Addiction

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Addiction
A primary, chronic, neurobiological disease,
with genetic, psychosocial, and environmental
factors influencing its development and
manifestations.
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Prevalence of Addictive Disorders

• General population 3-18
• Chronic pain population
• 3.2-18 1
• 24 2
• 27 3
• Hospitalized population 20-26 4,5
• Trauma population 40-62 6-9
• Cancer-related pain 27 10

1Fishbain DA, et al. Clin J Pain. 1992877-85.
2Hoffman HG, et al. Int J Addict.
199530919-927. 3Chabaln C, et al. Clin J Pain.
199713150-155. 4Regier DA, et al. Arch Gen
Psychiatry. 198441934-958. 5Graham AW. Arch
Intern Med. 1991151958-964. 6Heinemann A, et
al. Arch Phys Med Rehab. 198869619-624.
7Honkanen R, et al. J Stud Alcohol.
198344231-245. 8Reyna TM, et al. Ann Surg.
1985201194-197. 9Brown RL, et al. Wisc Med J.
199594135-140. 10Bruera E, et al. Acta
Oncologica. 199837749-757.
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Addiction

• Addiction can hide in the fabric of normal
• Seen through the rear-view mirror
• Addiction is not a disease of using, but one of
  thinking and behavior.
• Barry Rosen, MD

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Denial With Chronic Pain

• I only take meds as prescribed
• I only take meds because Im in pain
• Im not addicted
• Im different from others who have addiction
• I never got medications from the street
• I never shoot my drugs
• Im a good citizen

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Addiction

• Physiological, cognitive, and behavioral
  symptoms characterized by
• Loss of control (compulsive use)
• Continuation of use despite adverse consequences
  (family, legal, job, health, social, etc.)
• Preoccupation with obtaining and using the
• drug despite the presence of adequate analgesia
• Urge to rediscover high, which diminishes,
  leaving
• user in a less than normal feeling state
  (dysphoria)

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Addiction 5 Cs
Chronic Compulsive use, not assoc. with
willpower Control-impaired--unable to limit
intake Craving--desire for the drug when it is
absent Continued use despite harmirrational
pursuit of mood change/high at expense of
family, job, emotional well-being, and health
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The Action of Opioids
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Opiate Receptors
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Substance Dependence
DSM-IV Criteria
A problematic pattern of substance use, leading
to significant clinical impairment as manifested
by three or more of the following, occurring at
any time in a 12-month period.
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Substance Dependence
DSM-IV Criteria
5. Great deal of time procuring
hunter and gatherermultiple docs, driving
long distances 6. Important activities
given up 7. Continued use despite knowledge of
harm

• Tolerance
• Withdrawal
• Use of larger amounts over longer period
• Unsuccessful efforts to cut down or control
• substance

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Tolerance

• A state of adaptation in which exposure to a
  drug induces changes that result in a
  diminution of one or more of the drugs effects
  over time.
• Higher dose required to achieve effect.
• Variable over time with patient-to-patient
  variability.
• Tolerance to side effects desirable.
• Not necessarily addiction.

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Physical Dependence

• A state of neuroadaptation to the
• presence of a drug, in which a
• withdrawal syndrome emerges on
• abrupt cessation of the drug or rapid
• reduction of dose.
• Organism functions normally only in the
• presence of the drug.
• Natural physiologic reaction to ongoing
• exposure to certain drug classes.
• Interaction of frequency/duration/dose.

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Aberrant Drug Related Behaviors (Less Predictive)

• Aggressive complaining about the need for higher
  doses
• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs
• Prescriptions from other physicians
• Unsanctioned dose escalation
• Reporting mood altering effect not intended by
  the physician
• Passik and Portenoy, 2003

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Aberrant Drug Related Behaviors (More Predictive)

• Stealing or Borrowing drugs from another
  patient
• Obtaining Rx drugs from non-medical people
• Prescription forgery
• Selling prescription drugs
• Concurrent abuse of related illicit drugs
• Multiple unsanctioned dose escalations
• Repeated episodes of lost prescriptions
• Injecting oral formulations
• Passik and Portenoy

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Negative Consequences

• Pain no better, or only marginal improvement
• Function no better or worse
• Increasing pain complaints
• Cognitive Impairment/Intoxication
• Emotional ability
• Falls/MVAs

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Loss of Control

• Earlier requests for medications
• Unscheduled urgent office visits
• Emergency room visits for Rx
• Prescriptions stolen/lost/the dog ate it
• S.O. reports overuse/abuse intoxication
• Where are the unused pills/used patches?
• Reason for use to relieve emotional symptoms.

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Compulsion

• Preoccupation with meds
• Interested only in pain relief not in other
  rehabilitation activities
• Not interested in non-opioid modalities
• Will end up needing to see other docs
• Failure to comply with non-drug Rxs

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Pain and Addiction
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Pain and Addiction

• Dual diagnosis
• Each feeds on the other if both present
• Negative consequences interrelated

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Seddon Savage, M.D.
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Sleep Disturbance
Secondary Discomforts
Drug Dependence
Addiction
Pain
Functional Disability
Depression
Anxiety
Increased Stresses
Seddon Savage, M.D.
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Addiction-Pain Syndrome
Addiction- Pain Syndrome
Addictive Disorder
Pain Disorder

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Potential Train Wrecks???
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• Emotions and Pain

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Cognitive/Behavioral Therapies Are Effective for
the Treatment of Chronic Pain

• Meta-analysis by Morley et al, 1999 Pain 80
  1-13. Based on 25 controlled trials.
• Cognitive behavioral treatments for chronic pain
  reduce pain experience, behavioral expression of
  pain, and increase positive coping.
• More evidence of effectiveness of these therapies
  than there are for analgesic medications for
  treatment of chronic pain syndrome.

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Conditioning Learning that Pain Can Elicit
Reward

• A noxious stimulation in the presence of
  solicitous spouse
• Compared pain intensity and cingulate
  activation by EEG in the presence and
  absence of the spouse.
• The presence of the solicitous spouse (doting
  and overprotecting when pt. complains of pain)
  increased pain intensity and more than doubled
  cingulate activation from the electrical
  stimulus. Flor et al., 2003.
• Society for Neuroscience Annual meeting

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Conditioning Increases Pain in the Presence of
Cues Predicting Reward

• Social reward can reinforce the experience of
  pain ENABLING.
• Being regularly rewarded for experiencing pain
  will increase the amount of pain one
  experiences.
• This is especially important for patients who
  gain from their pain disability, e.g., receiving
  benefits for having pain can make the pain more
  intense and frequent.
• Physiological learning process
• Involves no conscious deceit or exaggeration on
  the part of the patient.
• Patients truly experience more pain if they are
  being rewarded for it.

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Reward

• Rewarding pain will increase pain.
• Rewarding functioning will increase functioning.
• Clinically, we want to reward non-pain behavior
  and pay less attention to pain behavior.

and the winner is
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The Presenting Complaint is Delivered by the
Patient

• What is a Good patient?
• Severity of symptoms correlates with an overtly
  diagnosable disorder
• Emotionally intact
• Compliant and doesnt challenge
• Grateful
• i.e. a good patient is a good fit with the
  acute medical model

Oresckovich
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Clarify Clinician Role in Treating Pain

• We are treating Pain Behaviornot just Pain!
• Acute Pain is totally different from Chronic
  Pain!
• Chronic Pain is a totally different disease.
• Chronic Pain patients have totally different
  needs.
• Chronic Pain needs a totally different model
• Curative Model
• vs.
• Rehabilitative/Restorative Model
• Paul Farnum, MD
• Physician Health Program, BC

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The CNCP Package

• Duration
• Diagnostic Dilemma
• Dramatization
• Drugs/Dont work
• Dependence
• Disuse/Deconditioning
• Disturbed Sleep
• Depression/Despair (x2!)
• Dysfunction Major!

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At Risk Patient

• Past history of SUD
• Emotionally traumatized
• Dysfunctional/alcoholic family
• Lacks effective coping skills
• Dependent traits
• Stimulus augmentersdeficit in hedonic tone
• Paul Farnum, MD
• Physician Health Program, BC

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Clinician/Physician at Risk Treating the Patient
with Chronic Pain

• Obsessive-Compulsive controlling style
• Perfectionist
• Exaggerated sense of responsibility
• Equate self-worth with success
• Care-aholic
• Strong relationship with patient
• Paul Farnum, MD
• Physician Health Program, BC

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Clinician/Physician at Risk

• Family of origin issues
• A strong and deep need to help
• Orientation toward immediate symptom relief that
  overshadows a consideration of long- term
  consequences
• A touch of grandiosity and omnipotence Only I
  statements
• Inability to handle own feelings if requested
  treatment is withheld
• Paul Farnum, MD
• Physician Health Program, BC

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• Modulating Factors

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Control

• Perceived control
• Gave patients a joystick and told them they could
  lessen the duration of a noxious thermal
  stimulus by making a quick response to a cuethe
  joystick actually did nothing
• Reduced pain intensity
• Reduced activation of the insular and cingulate
  cortices by noxious stimuli
• Therefore, the more patients take control of
  their situation, the less pain they perceive.
• Salomons et al., 2004. J Neurosci 24 7199-7203

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Attention

• Looked at pain from a noxious thermal stimulus
  during an interference task
• The interference task decreased pain intensity
  and activation of the insula.
• Therefore, the less patients focuses on their
  pain, the less the pain is perceived/
  experienced.
• Bantick et al., 2002. Brain 125 310-319

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A Behavioral Therapy Graded Exposure for
Pain-related Fear

• Patient identifies activities he/she fear will
  worsen his/her pain or injury
• Therapist exposes patient to these activities
  then compares pain expectation to actual pain
  experience during tasks

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Daily Log of Exposure Therapy
Daily measures of pain-related fear and pain of
Mr. A during baseline (A-B) and
exposure treatment (B-C).
Vlaeyen et al., 2002. In Psychological Approaches
to Pain management. (Turk Gatchel, eds.)