Chronic Pain and Addiction National Rx Drug Abuse Summit 4-10-12

1. Chronic Pain and
Addiction
April 10-12, 2012
Walt Disney World Swan Resort

2. Learning Objectives:
1. Distinguish the differences between proper
management of chronic pain and practices
that contribute to over-prescribing and drug
abuse.
2. Describe the effects and consequences of
prescription pain abuse as it progresses over
time.
3. Advocate the importance of continuing
education on addiction for pain
management providers.

3. Disclosure Statement
• Dr. Barbara Krantz has disclosed no relevant, real or apparent
personal or professional financial relationships.
• Dr. Lynn R. Webster has disclosed that he has a relationship with
AlphaBioCom, American Academy of Pain Management,
American Board of Pain Medicine, Cephalon, Inc., Covidien
Mallinckrodt, Pfizer, Adolor Corp, Alkermes Inc., Allergan Inc.,
Astellas, AstraZeneca, Bayer Healthcare, BioDelivery Systems
International, Boston Scientific, Cephalon, Collegium
Pharmaceuticals, Covidien, Eisai, Elan Pharmaceuticals, Gilead
Sciences, GlaxoSmithKline, Identigene (Sorenson), King
Pharmaceuticals, Meagan Medical, Medtronic, Merck, Naurex,
Nektar Therapeutics, NeurogesX Inc., Novartis, SchaBar, Shionogi
USA Inc., St. Renatus, SuCampo Pharma Americas USA, Takeda,
TEVA Pharmaceuticals (Sub-1), Theravance Inc., Vanda, Vertex,
Xandoyne Pharmaceuticals

4. Chronic Pain &
Addiction
Lynn R. Webster, MD
Medical Director, Lifetree Clinical Research
Salt Lake City, UT
(801) 269-8200
LRWebsterMD@gmail.com
Twitter: @LynnRWebsterMD

5. Finanical Disclosure
• Consultant/Honoraria/Advisory Board
– AlphaBioCom, American Academy of Pain Medicine,
American Academy of Pain Management, Boston
Scientific, Cephalon, Covidien, Medtronic, Pfizer
• Research
– Adolor, Alkermes, Allergan, Astellas, AstraZeneca, Bayer
Healthcare, BioDelivery Sciences International, Boston
Scientific, Cephalon, Collegium, Covidien, Eisai, Elan, F.
Hoffman La-Roche, Gilead, GlaxoSmithKline, Identigene
(Sorenson), King, Meagan Medical, Medtronic, Merck,
Naurex, Nektar, NeurogesX, Novartis, Pfizer, Professional
Service Solutions, Inc, SchaBar, Shionogi, Shire, St. Renatus,
Sucampo, Takeda, TEVA, Theravance, US WorldMeds,
Vanda, Vertex, Xanodyne Pharmaceuticals

7. The Opioid Pendulum
Avoidance
Even
dying
people
at
risk
Widespread
Use
for
addic4on
Opiophobia
must
go
Balance
Risk
stra4fica4on
and
principles
of
addic4on
medicine
applied
to
opioid
prescribing
regardless
of
the
pain
problem
at
hand

8. Definition of Terms
 Use
of
a
medica4on
(for
a
medical
purpose)
other
than
as
directed
or
as
Misuse
indicated,
whether
willful
or
uninten4onal,
and
whether
harm
results
or
not
 Any
use
of
an
illegal
drug
 The
inten4onal
self
administra4on
of
a
medica4on
for
a
non-­‐medical
Abuse
purpose
such
as
altering
one’s
state
of
consciousness,
e.g.
geFng
high
 A
primary,
chronic,
neurobiological
disease,
with
gene4c,
psychosocial,
and
environmental
factors
influencing
its
development
and
manifesta4ons
Addic0on
 Behavioral
characteris4cs
include
one
or
more
of
the
following:
Impaired
control
over
drug
use,
compulsive
use,
con4nued
use
despite
harm,
craving
 The
inten4onal
removal
of
a
medica4on
from
legi4mate
and
dispensing
Diversion
channels
Katz
N,
et
al.
Clin
J
Pain.
2007;23:648-­‐660.

9. Major Opioid Risks
• Opioid Use Outcomes
– Misuse
– Abuse
– Addiction
– Death
• Diversion

10. Statistics on Substance Use and
Chronic Pain in the United States
Category Statistic
Chronic pain patients who may have addictive 32 % (Chelminski et al., 2005)
disorders
People ages 20+ who report pain that lasted 56% (National Center for Health Statistics, 2006)
more than 3 months
People experiencing disabling pain in the 36% (Portenoy, Ugarte, Fuller & Haas, 2004)
previous year
People ages 65+ who experience pain that has 57% (National Center for Health Statistics, 2006)
lasted more than 12 months
Civilian, noninstitutionalized U.S. residents ages 5% (Substance Abuse and Mental Health
12+ who report nonmedical use* of pain relievers Services Administration [SAMHSA], 2007)
in past year
People ages 12+ who report that they initiated 19% (SAMHSA, 2008)
illegal drug use with pain relievers
People with opioid addiction who report chronic 29-60% (Peles, Schreiber, Gordon & Adelson,
pain 2005; Potter, Shiffman & Weiss, 2008; Rosenblum
*Nonmedical
use
is
use
for
purposes
other
than
that
for
which
the
medica4on
was
prescribed
et al., 2003; Sheu et al., 2008)
Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use
Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2011.

11. Spectrum of Behaviors
nal “Self-
reatio Treaters” “Adherent” “Chem
“Rec ers” ic
coper al
us s”
Nonmedical Users Pain Patients
Kirsh,
K.L.,
Passik,
S.D.
The
Interface
Between
Pain
and
Drug
Abuse
and
the
Evolution
of
Strategies
to
Optimize
Pain
management
while
Minimizing
Drug
Abuse.
Experimental
and
Clinical
Psychopharmacology
2008,
16
(5):
400-­‐404

12. Prevalence of Opioid Abuse/Addiction
Aberrant
Behavior:
40%
Abuse:
20%
Total
Pain
Addic0on:
2%
to
5%
Popula0on
Webster
LR,
Webster
RM.
Pain
Med.
2005;6(6):432-­‐442.

13. Significant Risk Factors for Abuse and
Overdose
• Pharmacologic substance
– Potency
– Tmax
– Cmax
– Availability
• Patient risk factors
– Individual risk factors
– Environmental risk factors
• Prescriber behavior
– Improper patient selection, dosing, and titration
– Improper patient counseling and management

14. Lifetime Opioid-Use Disorder Among Outpatients
on Opioid Therapy for Non-Cancer Pain
Associated With:
N
=
705
Source: Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients:
comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011 Jul-Sep;20(3):185-94.

15. Patient Risk Factors for Aberrant Behaviors/
Harm
Biological
Biological
Psychiatric
Psychiatric
Social
• Age
≤45
years
• Substance
use
• Prior
legal
problems
• Gender
disorder
• History
of
motor
• Family
history
of
• Preadolescent
vehicle
accidents
sexual
abuse
• Poor
family
support
prescription
drug
or
(in
women)
alcohol
abuse
• Involvement
in
a
• Cigarette
smoking
• Major
psychiatric
problematic
disorder
• Physical
Illnesses
subculture
(eg,
personality
• Pain
severity
disorder,
anxiety
or
• Unemployed
depressive
disorder,
• Isolation
• Pain
duration
bipolar
disorder)
• Sleep
disorders
• Depression
Katz NP, et al. Clin J Pain. 2007;23:103-118; Manchikanti L, et al. J Opioid Manag. 2007;3:89-100.
Webster LR, Webster RM. Pain Med. 2005;6:432-442.
Cheatle MD. Depression, Chronic Pain, and Suicide by Overdose: On the Edge. Pain Medicine. 2011;12(s2):S43-S48.
Utah Drug Overdose Mortality Report: Findings from interview with family and friends of Utah residents aged 13 and older who died of a drug overdose between
October 26, 2008 and October 25, 2009. Prepared by the Utah Department of Health.

16. Pain, Opioid Use and
Psychiatric Co-morbidities
Managing a critical
interplay…
Pain Opioids Psychiatr
ic Illness

17. The Chemical Coper
Key
Clinical
Features
*Alexythymic
*Soma4zing
*Overly
drug
focused
*Unmo4vated
for
non-­‐drug
therapies
*Make
li_le
progress
towards
psychosocial
goals

18. Major Depression & Pain
Blair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: A literature review. Arch Intern Med 2003; 163(20): 2433-45.

19. Depression & Pain
Comorbid Depression Chronic Pain
35%
21.9%
N=
1,179
Miller
LR,
Cano
A.
Comorbid
chronic
pain
and
depression:
Who
is
at
risk?
J
Pain
2009;
10(6):
619-­‐627

20. Depression
• Patients who have CNCP and comorbid
depression tend to:
– Have high pain scores
– Feel less in control of their lives
– Use passive-avoidant coping strategies
– Adhere less to treatment plans than patients who
are not depressed
– Have greater interference from pain, including
more pain behaviors observed by others
– Respond less well to pain treatment, unless
depression is addressed
Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use
Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2011.

21. Depression and Pain vs Smoking
Status
%
Hooten
WM,
Shi
Y,
Gazelka
HM,
Warner
DO.
(2011).
The
effects
of
depression
and
smoking
on
pain
severity
and
opioid
use
in
pa4ents
with
chronic
pain.
Pain
103,
16-­‐24.

22. ORT Validation
Mark
each
box
that
applies
Female
Male
1. Family
history
of
substance
abuse
 Alcohol

1

3
 Illegal
drugs

2

3
 Prescrip0on
drugs

4

4
2. Personal
history
of
substance
abuse
 Alcohol

3

3
 Illegal
drugs

4

4
 Prescrip0on
drugs

5

5
3. Age
(mark
box
if
16-­‐45
years)

1

1
4. History
of
preadolescent
sexual
abuse

3

0
ADD,
attention
deficit
disorder;
5. Psychological
disease
N=185
OCD,
obsessive-­‐compulsive
 ADD,
OCD,
bipolar,
schizophrenia

2

2
disorder.
 Depression

1

1
Webster
L,
Webster
R.
Pain
Med.
2005;6:432-­‐442.

23. Predicting Aberrant Drug
Behavior
Importance of Abuse History
Michna
E,
Ross
EL,
Hynes
WL,
et
al.
Predic4ng
aberrant
behavior
in
pa4ents
treated
for
chronic
pain:
Importance
of
abuse
history.
Journal
of
Pain
&
Symptom
Management
2004;
28(3)250-­‐8.

24. Opioid Use in High vs Low Risk
Patients
%

25. Genetic Vulnerability to
Addiction?
Fisher
344
Abs0nence
Drug
Rejec0ng
Lewis
Polysubstance
Drug
Seeking
Abuse
Sprague-­‐Dawley
Average
Drug
Neutral
Webster
L,
Dove
B;
Avoiding
Opioid
Abuse
While
Managing
Pain:
A
Guide
for
Practitioners.
1st
ed.
North
Branch,
MN:
Sunrise
River
Press;
2007.

26. Vulnerability to Opioid Addiction
Individuals
respond
differently
to
opioid
exposure
No
addic0ve
disease
with
exposure
No
addic0ve
disease
due
to
lack
of
exposure
Addic0ve
Disease
aRer
opioid
exposure

27. Level of Abuse in Stressful
Environments
Drug-­‐Abusing
Behavior
Low
Moderate
High
Pa0ent
Stress
Level
Webster
L,
Dove
B;
Avoiding
Opioid
Abuse
While
Managing
Pain:
A
Guide
for
Practitioners.
1st
ed.
North
Branch,
MN:
Sunrise
River
Press;
2007.

28. Suicide
20061
19991
2005
–
2007
1Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2005. NCHS Data
Brief 2009;22:1-8.
2Substance
Abuse
and
Mental
Health
Services
Administra4on,
Office
of
Applied
Studies.
Drug
Abuse
Warning
Network,
2007:
Es4mates
of
Drug-­‐Related
Emergency
Department
Visits.
Rockville,
MD:
Author,
2010.

29. Why Suicide?
Non-Pain Patients
Escape
from
severe
suffering
Only
option
Hopelessness
Permanent
Solution
Krao
TL,
Jobes
DA,
Lineberry
TW,
Conrad
A,
Kung
S.
Brief
report:
Why
suicide?
Percep4ons
of
suicidal
inpa4ents
and
reflec4ons
of
clinical
researchers.
Arch
Suicide
Res
2010;14(4):375-­‐82.

30. Suicide Ideation in Chronic Pain
Patients
• Hitchcock1
N=153
– 50% chronic pain pts
had suicidal
thoughts due to pain
• Fishabain2
– Pain severity
– Severe comorbidity
(depression)
1Hitchcock LS, Ferrell BR, McCaffery M. The experience of chronic nonmalignant pain. J Pain Symptom Manage 1994;9(5):213-8.
2FishbainDA. The association of chronic pain and suicide. Semin Clin Neuropsychiatry 1999;4)3):221-7.
3Smith MT, Edwards RR, Robinson RC, Dworkin RH. Suicidal ideation, plans and attempts in chronic pain patients: Factors associated with
increased risk. Pain 2004;111(1-2):201-8.

31. Risk for Suicide
Pain Patients
 Family history of  History of substance
suicide abuse
 History of childhood  Impulsive and
abuse aggressive behaviors
 Previous suicide  Losses such as work,
attempts family, self-esteem
 History of mental  Isolation
disorder, particularly  Physical illness
depression
 Hopelessness
+1:
Access
to
poten0ally
lethal
doses
of
prescrip0on
medica0ons
(ie
opioids)
1Fishbain
DA. The association of chronic pain and suicide. Semin Clin Neuropsychiatry 1999;(3):221-7.
2TangNK, Crane C. Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. Psychol
Med 2006;36(5):575-86.

32. Mitigate Risk
• Prescription monitoring programs
• Urine drug test
• Opioid agreements
• Mental health evaluations
• Limit dose where appropriate
32

33. Mitigate Risk
Cheatle
MD.
Depression,
Chronic
Pain,
and
Suicide
by
Overdose:
On
the
Edge.
Pain
Medicine.
2011;12(s2):S43-­‐S48.

34. Risk Stratification
Lower
Risk
Moderate
Risk
Higher
Risk
Primary
Care
Primary
Care
Patients
with
Pain
Specialist
Patients
Specialist
Support
Patients
ORT
Score:
0-­‐3
ORT
Score:
4-­‐7
ORT
Score:
8+
• No
past
or
current
• May
be
a
past
history
of
• Active
substance
use
history
of
substance
use
substance
use
disorders
disorders
disorders
• May
be
family
history
of
• Major,
untreated
• No
family
history
of
past
problematic
drug
use
psychopathology
or
current
substance
use
• May
have
past
or
• Poor
social
support
disorders
concurrent
• Actively
addicted
• No
major
or
untreated
psychopathology
• Inconsistent
UDT
psychopathology
• Not
actively
addicted
• PMP
multiple
prescribers
• Consistent
UDT
• Usually
consistent
UDT
• Moderate
to
sever
pain
• PMP
consistent
• PMP
consistent
• Pain
mild
to
moderate
• Mild
to
severe
pain
Adapted
from
Gourlay
DL,
Heit
HA,
Almahrezi
A.
Universal
precautions
in
pain
medicine:
A
rational
approach
to
the
treatment
of
chronic
pain.
Pain
J
Med.
2005;6(2):107–112
and
Webster
LR
Webster
RM.
Predicting
aberrant
behaviors
in
opioid-­‐
treated
patients:
preliminary
validation
of
the
Opioid
Risk
Tool.
Pain
Med.
2005;
6(6):432-­‐442.

35. 8
Prescribing
Guidelines
1. Assess
risk
for
opioid
abuse
2. Assess
and
treat
co-­‐morbid
mental
health
3. Use
conversion
tables
cau4ously
4. Avoid
benzodiazepines
with
opioids
5. Start
opioids
low
and
advance
slowly
6. Assess
for
sleep
apnea
at
>
100
mg/day
7. Reduce
opioids
with
URI’s,
flu
and
asthma
8. Avoid
long
ac4ng
opioids
with
acute
pain
http://www.painfoundation.org/painsafe/safety-tools-resources/

36. 8
Ways
Pa4ents
can
Prevent
Overdose
Deaths
1. Never
take
prescrip4on
pain
medica4on
that
is
not
prescribed
to
you
2. Never
adjust
your
own
doses
3. Never
mix
with
alcohol
4. Taking
sleep
aids
or
an4-­‐anxiety
medica4ons
together
with
prescrip4on
pain
medica4on
can
be
dangerous
5. Always
tell
your
healthcare
provider
about
all
medica4ons
you
are
taking
from
any
source
6. Keep
track
of
when
you
take
all
medica4ons
7. Keep
your
medica4ons
locked
in
a
safe
place
8. Dispose
of
any
unused
medica4ons
http://www.painfoundation.org/painsafe/safety-tools-resources/

37. Conclusion
• Pain is the most common cause of
disability in America
• Substance abuse is a serious public
health issue
• Co-occurring pain and substance
abuse is common and major
challenge for clinicians
• Treating pain while minimizing opioid
abuse requires vigilances and
compassion 37

38. Thank you!