Drug Seeking, Abuse or Legitimate Treatment?

1. Drug Seeking, Abuse or Legitimate Treatment? Presented to the National Association of Disability Examiners September 11, 2012 Dr. Michael Bourn DO The Center For Symptom Relief Medical Director, Pain and Palliative Medicine, Doctors Hospital, Columbus Ohio

2. Objectives 1. Recognize aberrant drug related behavior 2. Understand strategies to limit drug abuse 3. Differentiate between drug seeking and relief seeking 4. Aknowledge the difficulty in making this determination

4. America is in an Opiate Crisis 4 people die every day in Ohio from prescription drugs, more than car crashes Opiate pain medication deaths have overtaken heroin and cocaine combined Opiate prescriptions have gone up over 600% in the last 10 years, deaths are up over 300% Poor evidence that long term opiate therapy for chronic pain is effective

5. Some Definitions First Aberrant drug related behavior Abuse/Misuse Addiction Pseudoaddiction Diversion Physical dependance Tolerance

6. Aberrant Drug Related Behavior A behavior outside the boundaries of the agreed upon treatment plan which is established as early as possible in the doctor-patient relationship Can take many forms

7. Abuse/Misuse Any use of illegal drug The intentional self-administration of a medication for a nonmedical purpose such as altering one’s state of consciousness Use of a medication (for a medical purpose) other than as directed or as indicated, whether willful or unintentional, and whether harm results or not

8. Addiction Primary chronic, neuro-biologic disease Genetic, psychosocial, environmental factors influence development and manifestations Characterized by behaviors; Craving Impaired control over use Compulsive use Continued use despite harm

9. Pseudoaddiction Defined • Iatrogenic syndrome • Misinterpretation of relief seeking behavior as addiction behaviors • Behaviors resolve when pain is adequately controlled

10. Diversion The intentional transfer of a controlled substance from legitimate distribution and dispensing channels

11. Physical Dependence State of adaptation Drug class specific signs and symptoms produced by Cessation Rapid dose reduction Decreasing blood level Administration of antagonist Not the same as addiction

12. Tolerance Defined Physiologic state resulting from regular use of a drug Increased dosage required to produce specific effect Reduced effect seen with constant dose Does not equate with addiction

13. Is Addiction all we are Worried About? Opiate pain medication can be unsafe at any dosage Current epidemic of opiate deaths are not simply due to addiction Current studies have prompted the CDC to warn against high dose opiates(greater than 100 OME/day) Associated with an 8 fold increase in death from opiate medication

15. Behavior Predictive of Aberrant Drug Taking –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

16. More Behaviors Getting meds from more than one prescriber with out their knowledge Performed sex for drugs/prostitution Stole money for drugs Aggressive complaining about need for higher doses

17. More Behaviors –Drug hoarding during periods of reduced symptoms –Requesting specific drugs –Unsanctioned dose escalation –Unapproved use of the drug to treat another symptom –Reporting psychic effects not intended by the clinician

18. Options Available in Managing Chronic Pain Physical therapy Manipulative therapy(chiropractic/osteopathic) Interventional(epidural injections, nerve blocks) Surgery Adjuvant medications(gabapentin/cymbalta) Opiates should be reserved as a last resort

19. Federation of State Medical Boards Policy FSMB has a sample policy adopted by most states for use of opiates in cases of chronic non-cancer pain Lays out guideline for evaluation, consent, examination referral and monitoring Requires regular assessment of goals of care-typically functional goals Regular assessment of burden of opiate therapy

20. Screening Tools Used to Detect Aberrant Drug Taking Tools can be used to help determine risk of aberrant/dangerous/addicted behavior Tools should be administered prior to commencement of chronic opiate therapy ORT SISAP SOAPP-R COMM

21. Opioid Risk Tool(ORT) • Administered prior to opioid therapy • Scoring • 0-3: low risk (6%) • 4-7: modreate risk (28%) • 8 or higher: high risk (>90%) Webster & Webster. Pain Med.2005;6:432.

26. Additional Tools Prescription monitoring programs State run databanks, updated real time Pharmacy duty to enter prescribed meds VA does not participate MAT/methadone/suboxone clinics don't participate Can see number of prescribers, prescriptions and pharmacies used

27. Additional Tools Cont. Urine Drug Screening Confirm they are taking meds prescribed Confirm they are not abusing illegal/illicit drugs Random Pill Counts Confirm patient is taking meds appropriately Needs to be done on short notice-can actually rent pills if they have time