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Aberrant Drug-taking Behaviors in Medically Ill Pain Patients

Aberrant Drug-taking Behaviors in Medically Ill 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 APA, NYC, 05/03/04.

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Aberrant Drug-taking Behaviors in Medically Ill Pain Patients

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  1. Aberrant Drug-taking Behaviors in Medically Ill 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 APA, NYC, 05/03/04

  2. 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 submitted • Aberrant drug taking in cancer and AIDS patients, Passik et al, in prep • Retrospective Characterization of abusers of OxyContin seeking drug treatment in Kentucky, Hays, et al., JNCCN, 2003; Preliminary prospective data

  3. 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

  4. Differential Diagnosis of Aberrant Drug-Taking Attitudes and Behavior • Addiction • Pseudo-addiction (inadequate analgesia) • Other psychiatric diagnosis • Encephalopathy • Borderline personality disorder • Depression • Anxiety • Criminal Intent (Passik & Portenoy 1996)

  5. Physician-Ranking of Ab. Behs.(Passik, Kirsh, et al, J Pain Pall Care Pharm, 2002)

  6. 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)

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

  8. 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

  9. 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”

  10. Numbers of Aberrant Behaviors

  11. 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

  12. 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

  13. 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%)

  14. 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%)

  15. 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

  16. Aberrant Behaviors(Passik, Kirsh et al, in prep, 2004) (n = 215) (n = 98) (n = 33) (n = 26) (n = 16) Number of Behaviors Reported

  17. Characterization of OxyContin abusers seeking drug abuse treatment in KY • 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

  18. 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

  19. 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

  20. 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

  21. Rx Drug Abusers Entering Treatment(Passik, Kirsh, et al, in process) * At least once

  22. Rx Drug Abusers Entering Treatment(Passik, Kirsh, et al, in process) * Not mutually exclusive

  23. 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

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