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Cooccurring Disorders: Pain, Depression and Substance Abuse


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Title: Cooccurring Disorders: Pain, Depression and Substance Abuse

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

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?

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

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).

ECA DSM-III Diagnoses (rates per 100 people)
Regier, et al. (1990)
Lifetime Prevalence and Odds Ratios ECA Study
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 (

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

Drug Induced Psychopathology
  • Symptom Groups
  • Depression
  • Anxiety
  • Psychosis
  • Mania
  • Rounsaville 90
  • Drug States
  • Withdrawal
  • Acute
  • Protracted
  • Intoxication
  • Chronic Use

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
  • Risk Factor
  • Cocaine use
  • Major Depression
  • Alcohol use
  • Separation or Divorce

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
  • Rates increase with age ( as do other causes of
    CDC web site
  • Suicide rate among addicts is 5-10 times that of

    Preuss/Schuckit Am J Psych 03

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).
Comorbidity of Depression and Anxiety Disorders
50 to 65 of panic disorder patients have
Panic Disorder
70 of social anxiety disorder patients have
49 of social anxiety disorder patients have
panic disorder
Social Anxiety Disorder
67 of OCD patients have depression
11 of social anxiety disorder patients have OCD
The Four Quadrant Framework for Co-Occurring
  • 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
DSM and ICD The Bibles
Assessing for addiction in pain patients
Diagnostic and Statistical Manual of Mental
  • 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

4th ed, APA, 1994
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

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

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

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

Pain and Depression
  • Two thirds of new neurological patients have
  • 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
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

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

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

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
  • Patient feels neglected when others cant do all
  • Patient becomes anxious, angry and depressed
  • Patient assumes life style of chronic pain

Chronic pain identifying early risk factors
  • Attitude and belief of pain
  • Whose fault?
  • Behavior and compensation issues
  • Dx and Tx issues
  • Emotions
  • Family
  • Work

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

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
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

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

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
  • Addiction is not taking a lot of drugs its
    taking drugs and acting like an addict.Alan

Characterizing Pain
  • Pain An unpleasant sensory and emotional
    experience arising from actual or potential
    tissue damage or described in terms of such
  • 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
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?
Pain in Addiction More Than a
  • 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

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The Martyrdom of St. Sebastian by Hans Holbein
Chronic Pain and AddictionCommon Overlapping
  • 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

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
  • Most feel under treated
  • Most believe prescribed opiates led to
  • Most believe methadone is very helpful
  • Most have problems most of their lives
  • Most believe always need something to feel

  • Ref Jamison et al. (2000)

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?

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
  • 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
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

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
  • 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.
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.
Screener and Opioid Assessment for Patients in
Pain (SOAPP)
  • 14-item, self-administered form, capturing the
    primary determinants of aberrant drug-related
  • 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.
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
  • Unsanctioned dose escalation 1 2 times
  • Unapproved use of the drug to treat another
  • Reporting psychic effects not intended by the
  • Probably more predictive
  • Selling prescription drugs
  • Prescription forgery
  • Stealing or borrowing another patients drugs
  • Injecting oral formulation
  • Obtaining prescription drugs from non-medical
  • Concurrent abuse of related illicit drugs
  • Multiple unsanctioned dose escalations
  • Recurrent prescription losses

Passik and Portenoy, 1998
Aberrant Behaviors
Passik et al. 2003
Aberrant Behaviors in Cancer and AIDS
Passik et al. 2003
Therapeutic Maneuver Is the Pain Patient
Drug-seeking or increased requests for pain
? 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
Addictive disease
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
  • No unacceptable aberrant behavior (Aberrant
    bahavior Pees
  • The 4 As (Passik) the 4

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
Analogue Pain Scale
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

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

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

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)

Belief, Expectation, Outcome
  • What you believe and expect and do as a result
    are far more important than what situation youre
  • 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

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
  • Here are some specific strategies for Sx relief
    and for high risk situations
  • Lets develop a plan for your future

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

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

  • 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

  • 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

Treatment of Co-occurring Disorders
  • Treatment System Paradigms
  • Independent, disconnected
  • Sequential, disconnected
  • Parallel, connected
  • Integrated

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

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
  • Disorders are not completely independent
  • Diagnoses are often unclear and complex

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
  • Compliance problems with patients

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

Thank you, thank you, and thank you