but no loss of control All addicts are chemical copers but not all chemical copers are addicts Kirsh et al, 2007, Palliat Supp Care 18

19 Chemical Coping Treatment Treat non-pain conditions Titrate opioid dose in response to pain and pain-related function only Monitor closely Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Aberrant Drug Related Behaviours serious Selling drugs Stealing drugs Forging prescription Injecting oral drug Double doctoring Drugs from street/friends Illicit drug use Presents intoxicated Frequent requests for early refills Drug binging Multiple unsanctioned dose increases Recurrent lost prescriptions Deterioration in function Resistance to change in therapy in spite of adverse effects Drug-related crime Involved with drug culture Refuses UDT Portenoy, 1994, in "Progress in Pain Research and Management" 19

20 Addiction primary, chronic neurobiologic disease with genetic, psychosocial and environmental factors influencing its development and manifestations characterized by impaired control, compulsive use, continued use despite harm, and craving Savage et al, 2001, Consensus Document: AAPM, APS, ASAM Behaviours Suggesting Addiction Continued use despite harm Overmedicated: intoxicated, sedated, somnolent Declining function Increased sleep disturbance and pain Relationship dysfunction Impaired control, compulsive use Lost prescriptions, early refills Urgent calls, unscheduled visits Abusing alcohol, benzodiazepines, amphetamines or ilicit drugs Cannot produce medication on request Withdrawal symptoms noted Medication overuse or sporadic use Preoccupation with drug, craving Frequent missed appointments Resistant to non-opioid treatment, nothing works except opioids Intolerance to non-opioid medications Requests medications with high reward potential Altering route of delivery: injecting, crushing, biting Obtaining opioids from the street Savage, 2002, Clin J Pain Addiction Treatment Treat as CNCP with opioid addiction 20

21 Differential Diagnosis of Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Diversion Obtaining prescriptions for psychoactive drugs for unintended use by making false or exaggerated claims of pain and/or distress Sold or traded to obtain another drug for own abuse or addiction problem Diverted to friend/family for addiction or pain Sold for profit Diversion End of day, after hours, high volume Regular physician unavailable Multiple prescribers and pharmacists Pain unbearable, lack of objective signs headache, low back pain, abdominal/pelvic pain Elaborate stories, evasive answers Knowledgeable of pain disorder and drugs 21

22 Diversion Focuses on opioid Allergic/intolerant/resistant to non-opioid treatment nothing else works Requests for specific opioid immediate release with market value Manipulation flattery, pleading, anger, threats, guilt Creates sense of urgency Prescribed opioid not in urine Concentration of measured drug below cutoff (false ve) Synthetic/semisynthetic opioid not detected Rapid metabolism metabolic, pharmacologic induction Patient binging pseudoaddiction, chemical coping, addiction Patient taking less medication than prescribed side effects, symptom abatement, fear of addiction, hoarding Diversion Adulterated urine Laboratory error Heit et al, 2004, J Pain Symptom Manage; Reisfield, 2009, Bioanalysis Diversion Treatment Taper to zero Discontinue opioid without taper 22

23 Managing Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Chemical coping Diversion Managing Aberrant Behaviours Pain related problems Inadequate analgesia (pseudoaddiction) Tolerance Exacerbation of pain symptoms (pseudotolerance) Opioid induced hyperalgesia Failed opioid trial Non-pain related problems Opioid withdrawal Less Serious Chemical coping Diversion More Serious Aberrant Drug Related Behaviours less serious Multiple requests for dose Drug hoarding Openly getting opioids from pharmacy or other MD Requesting specific opioids (short acting) Concern from family/friends Requests for faxed Rx or fitin appointments Requests for Rx for travel Multiple injuries/accidents Requests for early refills Using opioid for other sx Occasional dose increases Unintended psychic effects Non adherence/intolerance to other treatments Missed appointments Presents sedated Opioid withdrawal symptoms Non-prescribed opioid in UDT Portenoy, 1994, in "Progress in Pain Research and Management" 23

24 Aberrant Drug Related Behaviours more serious Selling drugs Stealing drugs Forging prescription Injecting oral drug Double doctoring Drugs from street/friends Illicit drug use Presents intoxicated Frequent requests for early refills Drug binging Multiple unsanctioned dose increases Recurrent lost prescriptions Deterioration in function Resistance to change in therapy in spite of adverse effects Drug-related crime Involved with drug culture Refuses UDT Portenoy, 1994, in "Progress in Pain Research and Management" CNCP with? Addiction Rule out disease progression adherence and psychological issues drug interactions new pain Trial of dose increase or opioid rotation Chang et al, 2007, Med Clin N Am CNCP with? Addiction If: pain and/or function worsens or does not consistently improve to dose increases or: aberrant behaviours persist Consider failed opioid trial, OIH, chemical coping (less serious AB) addiction or diversion (more serious AB) Chang et al, 2007, Med Clin N Am 24

25 Summary 1. Maximize non-opioid therapy 2. Maintain boundaries 3. CNCP with history of addiction i. Tighten boundaries according to risk Summary 4. CNCP with active addiction i. Depressants: no opioid until in recovery ii. Stimulants: no opioid until in recovery or very tightly controlled opioid (daily witnessed dispensing) iii. Opioids: methadone or buprenorphine q8h 5. CNCP and? Addiction i. Carefully consider differential diagnosis of aberrant behaviours Thank you John Fraser