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Aberrant Drug-taking Behaviors in Pain Patients

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. Introduction.

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Aberrant Drug-taking Behaviors in Pain Patients

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  1. 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

  2. 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

  3. 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 “A’s” 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

  5. Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient’s 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 Aberrant Drug-taking Behaviors: The Model Passik and Portenoy, 1998

  6. 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)

  7. 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

  8. 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?

  9. 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)

  10. 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)

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

  12. 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

  13. 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”

  14. Numbers of Aberrant Behaviors

  15. Most Frequently Reported Aberrant Behaviors Aberrant BehaviorCancer patientsAIDS 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 else’s 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

  16. Least Frequently Reported Aberrant Behaviors Aberrant BehaviorCancer patientsAIDS patients (n= 100) (n = 73) Freq. % Freq. % Prescription forgery 0 0 1 <1 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

  17. Reported Pain Relief Cancer AIDS patientspatients (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%)

  18. AIDS Patients and Aberrant Behaviors Adequate Inadequate AnalgesiaAnalgesia (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%)

  19. The Four “A’s” 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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 – 4A’s • 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

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