Aberrant Drug-taking Behaviors in Pain Patients

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Aberrant Drug-taking Behaviors in Pain Patients

• Steven D. Passik, PhD
• Director, Symptom Management and Palliative Care
  Program - Markey Cancer Center
• Associate Professor of Medicine and Behavioral
  Sciences
• University of Kentucky
• Lexington, KY
• FDA, ALSDAC, 9/09/03

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Introduction

• Who/what should be monitored
• Long term studies of (bad) outcomes in opioid
  therapy are virtually absent
• Aberrant behaviors and their frequency and
  meaning have been poorly studied
• The relationship between aberrant behavior in
  pain patients and addiction has been poorly
  articulated

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Who/What Should Be Monitored?

• Pain patients?/Pain Treatment
• Bad outcomes in the aberrant drug-taking spectrum
• Recreational users?/Addicts?
• Abusers with Pain?
• Doctor shoppers and dealers?

4
The Four As of Pain Treatment Outcomes

• Analgesia modest but meaningful
• Activities of Daily Living (psychosocial
  functioning) 80 rated as improved overall
• Adverse effects (side effects) common but
  tolerable
• Aberrant drug taking (addiction-related outcomes)

Passik Weinreb, 1998
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Aberrant Drug-taking Behaviors The Model

• 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

• Probably less predictive
• Aggressive complaining about need for higher
  doses
• 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

Passik and Portenoy, 1998
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The Multiple Etiologies of Aberrant Drug-Taking
Attitudes and Behavior

• Addiction/Abuse
• Pseudo-addiction (inadequate analgesia)
• Self medication (chemical coping) of psychiatric
  problems
• Encephalopathy
• Personality disorders
• Depression and Anxiety disorders
• Poor coping and medication of situational
  stressors
• Criminal Intent

(Passik Portenoy 1996)
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Bad Outcomes in the Aberrant Drug-taking Spectrum

• Abuse how common?
• Addiction probably rare in non-vulnerable
  patients
• Chemical coping
• Aberrant use patterns that do not qualify as
  compulsive or out of control use
• On the fringes of the opioid agreement
• In a patient who fails to improve or reach
  psychosocial goals

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Which Pain Patients are Vulnerable to Aberrant
Drug-taking?

• Little data, largely unknown exposure alone is
  not a risk factor
• Vulnerability to addiction in those exposed to
  drugs is generally related to risk factors in
  the following categories
• Genetic
• Psychiatric
• Social
• Familial
• Spiritual
• Many pain patients have risk factors in these
  areas
• Which ones then go on to self-medicate and how
  many of those who self-medicate go on to abuse?

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Indiana/UK Studies on Aberrant Drug-taking in
Pain Management

• Attitudes and behaviors in cancer patients and
  women with AIDS (Passik, et al., JPSM,1998)
• UTS in pain management, Passik et al, JPSM, 1998
• Survey of clinicians perceptions of ADTB (Passik
  et al, JPSMPC, 2002)
• Development of a tool to assess pain outcomes in
  chronic opioid therapy (Passik et al, 2003
  submitted)
• Aberrant drug taking in cancer and AIDS patients
  (Passik, Kirsh, Donaghy, Wolf and Portenoy, 2003
  submitted)
• Characterization of abusers of Oxycontin seeking
  drug treatment in Kentucky, (Hays, Kirsh, and
  Passik, JNCCN, 2003)

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Aberrant drug-taking in cancer and AIDS

• 73 patients with AIDS - 100 with reported past
  or current history of substance abuse (42 of
  total sample)
• 100 patients with cancer -18 reported past or
  current history of substance abuse (58 of total
  sample)
• 101 men (58 ), 72 women (42)
• 118 Caucasian (68), 50 African-American (29)
  5 Other (3) Mean age 51.6 (SD 15.2)

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Measures

• SCID substance abuse module
• Brief Pain Inventory
• Pain Management Index
• Brief Symptom Inventory
• Memorial Symptom Inventory
• Marlowe Crowne Social Desirability
• Aberrant Behavior Interview

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Results

• Compared to cancer patients , patients with AIDS
  were significantly more likely to -Be single
• -Be male
• -Be of a minority ethnic group
• -Be younger
• -Report past or present psychiatric problems
• -Report being inadequately medicated for pain

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Aberrant Behaviors Reported

• Total Sample Cancer patients AIDS patients
• (n 173) (n 100) (n 73)
• Total aberrant behaviors 590 142 448
• (100) (24) (76)
• Average of aberrant behavior 3.41 1.42 6.14
• Total of aberrant behaviors 423 122 301
• probably less predictive of (72) (86) (67)
• addiction
• Total aberrant behaviors 167 20 147
• probably more predictive (23) (14) (33)
• of addiction

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Numbers of Aberrant Behaviors
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Most Frequently Reported Aberrant Behaviors

• Aberrant Behavior Cancer patients AIDS
  patients
• (n 100) (n 73)
• Freq. Freq.
• Expressed anxiety or 27 27 37
  51
• desperation over
• recurrent symptoms
• Hoarded medications 22 22 28
  39
• Taken someone elses 11 11 36
  50
• pain medicine
• Aggressively complained 13
  13 29 40
• to doctor for more drugs
• Requested a specific drug 18
  18 24 33.3

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Least Frequently Reported Aberrant Behaviors

• Aberrant Behavior Cancer patients AIDS patients
• (n 100) (n
  73)
• Freq. Freq.
• Prescription forgery 0 0 1 lt1
• Prostituted others for drugs 0 0 4 6
• Sold prescription drugs 0 0 6 8
• Stolen drugs from others 0 0 7 10
• Performed sex for 0 0 7 10
• money to obtain drugs

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Reported Pain Relief

• Cancer AIDS
• patients patients
• (n 100) (n 73)
• Percent of pain relief 76 37
• Adequate pain relief (PMI) 92 49
  (92) (67)
• Inadequate pain relief (PMI) 8 24
• (8) (33)

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AIDS Patients and Aberrant Behaviors

• Adequate Inadequate
• Analgesia Analgesia
• (n 49) (n 24)
• Total aberrant behaviors 305 152 (6.2)
  (6.3)
• Aberrant behaviors probably 239 116
• less predictive of addiction (78) (74)
• Aberrant behaviors probably 66 40
• more predictive of addiction (22) (26)

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The Four As of Pain Treatment Outcomes

• Analgesia modest but meaningful
• Activities of Daily Living (psychosocial
  functioning) 80 rated as improved overall
• Adverse effects (side effects) common but
  tolerable
• Aberrant drug taking (addiction-related outcomes)

Passik Weinreb, 1998
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Aberrant Behaviors (n 388)(Passik, Kirsh et
al, in prep, 2002)
(n 215)
(n 98)
(n 33)
(n 26)
(n 16)
Number of Behaviors Reported
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Characterization of Oxycontin abusers seeking
drug abuse treatment in KY (Hays, Kirsh and
Passik, JNCCN, 2003)

• Chart review survey of admissions to drug
  treatment center in Lexington at height of media
  coverage of the epidemic
• 195 admissions for Oxycontin abuse
• SCID diagnoses and other medical/demographic data
  recorded

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Characterization of Oxycontin abusers seeking
drug abuse treatment in KY

• Oxycontin abusers were
• Using on average, 180mgs per day
• History of other DSM IV, nonsubstance abuse Dx
• History of poly-substance abuse
• History of other prescription drug abuse
• Oxycontin abusers compared to other opioid
  abusers
• Younger
• Male
• Rural

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Characterization of Oxycontin abusers seeking
drug abuse treatment in KY

• The 60 patients who ostensibly began using in
  pain treatment
• Treated mainly by primary care and other non pain
  experts
• Similar med/demos to other oxycontin abusers
• Equally likely to alter route of administration,
  with 13 reporting crushing and injecting

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Characterization of Oxycontin abusers seeking
drug abuse treatment in KY

• The 60 patients who ostensibly began using in
  pain treatment
• Treated mainly by primary care and other non pain
  experts
• Similar med/demos to other oxycontin abusers
• Equally likely to alter route of administration,
  with 13 reporting crushing and injecting

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Who or What Should Be Structured or Limited?

• Prescribing in General or Individual Treatment
  Plans for Patients Based on Vulnerability
  Assessment?
• Bad outcomes in pain management are likely not
  common enough to justify limiting prescribing
• Especially when the numbers are considered
• 50 million pain patients, 5000 pain specialists
• Instead, individual treatment plans can be
  derived that structure and limit individual
  patients
• Uncomplicated
• Chemical Copers
• Abusers with pain
• Physicians can identify vulnerability and triage
  patients

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Conclusions

• Patients of all types engage in some ambiguous
  drug-taking behavior
• Substance abuse history is associated with
  increased number of aberrant behaviors and types
  of aberrant behaviors
• Provision of adequate analgesia may not be
  enough to limit aberrant behaviors in complex
  patients who have a history of drug abuse
• Assessment should be multimodal 4As
• Physicians need to assess vulnerabilities at the
  outset of opioid therapy
• Patients should be stratified to more or less
  structured approaches based on vulnerability
  assessment
• Physicians should treat the patients for whom
  they can provide the appropriate level of
  structure
• Long term studies of outcomes in opioid therapy
  are needed
• Monitoring systems for recreational abusers,
  doctor shoppers and dealers are unlikely to shed
  light on these complex clinical issues