1. NYSAM 2011 Case Presentation
Edwin A. Salsitz, M.D. FASAM
Beth Israel Medical Center
New York City

2. Physician Clinical Support System
PCSS…
answers questions about opioids, including methadone, for treatment of chronic pain
answers questions about use of buprenorphine for treatment of opioid dependence

3. Physician Clinical Support System
PCSS…
is free, for interested physicians and staff
is supported by SAMHSA through the Center for Substance Abuse Treatment (CSAT) and administered by the American Society of Addiction Medicine (ASAM)

4. Physician Clinical Support System
Ask a clinical question…
get a response from an expert PCSS mentor
on line by
by phone
From
download clinical tools, helpful forms and concise guidance's (like FAQs) on specific questions

5. ADDICTION/PAIN TREATMENT
“All Treatments Work For Some People/Patients”
“No One Treatment Works for All People/Patients”
Alan I. Leshner, Ph.D
Former Director NIDA

6. CT 2010 Case Presentation 54 y.o. ♀ evaluated on 6/19/09
Headaches major medical problem
? Paternal uncle—EtOH
Lives with husband, has 2 adult stepchildren
Upper level executive in marketing, 250K
Through H.S. no drugs or EtOH

7. CT 2010 Case Boyfriend 1st year of college introduced to heroin IN
1st use may have led to gang rape? Uncontrollable crying over story
1st “migraine” around this time, frequent & severe
“nervous breakdown” after boyfriend ends relationship in 2nd year college
Heroin INIV x 2yrsillicit methadoneTC Abstinent age 25

8. CT 2010 Case Migraines lessened in 30’s and 40’s
 frequency and severity post-menopause
Opioids X 4 years—oxyCR & oxyIR
Nationally known HA clinic—weaned off opioids 2 yrs ago—severe HAsopioids(1 mo.)
Neuro and Pain Specialist—ran out of meds 1 week early? Inpatient “detox”--?work
Current meds. Oxy CR 30mg tid OxyIR 5mg qid(NSAID, ondansetron, prednisone, venlafaxine, topiramate)

9. CT 2010 Case
Age 17—appendectomy—1st opioid— “felt good,” “took away my insecurities”
Subsequent heroin--- “energized”
Sobbing and Crying at mention of mother who died 9 mos ago at age 93
Felt she was a terrible disappointment to mother
Saw therapist on and off for many years—currently not in psychotherapy

10. Diagnosis and Plan After Initial Consultation
Opioid Physical Dependence
Pain Paradigm
Husband to Dispense Opioids
Attempt to taper opioids
Rx Oxy CR 30mg—attempt bid
One week later 1.Oxy CR bid 2. D/C venlafaxine, start duloxetine 3. Oxy IR 5 q6h prn

11. 3 Weeks later
Headaches have markedly increased while on vacation—husband not in agreement on chronic opioid paradigm
Neurologist adds gabapentin 300mg tid and topiramate(now 100mg.qd)
Continued attempts to taper opioids not successful

12. 4 Weeks Later Husband no longer coming in with patient
Headaches daily—making work and home difficult
After long discussion, OXY CR d/c’d and methadone low dose started and titrated upwards

13. After 7 months Stable methadone dose 30mg tid
Infrequent short acting opioids
Significant improvement in headache frequency, severity,
Improved function at work
Stopped therapy, and refuses new therapy
Marital issues difficult to discuss
All urines, pill counts, appts., etc reveal no problematic behavior
Overall patient rating 93(as of 4/13/10)

14. April 2010Present June 2010—2 Rxs given for methadone
October Short Acting Opioids D/C’d
October Methadone  30mg bid
Headaches present, but  intensity/frequency
Stigma issue around methadone continues
Marital issue, no psychosocial
Random urines negative

15. 41(59%) Responders by 50% in SHI—freq x duration severe headache/week
NEUROLOGY 2004;62:
160 enrolled 70 remained on daily scheduled opioids X 4 yrs 74% LA, 26% SA
41(59%) Responders by 50% in SHI—freq x duration severe headache/week

16. Figure 1. Medical record versus visual analog scale: mean percentage improvement in year 3 or 4 of daily scheduled opioids (year 4 for patients in program for 4 years or more)‏
Saper, J. R. et al. Neurology 2004;62:

17. Dose Violation most common Most problems not “severe”
Figure 2. Problem drug-related behavior: patients with any incident of problem opioid behavior over 4 years of daily scheduled opioids
Saper, J. R. et al. Neurology 2004;62:
Dose Violation most common
Most problems not “severe”

18. OPIOIDS ? Endorphin DeficiencyU B E T
Chronic Pain
Addiction
Somatic Sxs
Hedonic Tone
OPIOIDS ? Endorphin Deficiency
Anti-Depressants
Anti-Convulsants
Mood Stabilizers
Pain Medicine
Prescriptions
Pharmacies
Legitimate
Addiction Treatment
Methadone Clinics
Regulations
Stigma
Buprenorphine

19. *Anterior Cingulate Gyrus

20. MesoLimbic Dopaminergic Circuit Pleasure/Reward Center
Acc
VTA
Amphetamine
Cocaine
Opiates
Cannabinoids
Phencyclidine
Ketamine
HIPP
GLU
FCX
AMYG
CRF
GLU
5HT
GABA
OPIOID
OPIOID
ENK
GABA
GABA VP
DYN
5HT
OFT DA
BNST
GABA NE
ABN LC
Opiates
PAG NE
HYPOTHAL
END
LAT-TEG
To dorsal horn
Opiates
Ethanol
Barbiturates
Benzodiazepines
Nicotine
Cannabinoids
5HT
ICSS
Raphé
MesoLimbic Dopaminergic Circuit Pleasure/Reward Center
H2O, Food, Sex, Parenting, Socializing
RETIC

21. HCC=Healthcare for Communities
1998,

22. Association of common mental disorders in 1998 with regular prescription opioid use in 2001: unadjusted odds ratios with 95% confidence intervals
Sullivan, M. D. et al. Arch Intern Med 2006;166:
Non-Cancer Pain
Copyright restrictions may apply.

23. Journal of Addictive Diseases, Vol.27(3) 2008

24. Journal of Addictive Diseases, Vol.27(3) 2008

25. Problematic (Aberrant) Behaviors
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
Passik and Portenoy, 1998

26. The ORT Form-Opioid Risk Tool
Mark each box that applies
1. Family history of substance abuse Female Male
Alcohol [ ] [ ]
Illegal drugs [ ] [ ]
Prescription drugs [ ] [ ]
2. Personal history of substance abuse
Alcohol [ ] [ ]
3. Age (mark box if 16-45) [ ] [ ]
4. History of preadolescent sexual abuse [ ] [ ]
5. Psychological disease
Attention deficit disorder, obsessive-
compulsive disorder, bipolar, schizophrenia [ ] [ ]
Depression [ ] [ ] 1 2 4 3 5
Patients are asked to identify their age; history of preadolescent sexual abuse; family and personal history of substance abuse, including alcohol, illegal drug, or prescription drug abuse; and psychological diseases such as attention deficit disorder, obsessive-compulsive disorder, bipolar disorder, schizophrenia, or depression. The probability of opioid abuse increases with the number of positive responses.
Responses to each question are weighted differently based on gender and risk factor. Each risk factor is assigned a point value comparative to other risk factors.
Courtesy of Lynn Webster, M.D.

27. Validation Study Results
Total score risk category 
 Low risk: 0–3 
 Moderate risk: 4–7 
 High risk: ≥ 8
Validation Study Results
ORT Total Score Risk Category
100
90.9 80 60
Aberrant Behavior Displayed (%) 40 28
The validation study of the ORT showed a strong relationship of the link between the total score risk category and observed aberrant behavior. For those patients in the low risk category, “unlikely to abuse opioids”, only 5.6% displayed an aberrant behavior. For those patients in the moderate risk category, “as likely to abuse opioids as not to abuse opioids”, 28% displayed aberrant behaviors. For those patients in the high risk category, “likely to abuse opioids”, 90.9% displayed aberrant behavior.
The ORT displayed excellent discrimination for both sensitivity and specificity and provided gender-specific positive predictive values for high risk patients of 87% to over 95%. 20
5.6
Low
Moderate
High
Webster LR and Webster RM. Predicting aberrant behaviors in opioid-treated patients: validation of the Opioid Risk Tool. Pain Med. 2005;6:
Non-Cancer Pain

28. Russell Portenoy, M.D.

29. “…as we know, there are known knowns, there are things we know we know
“…as we know, there are known knowns, there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know.”
– Donald Rumsfeld

30. “MORPHINE IS GOD’S OWN MEDICINE” Sir William Osler

31. ADDICTION/PAIN TREATMENT
“All Treatments Work For Some People/Patients”
“No One Treatment Works for All People/Patients”
Alan I. Leshner, Ph.D
Former Director NIDA

32. SUPPORT ASAM!!