Dependence, Addiction and Withdrawal

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Dependence, Addiction and Withdrawal

• Kevin Kunz, M.D., M.P.H., FASAM

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Overview1. Changing Opioid Opinions2.
Dependence or Addiction ?3. Tolerance,
Behavior, Hyperalgesia4. Acute and Protracted
Withdrawal5. Withdrawal or Detoxification ?6.
Pain and Addiction
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Case Management Example - 1

• 43 year-old woman with fibromyalgia, breast
  cancer in remission, she copes better with
  current meds. Works full time. No tobacco, no
  alcohol, married with 3 school-age children.
  NKDA. Meds Tamoxifen OTC NSAIDs
  SSRIKlonipin 2mg 1/2qhs and Vicodin 10/500 6 q
  day x 3 years.

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Case Management Example - 2

• 57 year-old man with chronic post-laminectory
  pain. Disabled, lives with sister, watches her
  children, and fishes. Tobacco , marijuana for
  pain alcohol 14 drinks/week, used to be
  heavy drinker NKDA intolerant to NSAID
  long-acting morphine 120mg/day, Ultram 400mg/day
  for breakthrough pain, Soma qid, Valium 10mg
  qhs for sleep. Your practice partner retired
  early and he is now your patient.

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Changing Opioid Opinions

• The use of narcotics in terminal cases is to be
  condemnedmorphine use is an unpleasant
  experience to the majority of human subjects
  because of undesirable side effects. Dominant on
  the list of these unfortunate effects is
  addiction.
• American Medical Association Consensus Paper,
  1940
• Reiderberg MM, Lancet 3471276, 1996. Barriers
  to controlling
• pain in patients with cancer.

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Changing Opioid Opinions

• In an apparent first for the nation, an Oregon
  Medical Board acts against a doctor primarily for
  under-treatment of pain.
• The Oregonian. September 2, 1999

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Changing Opioid Opinions

• Jury Awards 1.5 Million to San Francisco Mans
  Family
• ( June, 2001)
• Judgment against physician for failing to
  provide adequate pain medication to terminal
  cancer patient.

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Changing Opioid Opinions

• JACHO Guidelines 2000
• Mandate pain assessment and treatment
• Nurse and physician education required
• Pain as the fifth vital sign

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Changing Opioid Opinions

• Physicians told not to fear discipline for pain
  treatment
• amednews.com The Newspaper for Americas
  Physicians, June 16, 2003

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Reasons for Inadequate Prescription of Analgesics

• Inhibitory influences of regulations and boards
• Lack of suitable knowledge base
• Cultural and societal barriers
• Adherence to customary prescribing behaviors
• Unconscious bias toward different groups
• Fear of producing dependency and addiction

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Physical Dependence or Addiction?

• Physical dependence is a normal physiologic
  response to the medical use of opioids
• Addiction involves the non-medical use of opioids
• Erroneous fear of addiction tragically promotes
  the under-treatment of pain

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Addiction-phobia

• The public a strong negative attitude
• 87 fearful of becoming over reliant on pain
  medication
• 82 concerned about addiction, 41 believe that
  physicians over prescribe
• 50 dont believe acute or chronic pain can be
  significantly relieved
• (The Mayday Fund, 1993)
• The Patients
• Reluctant to report pain and use analgesics,
  concerned with addiction, adverse effects,
  injections, tolerance, Good patients dont
  complain, pain is inevitable (Pain Clinical
  Manual, Second Edition McCaffery M, Pasero C, p
  9, 1999. Mosby
• RNs estimate of addiction off by 500
• 76 believed 5of patients would become
  addicted after 3 months of continuous opioids
• (McCaffery M, Ferrell BR Nurses knowledge
  of pain assessment and management. J. Pain
  Symptom Manage 14 175-188, 1997)
• Physicians
• Fear of regulatory scrutiny, reputation as drug
  doctor
• Adverse effects difficult to manage
• Scant education and thin pain network

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Addiction in Pain Patients The Facts

• 7 of 24,000 pain patients became addicted
• Friedman DP Perspectives on the medical sue of
  drugs of abuse. J. Pain Symptom Manage (Suppl
  1) S2-5, 1990
• 4 of 11,882 pain patients became addicted
• Porter J, Jick H Addiction rare in patients
  treated with narcotics, N Engl J Med 302123,
  1980
• 0 of 500 patients receiving heroin for pain
  became addicted
• Twycross RG Clinical experience with
  diamorphine in advanced malignant disease. Int J
  Clinical Pharmacol 9184-198, 1974
• 0 of 10,000 burn patients became addicted
• Perry, Heidrich, Pain 1982
• Iatrogenic addiction for persons with no history
  of addiction is less than 1
• Principles of Addiction Medicine, Second Edition.
  Grahm WG, Schultz TK, Editors. 1998 p914

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Physical Dependence

• A state of neuroadaption manifested by a drug
  class-specific withdrawal syndrome
• Produced by abrupt cessation, rapid dose
  reduction, decreasing bioavailability, or use of
  antagonist.
• An expected occurrence in all individuals in the
  presence of continuous use of opioids for days
  or weeks.

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Physical Dependence Therapeutic Dependence

• Therapeutic Dependence
• Patients taking opioid drugs for the relief of
  pain are using them therapeutically they do not
  seek psychic effects as do individuals who are
  addicted.
• Portenoy RK Opioid therapy for chronic
  non-malignant pain current status. In Fields
  HC. Liebeskind JC Progress in Pain Research and
  Management, Vol 1, pp247-287, Seattle, 1994, IASP
  Press
• In no way implies or indicates addiction
• Problems arise when opioids are not tapered as
  pain resolves, or are inappropriately withheld

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Tolerance

• Higher or more frequent dosing to achieve the
  initial effects of the drug
• Neuroadaption to continuously administered
  opioids
• Occurrence variable, not always linked with
  dependence
• Tolerance to non-analgesic effects beneficial
• Analgesic tolerance rarely the cause for dose
  escalation
• Dose escalation usually indicates disease change
• Tolerance does not imply addiction

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Pseudo-addiction

• Iatrogenic pattern of drug seeking behavior in
  patients receiving inadequate pain relief, or in
  withdrawal, that can be mistaken for addiction
• Clock-watching, hoarding, seeking extra
  pre-scriptions, demanding, whining, MD
  shopping,drug seeking manipulation is without
  criminal or ill-intent
• Resolves with adequate pain/withdrawal management

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Addiction

• Addiction is a primary, chronic, neurobiologic
  disease, with genetic, psychosocial, and
  environmental factors influencing its development
  and manifestations.
• It is characterized by behaviors that include one
  or more of the following impaired control over
  drug use, compulsive use, continued use despite
  harm, and craving.
• Consensus Document, 2001. American Academy of
  Pain Medicine, A. PainSociety, American Society
  of Addiction Medicine.

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Substance Addiction Rating

• How easy to get hooked, how hard to stop ?
• Highest Addiction Potential
• nicotine, ice, cocaine (smoked or IV)
• Mid-range Addiction Potential
• alcohol, Valium, Seconal, heroin
• Addictive
• Caffeine, marijuana, Ectasy, psychedelics
• Health, Nov-Dec, 1990

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What Does Addiction Look Like?

• Non-medical use of drugs
• 6-15 of U.S. population (excluding nicotine)
• Patients often unable to discern negative impact
  on quality of life
• Denial, minimalization, rationalization, other
  defense mechanisms prominent
• Affective Component
• Set, Setting, Substance

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Screening for Addiction

• DSM criteria inadequate for pain patients
• Simple Screening Tools
• Do you use____? How much? How often?
• CAGE (Cut down, Angry, Guilty, Eye-opener)
• CAGE AID
• Comprehensive Addictions Psychological
  Evaluation (Axis I, II) www.evinceassessment.com
• Referral to Substance Abuse Professional
• 5 Cs Control (loss of), Continued use despite
  Consequences, Compulsive use, Craving

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Addiction A Spiritual Problem?

• Relationship to self
• Relationship to others
• Relationship to, and Acceptance of life

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Opioid Withdrawal

• Acute
• Autonomic
• Rebound increased NE activity from locus
  coeruleus
• Increase BP, HR, peristalsis, diaphoresis, CNS
  irritability, etc.
• Affective
• Suppressed in the dopaminergic reward pathways
• Depression, anxiety, anhedonia, craving, anergia
• Protracted
• 3-6 months or longer
• Anxiety, insomnia, craving, cyclic changes in
  wgt, pupil size

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Medical Withdrawal vs. Medical Detoxification

• Withdrawal the process of safely and
  comfortably discontinuing opioids from a patient
  who is physically dependent
• Detoxification the process of safely and
  comfortably discontinuing opioids from a person
  who is opioid addicted

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When is Withdrawal Needed?

• Pain is subsiding or pain generator removed
• Contributing factors reduced
• Insurance issues, cost issues
• Adverse effects physical, social etc.
• Not following Rx plan, change in Rx plan
• Accelerating tolerance, loss of control
• Cultural, personal issues
• Trial off opioids may improve pain !, (and life)

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Opioids can increase pain!

• 30 of pain patients on chronic opioid therapy
  feel better after withdrawal
• Opioids can cause hyperalgesia, decrease of
  tolerance to painful stimuli
• Basbaum AL Insights into the development of
  opioid tolerance, Pain 61 347-352, 1995 Mao j,
  Price DD, Mayer DJ Mechanisms of hyperalgesia
  and morphine tolerance. Pain 62259-274, 1995

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Medical Withdrawal Options

• Taper by 50 every several days (weaning),
  without signs/symptoms of withdrawal
• Goodman Gilmans The Pharmacologic Basis of
  Therapeutics, Ninth Edition. McGraw-Hill 1996.
  P. 533
• As pain lightens, transition to longer acting
  analgesic (propoxyphene, methadone if
  experienced) and taper
• Symptomatic Rx clonidine, NSAID,
  anti-anxiety/sleeper, muscle relaxant, etc.
• Suboxone safe, easy, effective
• Always educate patient on withdrawal and WD Rx

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Opioids in Co-Morbid Pain Addiction

• Highly structured environment/interactions
• Prohibit monitor alcohol, other drugs
• Marijuana must have use certificate
• Frequent visits (q week, then q 2 weeks)
• Referral for substance abuse Rx, 12-step
• Multidisciplinary support
• Spouse/Family involvement
• Addiction Medicine, Pain Medicine, or Pain
  Management consult periodically
• Collect medical records, document all encounters

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Prescribing Opioids to Addicts

• 20 patients with chronic non-malignant pain and
  history of substance abuse
• 11 that did not abuse Rx, had active 12-step
  recovery, supportive family
• 9 that did abuse Rx abused early in trial
  no12-step Rx lost or stolen frequent, rapid
  dose increase calls/visits-no appt.
• Dunbar, Katz Pain and Symptom Manage. Vol. 11,
  No 2, pp 163-171, March 1996

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Unacceptable Addictive Behaviors Detox Warranted

• Repeated unsanctioned dose escalation
• Borrowing, trading, buying street drugs
• Use of illicit drugs, at-risk EtOh use
• Recurrent Rx losses, thefts
• Prescription forgery, multiple prescribers
• Intoxication
• Non-compliance with treatment plan

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Detoxification Options

• Detoxification the treatment that is not a
  treatment provides a drug free person with an
  addictive disease, not a disease free person!
• Ultra-Rapid Detox (with general anesthesia)
• Naltrexone induced, hospital setting
• Licensed methadone clinic (detox or maintenance)
• Symptomatic medications
• Clonidine, NSAID, Vistaril, Robaxin etc. high
  fail rate
• Subutex/Suboxone (detox or maintenance)
• Still need Rx for primary disease of addiction

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Buprenorphine

• Opioid agonist/antagonist. Low diversion risk.
• Replacing methadone in France, ? US
• Excellent safety profile, decades of experience
  as IM-IV-SL analgesic. MDs now Rx for pain.
• FDA approved for opioid detox or maintenance
• Formulated as Subutex, and Suboxone -naloxone
  added to deter IV use, diversion
• Being used in addiction and dependence
• MDs can acquire DEA Detox OK CME required

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Guidelines for the Use of Controlled Substances
for the Treatment of PainAdopted by Hawaii
Medical Association, May 2003

• Patient Evaluation, indication for opioids use
• Written Treatment Plan
• Informed Consent , Agreement for Treatment
• Periodic Review
• Consultation
• Medical Records
• Compliance with Laws and Regulations

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Case Management Example - 1

• 43 year-old woman with fibromyalgia, breast
  cancer in remission, she copes better with
  current meds. Works full time. No tobacco, no
  alcohol, married with 3 school-age children.
  NKDA. Meds Tamoxifen OTC NSAIDs
  SSRIKlonipin 2mg 1/2qhs and Vicodin 10/500 6 q
  day x 3 years.

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Case Management Example - 2

• 57 year-old man with chronic post-laminectory
  pain. Disabled, lives with sister, watches her
  children, and fishes. Tobacco , marijuana for
  pain alcohol 14 drinks/week, used to be
  heavy drinker NKDA intolerant to NSAID
  long-acting morphine 120mg/day, Ultram 400mg/day
  for breakthrough pain, Soma qid, Valium 10mg
  qhs for sleep. Your practice partner retired
  early and he is now your patient.

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Best References

• Pain Clinical Manual 2nd Edition
• Margo McCaffery, Chris Pasero
• 1999, Mosby
• Principles of Addiction Medicine 3rd Ed
• American Society of Addiction Medicine, 2001
• www.asam.org
• American Academy of Pain Management
• www.aapainmanage.org
• American Pain Society www.ampainsoc.org

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The patient cannot be seen simply as his/her
disease

• ..Neither can the health professional limit
  his/her care to medical technology. The full
  healing potential of their relationship often
  depends on their interaction as whole human
  beings, and far exceeds the treatment of disease.

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Every person achieves a unique interdependent
relationship of body, mind, emotions and spirit

• inseparable from other indiivuals and
  society. Illness can best be understood as a
  disturbance within the dynamic balance of these
  relationships. Health may be defined as the
  harmony of the whole, and the work of the health
  professional as aiding in the reestablishment of
  a more fully conscious equilibrium within the
  whole.

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The patient and the health professional are
colleagues

• their collaboration activates the latent
  human and biological resources within the patient
  for healing. The patient is encouraged to be
  aware of his/her choices and to become
  increasingly repsonsible for his/her own health,
  growth and fulfillment.

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Illness may provide an opportunity for personal
growth..

• the experience of disease may be used
  creatively to re-evaluate life goals and values,
  provide clarity in setting priorities and to
  mobilize previously untapped strengths. The
  health professional enables the patient to evolve
  a positive value from the experience of disease,
  to maintain identity, and to reaffirm his/her
  dignity as a person.

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Illness must be seen in the context of the life
span of the individual..

• Indeed, it may have a unique meaning when seen in
  reference to the total life of the patient.
  Physical disease and emotional suffering have an
  individual message for each patient, yielding
  information about such personal issues as
  lifestyle, self-worth and value of time. The
  knowledge gained through the understanding of
  this individual meaning may enable the patient to
  enrich the quality of his/her life.

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Principles for the Care of the Person

• The patient cannot be seen as simply his/her
  disease
• Every person achieves a unique interdependent
  relationship of body, mind, emotions and spirit
• The patient and the health professional are
  colleagues
• Illness may provide an opportunity for personal
  growth
• Illness must be seen in the context of the life
  span of the individual
• See last 5 slides for expansion