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Dependence, Addiction and Withdrawal

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Title: Dependence, Addiction and Withdrawal


1
Dependence, Addiction and Withdrawal
  • Kevin Kunz, M.D., M.P.H., FASAM

2
Overview1. Changing Opioid Opinions2.
Dependence or Addiction ?3. Tolerance,
Behavior, Hyperalgesia4. Acute and Protracted
Withdrawal5. Withdrawal or Detoxification ?6.
Pain and Addiction
3
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.

4
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.

5
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.

6
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

7
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.

8
Changing Opioid Opinions
  • JACHO Guidelines 2000
  • Mandate pain assessment and treatment
  • Nurse and physician education required
  • Pain as the fifth vital sign

9
Changing Opioid Opinions
  • Physicians told not to fear discipline for pain
    treatment
  • amednews.com The Newspaper for Americas
    Physicians, June 16, 2003

10
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

11
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

12
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

13
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

14
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.

15
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

16
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

17
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

18
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.

19
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

20
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

21
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

22
Addiction A Spiritual Problem?
  • Relationship to self
  • Relationship to others
  • Relationship to, and Acceptance of life

23
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

24
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

25
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)

26
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

27
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

28
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

29
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

30
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

31
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

32
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

33
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

34
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.

35
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.

36
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

37
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.

38
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.

39
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.

40
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.

41
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.

42
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
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