Co-occurring Disorders: Pain, Depression and Substance Abuse

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Co-occurring Disorders Pain, Depression and
Substance Abuse

• Walter Ling MD
• Integrated Substance Abuse Programs
• UCLA
• lwalter_at_ucla.edu
• www.uclaisap
• Fifth Annual Statewide Conference on Co-Occurring
  Disorders
• October 3, 2006
• Long Beach Convention Center
• Long Beach, California

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Scope of the Talk

• Whats the big deal? Why bother with it?
• How big a problem is it?
• How do we go about it?
• What can we do?
• A few specific tricks?

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Whats the Big Deal?

• Common clinical problems
• Overlaps in neurobiology
• Confusing diagnosis
• Complicates treatment , presence of one predicts
  poor treatment outcome of the other
• Strain on treatment systems and resources

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Whats the Problem?

• Estimates of psychiatric co-morbidity among
  clinical populations in substance abuse treatment
  settings range from 20-80
• Estimates of substance use co-morbidity among
  clinical populations in mental health treatment
  settings range from 10-35
• Differences in incidence due to nature of
  population served (eg homeless vs. middle
  class), sophistication of psychiatric diagnostic
  methods used (psychiatrist or DSM checklist) and
  severity of diagnoses included (major depression
  vs. dysthymia).

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ECA DSM-III Diagnoses (rates per 100 people)
1 Month Lifetime
Any Alcohol, Drug or Mental Health Disorder 15.7 32.7
Any Mental Disorder 13.0 22.5
Alcohol Dependence 1.7 7.9
Drug Dependence 0.8 3.5
Regier, et al. (1990)
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Lifetime Prevalence and Odds Ratios ECA Study
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Chronic pain, Depression and Anxiety

• National Co-morbidity Study (8098 15-54 y.o.
  chronic pain arthritic patients vs general
  population control)
• Mood disorder 27 patients vs 10 controls
• Anxiety disorder 35 vs 9
• Depression 20 vs 9
• Generalized anxiety disorder 7 vs3
• Panic disorder 7 vs 2
• PTSD 11 vs 3
• Odds of disability from chronic pain increase
  anxiety (2.86) depression (2.8)panic disorder (
  4.27)

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The ideal, but infrequent patients for the
separated service delivery systems

• The mental health service system
• The uncomplicated schizophrenic
• The simple affective disordered individual
• The pure bi-polar patient

• The substance abuse service system
• The plain alcoholic
• The addict who uses only heroin
• The stimulant dependent individual w/o other
  psych diagnoses

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Drug Induced Psychopathology

• Symptom Groups
• Depression
• Anxiety
• Psychosis
• Mania
• Rounsaville 90

• Drug States
• Withdrawal
• Acute
• Protracted
• Intoxication
• Chronic Use

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Likelihood of a Suicide Attempt

• Increased Odds Of Attempting Suicide
• 62 times more likely
• 41 times more likely
• 8 times more likely
• 11 times more likely
• ECA EVALUATION

• Risk Factor
• Cocaine use
• Major Depression
• Alcohol use
• Separation or Divorce
• NIMH/NIDA

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Facts about Suicide

• 500,000 ER visits for attempts in 1997
• Four times as many US citizens died by suicide
  during the Viet Nam War period than died as
  soldiers.
• Rates increase with age ( as do other causes of
  death)
  CDC web site
• Suicide rate among addicts is 5-10 times that of
  non-addicts
  
  Preuss/Schuckit Am J Psych 03
• 
  

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Less than than half of the women with
interpersonal trauma and co-morbidity will
receive treatment that addresses their trauma
history and co-occurring conditions

(Timko Moos, 2002).
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Comorbidity of Depression and Anxiety Disorders
50 to 65 of panic disorder patients have
depression
Panic Disorder
70 of social anxiety disorder patients have
depression
49 of social anxiety disorder patients have
panic disorder
HIGHLY COMMON HIGHLY COMORBID
Social Anxiety Disorder
Depression
67 of OCD patients have depression
11 of social anxiety disorder patients have OCD
OCD
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The Four Quadrant Framework for Co-Occurring
Disorders

• A four-quadrant conceptual framework to guide
  systems integration and resource allocation in
  treating individuals with co-occurring disorders
  (NASMHPD,NASADAD, 1998 NY State Ries, 1993
  SAMHSA Report to Congress, 2002)
• Not intended to be used to classify individuals
  (SAMHSA, 2002), but  . . . 

High severity
More severemental disorder/more severe
substanceabuse disorder
Less severemental disorder/more severe
substanceabuse disorder
Less severemental disorder/less severe
substanceabuse disorder
More severemental disorder/less severe
substanceabuse disorder
High severity
Lowseverity
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DSM and ICD The Bibles
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Assessing for addiction in pain patients
Diagnostic and Statistical Manual of Mental
Disorders

• Substance Abuse
• One or more within a 12 month period
• Failure to fulfill major role obligation
• Recurrent use in hazardous situations
• Recurrent legal problems
• Recurrent social or interpersonal problems

• Substance Dependence
• Three or more within a 12 month period
• Abuse criteria, plus
• Tolerance
• Withdrawal
• Larger amount/longer time than intended
• Persistent desire to control use
• Great deal of time spent in activities related to
  use

4th ed, APA, 1994
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Pain and Depression

• What comes first?
• The antecedent hypothesis
• The consequence hypothesis
• The scar hypothesis
• Pain-prone personality
• Life experience and personal mastery
• Does it really matter?
• Pain and depression make each other worse

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Pain and Depression

• Between 30 and 60 of depressed patients have
  chronic pain
• Chronic pain patients who are depressed are 9
  times more likely to be disabled
• This depression is responsive to treatment
• Treatment lowers pain intensity and improves
  function and quality of life
• Treatment needs to be adequate and sustained
  combined pharmacotherapy with behavioral therapy,
  aim to improve self management, beware of
  increased suicide risks

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Depression IS Pain

• Pain is second most common somatic symptom in
  depression, second only to insomnia.
• Pain occurs in over 50 of depressed patients
• Common pain in depressed patients headaches,
  facial pain, neck and back pain, chest and
  abdominal pain and extremity pain
• Pain often dominate clinical picture
  overshadowing other depressive symptoms

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Pain and Depression

• Pain is depressive equivalent
• Chronic pain leads to depression
• Circular relationship, vicious circle
• Common association and overlapping
• Common neurobiological substrate
• Psychological determinants critical
• Responsive to antidepressants
• Non-pharmacological strategies critical

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Pain and Depression

• Two thirds of new neurological patients have
  pain.
• One third are depressed 75 of them have pain.
• One quarter have both pain and depression.
• Neuropathy, neuromuscular disease, headaches.
• Sx persist at 3 12 mo. follow up
• Pain predicts depression at f/u and vice versa
• Odds of pain increase female, depressed, NMD
• Odds of depression increase CVD, Cognitive dis

Williams LS et al J Neuro Neurosurg Psych. 2003
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Pain IS Depression

• Somatic cyclothymia
• Periodic melancholy
• Vegetative depression
• Masked depression
• Affective equivalents
• Depressive equivalents
• Variant of depressive disease

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Pain and Depression

• Co-occurrence makes diagnosis difficult
• Pain patients tend to show more irritability,
  anhedonia, loss of interest, reduced capacity to
  experience pleasure.
• Depressed patients tend to exhibit more
  dysphoria, early morning awakening,
  indecisiveness, despair and suicidal ideations

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Treating Co-morbid Pain and Depression

• Tricylclic antidepressants
• Efficacy in neuropathic pain
• SSRIs
• Safety profile
• Dual-acting agents
• Effective for depression and pain
• Detke MJ 2002

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Treating Co-morbid Pain and Depression

• Non-pharmacological treatment
• Cognitive behavioral treatment
• Operant behavioral treatment
• Biofeedback training
• Motivational interviewing
• Private emotional disclosure
• Integrating pharmacotherapy and behavioral
  treatment

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What happen when pain becomes chronic

• The one certain thing treatment didnt work
• Patient frustrated and lost faith in doctors
• Patient blamed for not getting better
• Lost role becomes dependent on others
• Others must pick up slack and must provide
  support
• Patient feels neglected when others cant do all
• Patient becomes anxious, angry and depressed
• Patient assumes life style of chronic pain

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Chronic pain identifying early risk factors

• Attitude and belief of pain
• Whose fault?
• Behavior and compensation issues
• Dx and Tx issues
• Emotions
• Family
• Work

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Early signs of chronic pain

• Not healing as expected
• Perceived neglect or ill treatment
• Perceived management abandonment
• Not adequately treated
• Accident was some ones fault
• Expanding Sx
• Sleep disturbance, anger fear

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Opioid, Pain and Addiction Confluence of Events

• Under treatment of pain
• Increasing availability of opioids
• Rise in abuse of prescription opioids

New Demand Core competency in pain and in
addiction
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From Pain Relief to Addiction Opioids and the
Faces of Janus

• Relieve pain
• Relieve pain and suffering
• Relieve suffering and misery
• Make you feel better
• Make you feel good
• Make you high

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The Clinicians Dilemma

• What God hath joined together, can man put
  asunder?
• What to do in the meantime to maximize pain
  relief while minimizing abuse ?

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Definitions Addiction

• Addiction- primary, chronic, neurobiologic
  disease characterized by behaviors that include
  one or more of the following impaired control
  over drug use, compulsive use, continued use
  despite harm, and/or craving
• American Pain Society. Available at
  http//www.ampainsoc.org/advocacy/opioids2.htm
• Addiction is not taking a lot of drugs its
  taking drugs and acting like an addict.Alan
  Leshner

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Characterizing Pain

• Pain An unpleasant sensory and emotional
  experience arising from actual or potential
  tissue damage or described in terms of such
  damage
• It is always subjective each individual learns
  the application of the word (pain) through
  experiences related to injury in early lifeIASP

IASP International Association for the Study of
Pain.
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Acute Versus Chronic Pain

• Chronic pain
• Cause not often easily identified
• CNS changes
• Not repeated acute pain episodes

• Acute pain
• Related to a particular event (eg fall)
• Resolution expected within days/weeks

Acute pain a sensation what pain does the
patient have? Chronic pain a life style what
patient does the pain have?
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Pain in Addiction More Than a
Feeling

• Feeling (sensory experience) pain
• Meaning (emotional and cognitive) suffering
• Historicalearly life
• Learnedexperience
• Privatesubjective
• Uniqueindividual
• Actionexpression of the word behavior
• Chronic pain is not having lots of pain it is
  having pain and behaving like a chronic pain
  patient

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The Martyrdom of St. Sebastian by Hans Holbein
(1516)
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Chronic Pain and AddictionCommon Overlapping
Features

• Chronic pain
• Early trauma
• Loss of mastery
• Loss of control
• Loss of sense of self
• Cognitive error
• Personalization
• Overinterpretation
• Catastrophizing

• Addiction
• Early trauma
• Loss of mastery
• Loss of control
• Loss of self-efficacy
• Cognitive error
• Nirvana
• Denial

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Chronic Pain Common in Methadone Clinics

• Over 60 of methadone clinics patients experience
  chronic pain
• Less employed more disabilities
• More medically and psychiatrically ill
• Take more prescribed and non-prescribed
  drugs
• Most feel under treated
• Most believe prescribed opiates led to
  addiction
• Most believe methadone is very helpful
• Most have problems most of their lives
• Most believe always need something to feel
  good
• 
  Ref Jamison et al. (2000)

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With respect to chronic opioid therapy and the
patient with chronic non-malignant pain,

• How does one identify addiction in the patient on
  chronic opioid therapy?
• How does one identify the patient at risk for
  becoming addicted to chronic opioid therapy?

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Published rates of abuse and/or addiction in
chronic pain populations are 10 (3-18)

• Suggests that known risk factors for abuse or
  addiction in the general population would be good
  predictors for problematic prescription opioid
  use
• History of early substance use
• Personal/family history of substance abuse
• Co-morbid psychiatric disorders

Adams et al., 2001 Brown, 1996 Fishbain,
1986, 1992 Kouyanou et al., 1997
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Whos at Risk for Addiction and How to Tell?

• 4 Ways to identify patients at risk
• Historypersonal history and family history
• Screening instruments
• Behavioral checklists
• Therapeutic maneuver

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Screening Instruments

• Several clinical tools are available that
  estimate risk of noncompliant opioid use1,2,3
• The results determine how closely a patient
  should be monitored during the course of opioid
  therapy3
• Scores implying a high risk of abuse are not
  reasons to deny pain relief3

1 Webster, et alr. Pain Med. 20056432. 2
Coambs, et al. Pain Res Manage. 19961155. 3
Butler, et al. Pain. 200411265.
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Opioid Risk Tool (ORT)

• Administration
• On initial visit
• Prior to opioid therapy

• Scoring
• 0-3 low risk (6)
• 4-7 moderate risk (28)
• gt 8 high risk (gt 90)

Webster, et al. Pain Med. 20056432.
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Screener and Opioid Assessment for Patients in
Pain (SOAPP)

• 14-item, self-administered form, capturing the
  primary determinants of aberrant drug-related
  behavior
• Validated over a 6-month period in 175 chronic
  pain patients
• Adequate sensitivity and selectivity
• May not be representative of all patient groups
• A score of 7 identifies 91 of patients who are
  high risk

Butler, et al. Pain. 200411265.
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Aberrant Drug-Taking Behaviors The Model

• Probably less predictive
• Aggressive complaining about need for higher dose
• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs
• Acquisition of similar drugs from other medical
  sources
• Unsanctioned dose escalation 1 2 times
• Unapproved use of the drug to treat another
  symptom
• Reporting psychic effects not intended by the
  clinician

• Probably more predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or borrowing another patients drugs
• Injecting oral formulation
• Obtaining prescription drugs from non-medical
  sources
• Concurrent abuse of related illicit drugs
• Multiple unsanctioned dose escalations
• Recurrent prescription losses

Passik and Portenoy, 1998
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Aberrant Behaviors
N388
Passik et al. 2003
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Aberrant Behaviors in Cancer and AIDS
Passik et al. 2003
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Therapeutic Maneuver Is the Pain Patient
Addicted?
Drug-seeking or increased requests for pain
medication
? Pathology/pain of new source
Detailed pain work-up
No new pain pathology
? Opioid dose
Improved functioning Absence of toxicity
Unimproved functioning Presence of toxicity
Therapeutic dependence
Pseudoaddiction
Addictive disease
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Treating Pain with Opioids What Can We Expect
to Achieve?

• Reduction in pain and suffering
• Meaningful pain reduction (Analgesia Pain)
• Acceptable side effects (Adverse effects Price)
• Improved functionality
• Meaningful functional improvement (Activities
  Performance)
• No unacceptable aberrant behavior (Aberrant
  bahavior Pees
• The 4 As (Passik) the 4
  Ps

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Meaningful Pain Reduction How Much?

• Using a VAS or numeric scale of 010 (46
  moderate pain 710 severe pain)
• For moderate pain (mean 6)
• Meaningful reduction 2.4 (40)
• Very much better 3.5 (45)
• For severe pain (mean 8)
• Meaningful reduction 4.0 (50)
• Very much better 5.2 (56)

VAS visual analogue scale. Cepeda MS. Pain.
2003105151157. Evidence Level B
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Analogue Pain Scale
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Evaluation of Functional Restoration

• physical capabilities
• psychological intactness
• family and social interactions
• Relationships with healthcare professionals and
  therapeutic outcomes
• degree of health care utilization
• drug use for symptom control

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Remission of Addictive Disease

Improves Pain and Functionality

• Increased ability to comply with regimes
• Enhanced cognitive skills
• Able to use behavior modification techniques
• Improved social support
• Better management of neuropsychiatric problems
• Improved stress control

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Meaningful Functional Improvement My Favorites

• Patient perspective of improvement
• Used to do, cant do now, would like to do again
• Could be physical, social, recreational
• With friends, family, church, neighborhood
• Achievable, enjoyable, and meaningful
• Hobbies
• Volunteer work

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Pain Behavior

• Pt behavior is total out put of
• Belief
• Emotional reaction to perceived pain
• Modulation by internal neural mechanism
• Modulation by external social mechanism (family)

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Belief, Expectation, Outcome

• What you believe and expect and do as a result
  are far more important than what situation youre
  in.
• Prayers and hope are useless if you dont
  recognize the answers.
• Behavior are largely self-fulfilling prophesies
  if the sky falls, it will fall on those who
  believe the sky is falling
• Pain is part of life, so is uncertainty

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Dr. to Patients

• What are your concerns, worries, and goals for
  this visit?
• What condition you have, what will happen, what
  we can expect, and why we recommend what we
  recommend
• Here are some specific strategies for Sx relief
  and for high risk situations
• Lets develop a plan for your future

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Treating Neuropathic Pain

• Five first-line drugs
• Gabapentin
• 5 lidocaine patch
• Opioid analgesics
• Tramadol
• Tricyclic antidepressants
• NIH consensus panel Arch Neurology 2003
  601537-1540

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Opioids for Neuropathic Pain

• Postherpetic neuralgia
• Neurology 1998 50 1837-41(60 mg/d )
• Neurology 2002 591015-21 (controlled release ms
  240 mg/d
• Diabetic neuropathy
• Neurology 2003 60927-34 (120 mg Oxycontin)
• Phantom limb pain
• Pain 2001 9047-55 (300mg/d)
• Peripheral and central neuropathic pain
• NEJM 2003 348 1223-1232

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Documentation

• Why opioids are prescribed in this case
• What reduction in pain has been achieved
• What functional improvement has occurred
• Document acceptable side effects
• Document responsible medication use and absence
  of aberrant behaviour

Remember 1.What is not written down didn't
happen. 2.Your record will testify in public not
what patients you have but what doctor they have

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Summary

• Pain and addiction public health problems
• Opioids critical in both
• Demarcation is not always clear
• Pathophysiological and clinical overlaps
• Identifying risks challenging, not hopeless
• Core competency in both pain and addiction

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Treatment of Co-occurring Disorders

• Treatment System Paradigms
• Independent, disconnected
• Sequential, disconnected
• Parallel, connected
• Integrated

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Treatment of Co-occurring Disorders

• Independent, disconnected model
• Result of very different and somewhat
  antagonistic systems
• Contributed to by different funding streams
• Fragmented, inappropriate and ineffective care

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Treatment of Co-occurring Disorders

• Sequential Model
• Treat SA Disorder, then MH disorder
• Treat MH Disorder, then SA disorder
• Urgency of needs often makes this approach
  inadequate
• Disorders are not completely independent
• Diagnoses are often unclear and complex

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Treatment of Co-occurring Disorders

• Parallel Model
• Treat SA disorder in SA system, while
  concurrently treating MH disorder in MH system.
  Connect treatments with ongoing communication
• Easier said than done
• Languages, cultures, training differences between
  systems
• Compliance problems with patients

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Treatment of Co-occurring Disorders

• Integrated Model
• Model with best conceptual rationale
• Treatment coordinated best
• Challenges
• Funding streams
• Staff integration
• Threatens existing system
• Short term cost increases (better long term cost
  outcomes).

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Thank you, thank you, and thank you