Presentation on theme: "Pain and Addiction: More Than a Feeling"— Presentation transcript:
1Pain and Addiction: More Than a Feeling Walter Ling, MDIntegrated Substance Abuse Programs (ISAP)UCLA Dept. of PsychiatryPacific Southwest ATTCTenth Annual Training and Educational SymposiumSeptember 18, 2013California Endowment Center Yosemite A North Alameda St.1
2Pain and Addiction: Role of the Opioids Scope of the talk:Addiction: a brain diseaseOn becoming and staying addictedDefining pain: acute and chronic painAddiction in pain patients: how to tellOpioids: the two faces of JanusOpioids in chronic painOvercoming addiction and chronic pain
3Addiction: A Brain Disease What, Where, and How Our Three BrainsReptilian brain: Survival--feeding, fighting, fleeing, reproducingLimbic brain: memory and emotion—love, attachment, consideration for others, foundation for community and civilizationCortical brain: CEO and operating system--intelligence, intuition, insight flexibility, speed, efficiency, creativity, morality, free will, meaningful life, uniquely human, under constructionReptilian brain: a billion years ago, it does 4 things for survival. Next time we have a road rage, you’re operating your reptilian brain. To keep control: STOP—stop, take 3 deep breaths and smile, really smile, observe inside and out, proceed with reflection.Limbic brain: community and civilization made possible by love and attachment, care and consideration. People who need people are luckiest people..drama queen vs cold fishCortical brain: CEO, uniquely human free will and creativity and morality. Still not finish, not sure where we are going.
4Addiction: Why Do People Take Drugs? People Take Drugs To:Feel Good (Sensation seeking)Feel Better (Self medication)DopamineOne way or the other they like what drugs do to their brain10020030040012345 hrTime After Cocaine% of Basal ReleaseDADOPACHVAAccumbensCOCAINE1002003004005006007008009001000110012345 hrTime After Amphetamine% of Basal ReleaseAMPHETAMINE10015020025012345hrTime After Morphine% of Basal ReleaseAccumbens0.51.02.510Dose (mg/kg)MORPHINE100150200250123 hrTime After Nicotine% of Basal ReleaseAccumbensCaudateNICOTINEHow does it happen? Dopamine
5Conditioned Response: Reward Driven Learning, Memory and Behavior DopamineDopamine: the brain’s motivational or “feel good” chemical. It makes us want to do it again—to repeat what activates its releaseDopamine is also involved in reward-driven learning and memory: conditioningConditioned Response: Reward Driven Learning, Memory and BehaviorPavlov’s DogConditioned learning incorporates the drug use environment into drug use memories and adds weight –salience—to these memories, giving them higher priority in driving drug use behavior until it takes over everything.Dopamine is key to reward driven learning—conditioned response-- which creates hightened-value memory that determines the behavioral basis of addiction. Slide 2A trigger is a stimulus which has been repeatedly associated with the preparation for, anticipation of or the use of drugs and/or alcohol. These stimuli include drugs, cues, people, things, places, times of day, and emotional states.Conditioned response is reward-driven learning which involves dopamine.Definition of a trigger.(
6How the Brain Got Its Addiction You begin with a normal brain and subject it to repeated exposures to drugs: dopamine spikesRepeated reward-driven, salient, learning experiences became encoded as enduring conscious and unconscious memories.The reward-driven salient drug use memories gain higher and higher priority in driving drug use behaviors until they take over everything—extreme take over.This is how the brain got its disease of addiction.How the addict got his brain disease“First the man takes a drink,then the drink takes a drink,then the drinks takes the man” Japanese proverbDisconnection between the limbic and cortical brain, an extreme take over brain disease
7Becoming and Staying Addicted: A Matter of Drugs and Memory Becoming addicted is a matter of drugsStaying addicted is a matter of memoryThe problem of addiction is not getting off drugs; it’s staying off drugs.Detoxification may be good for a lot of things, but staying off drugs is not one of themTo stay off drugs—relapse prevention—you have to deal with drug memories: no memory, no relapseRelapse prevention means substituting drug memories with non-drug memories.Detoxification may be good for a lot of things, staying off drugs is not one of themNext time you talk about substitution therapy, remember it’s the memories, not the drugs, you are trying to substitute.
8Defining PainPain: An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.It is always subjective. Each individual learns the application of the word through experiences related to injury in early life.—IASPIASP = International Association for the Study of PainEarly life -- historical Experience--learnedSubjective--private Individual--unique
9Acute vs Chronic Pain:Acute PainPhysiological; protectiveCauses external; obviousTissue damage; resolutionexpected within days/wksSymptom of illnessHappens TO youKey issue: what pain?Meds/big role vs selfChronic PainPathological; non-protectiveCauses internal; obscuredCNS changes; resolution depends on mastery/controlDisease & way of lifeHappens IN youKey issue: what patient?Meds/limited role vs selfThe Acute pain patient is afflicted; the Chronic patient is transformed. Chronic pain sufferer suffers for nothing
10When Pain Becomes Chronic The one certain thing: treatment didn’t workPatient frustrated and lost faith in doctorsPatient blamed for not getting betterLost “role”; becomes dependent on othersOthers must pick up slack and provide supportPatient feels neglected whenothers can’t do allPatient becomes anxious,angry and depressedPatient assumes life style of chronic painSeries of referral letters from surgeon: thank you ..sure will do well; surgery went well, expect return soon; healing fine, seem less than enthused about return to work; despite success, doesn’t seem motivated to return, obviously need psychiatrist.
11Defining Addiction in Pain Patients Addiction….is characterized by behavior that includes one or more of the following: impaired Control over drug use, Compulsive use, Continued use despite harm, and Craving AAPM/APS/ASAMAddiction is not taking lots of drugs; it’s taking drugs and acting like an addict.Addicts are addicts not for who they are, but for what they do.The 4 C’s: Control, compulsion, Continued use, Craving; Plus Chronicity
12Who’s at Risk and How to Tell? 4 Ways to identify patients at riskHistory—personal history and family historyScreening instrumentsBehavioral checklistsTherapeutic maneuver
13Screening Instruments HistoryWhat predicts addiction?Personal history of drug useFamily history of drug useCurrent addiction to alcohol or cigarettesHistory of problems with prescriptionsCo-morbid psychiatric disordersSame predictors as in non-pain patientsScreening InstrumentsSeveral clinical tools are available that estimate risk of noncompliant opioid use1,2,3The results determine how closely a patient should be monitored during the course of opioid therapy3Scores implying a high risk of misuse are not reasons to deny pain relief31 Webster, et alr. Pain Med. 2005;6:432.2 Coambs, et al. Pain Res Manage. 1996;1:155.3 Butler, et al. Pain. 2004;112:65.
14Opioid Risk Tool (ORT) Administration Scoring On initial visit Mark each box that applies: Female MaleFamily history of substance abuseAlcoholIllegal drugsPrescription drugsPersonal history of substance abuseAlcoholIllegal drugsPrescription drugsAge (mark box if between years)History of preadolescent sexual abusePsychological diseaseADO, OCD, bipolar, schizophreniaDepressionScoring totals:AdministrationOn initial visitPrior to opioid therapyScoring0-3: low risk (6%)4-7: moderate risk (28%)> 8: high risk (> 90%)Webster, et al. Pain Med. 2005;6:432.
15Screener and Opioid Assessment for Patients in Pain (SOAPP) 14-item, self-administered form, capturing the primary determinants of aberrant drug-related behaviorValidated over a 6-month period in 175 chronic pain patientsAdequate sensitivity and selectivityMay not be representative of all patient groupsA score of ≥ 7 identifies 91% of patients who are high riskButler, et al. Pain. 2004;112:65.SOAPP® V.1 – 24QButler S et al, Pain, 2005
16Aberrant Drug-Taking Behaviors Probably less predictiveAggressive complaining about need for higher doseDrug hoarding during periods of reduced symptomsRequesting specific drugsAcquisition of similar drugs from other medical sourcesUnsanctioned dose escalation 1 – 2 timesUnapproved use of the drug to treat another symptomReporting psychic effects not intended by the clinicianProbably more predictiveSelling prescription drugsPrescription forgeryStealing or borrowing another patient’s drugsInjecting oral formulationObtaining prescription drugs from non-medical sourcesConcurrent abuse of related illicit drugsMultiple unsanctioned dose escalationsRecurrent prescription lossesThe problem with this is that the good predictors don’t happen very often; the common ones are not very predictive.Passik and Portenoy, 1998
17Aberrant Behaviors in Cancer and AIDS However, even a simple count may be very usful.Passik et al. 2003
18Probability of positive urine toxicology by number of aberrant behaviors Higher prevalence of SUD among pts on opioids for chronic pain than general population (8.1% current users)Katz N et al, Clin J Pain, 2002
19Therapeutic Maneuver: Is the Pain Patient Addicted? Drug-seeking or increased requests for pain medication Pathology/pain of new sourceDetailed pain work-upNo new pain pathology Opioid doseImproved functioningAbsence of toxicityUnimproved functioningPresence of toxicityTherapeutic dependencePseudoaddictionAddictive disease
20Opioids in Chronic Pain: The Two Faces of Janus Relieve painRelieve sufferingRelieve miseryMake you feel betterMake you feel goodMake you “high”
22Treating Pain with Opioids: What Can We Expect to Achieve? Reduction in pain and sufferingMeaningful pain reduction (Analgesia; Pain)Acceptable side effects (Adverse effects; Price)Improved functionalityMeaningful functional improvement (Activities; Performance)No unacceptable aberrant behavior (Aberrant behavior; “Pees”The 4 A’s (Passik); the 4 “P’s”
23Meaningful Pain Reduction Using a VAS or Numeric scale of 0-10(4-6= mod pain; 7-10= 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%)M. Soledad Cepeda et al.Proc 10th world Cong on Pain vol 24; pp IASP press 2003
24Meaningful Functional Improvement: My Favorites Patient perspective of “improvement”Used to do, can’t do now, would like to do againCould be physical, social, recreationalWith friends, family, churchAchievable, enjoyable, and meaningfulHobbiesVolunteer workNotice emphasis on new or renewed activities to rebuild a different new memory bank.
25Chronic Pain and Suffering: Some Basics Chronic pain hurts, but seldom harmsChronic pain patients are not bothered by pain; they are plagued by suffering.Pain happens to you, suffering happens in you.Pain is the enemy outside; suffering is the demon within.Pain is inevitable and universal, suffering is optional and individualPain can be likened to how much money you owe; suffering is how poor you feel.Suffering cannot be cured, it can only be conquered and mastered.
26Chronic Pain and Addiction: Memory Matters Characterized by aberrant behaviors that persist despite their being destructive and detrimental to one’s best interest.Behaviors are based on a distorted belief system rooted in deeply ingrained learning and memory of past experiences.Both involve brain changes that result in the hyperexcitability of a lower brain and loss of control from a higher rational brainNeither can be gotten rid of but must be overcome with new and different reward-driven learning life experiences creating a new memory bank and a new belief system and new behaviors.We are all created equal, but we don’t sit down at the table with the same hand; hence, different clinical expressions.Series of referral letters from surgeon: thank you ..sure will do well; surgery went well, expect return soon; healing fine, seem less than enthused about return to work; despite success, doesn’t seem motivated to return, obviously need psychiatrist.
27Chronic Pain and Addiction: Common Overlapping Features Early traumaLoss of masteryLoss of controlLoss of sense of selfCognitive error“Personalization”Over interpretation“Catastrophization”AddictionEarly traumaLoss of masteryLoss of controlLoss of self-efficacyCognitive error“Nirvana”Denial
28Overcoming Chronic Pain The sufferer of chronic pain is permanently preoccupied by it and suffers as a result.Overcoming chronic pain means learning to overcome suffering, no matter what happens.Be prepared physically and emotionallyActually engage in the act and take chargeReconnect and become engaged with friends and family and communityRegain a meaningful balanced lifeBusiness adventure as analogy; whether or not you make money depends on what you do after you start to work on it; but it’s chances of making money is a lot better if you go into it believing that you’ll be successful.And of course you have to actually do it.
29How Not to Succeed 1. Don’t attend 2. Try not to learn anything 3. Don’t do any of the exercises4. Don’t try any of the techniques5. Keep a closed mind6. Resist change7. Look and act miserable8. Tell yourself “nothing will help me”9. Remain very serious and never smile10. Don’t share anything (R. N. Jamison)
30Relapse: A Three-Character Play Drug memories: …everything, seems to bring memories of you…(Eubie Blake)Cues and triggers: external and internal; craving and desire for love lost—regression & comfortEmotional buildup: justification for use—the internal dialogue making use okay and naturalRelapse does not happen by accident.
31Treating Chronic Pain and Relapse Prevention: Forget It? Addiction is memory; so is chronic painNo memory, no relapse; no memory, no sufferingBoth are brains transformed—cannot be gotten rid of, can only be conquered and controlledBoth require memory substitutionBehavior creates experience, experience creates memory, memory creates belief systems, belief systems determine new behavior, new behavior determines new outcome.Change your memory, change your brain, change your brain, change your life.The only way to have your life turn out different is to act differently.And we learn how learning and memory is the basis of relapse, which is what makes addiction a chronic relapsing brain disease. The protein Delta-Fos B produced after repeated exposure; once produced, switches on, regulates genes in Nu accumbens making it sensitive to glutamate which increases sensitivity to drugs. Everybody knows what craving is but no one can really define it. But we all know it has to do with relapse, triggered by drugs.cues, and stress. It began with the abused drugs increases DA in the mesolimbic reward circuit but it doesn’t stay there. With conditioned responses it became learned and is stored in memory and gives it added meaning and value; “value added memory” so to speak. Learning and memory extend beyond mesolimbic circuitry into dorsal striatum. Repeated esposure sensitize the neuronal circuitry not only increase the magnitude of the response but also gives it added value (salience) maiking it more desirable and moving from “liking” it from the drug effect into “wanting” it more and more and pretty soon it becomes all that matters is to seek drug and use.Craving: A strong desire or urge.
32Creating Non-Drug Memories: The Old Fashion Way Experience–activities—leads to protein synthesisProtein synthesis activates new gene expressionsGene expressions create new brain connectionsNew brain connections produce new memoriesNew non-drug memories create non-drug belief systems that determine behaviors that determine how life turns out.The only way to change your life is to do things differently so they will turn out different.Forgetting old drug memories and creating non-drug memories the old fashion way.
33Preventing Relapse: Eight Steps to a Drug-Free Life Sound physical healthSound mental healthStay off drugs and stay busyTake care of business: out of jail and on the jobTake personal responsibilitiesLive in harmony with family and friendsBe a good member of the communitySearch for a meaning in life.First ready yourself, then put the house in order, then govern the country, then conquer the world—ConfuciusIf there be righteousness in the heart, there will be beauty in the character; If there be beauty in the character, there will be harmony in the home; if there be harmony in the home there will be order in the nation; if there be order in the nation, there will be peace in the world.
34Spirituality, Mindfulness, and a Meaningful Life In a NutshellMindfulness of motivation: Doing good for someone else is better than feeling good yourself; it’s the true path to happiness.Mindfulness of wisdom: Conventional reality is an illusion; Inherent reality is emptiness. All things follow the laws of impermanence and non-self. Nothing lasts forever, nothing can be possessed, and you can’t take anything with you.To be successful in mindfulness you have to have a pretty sense of yourself, like what am I? Why am I here? Is there some purpose for me being here. Is it a miracle or a meaningless accident? If you think about it with all the things going around in the universe, the chance of your being here is nothing short of a true miracle, and that goes for everybody who is here. That alone should make us see ourselves differently and treat eachother differently. Then the two pillars of the mindfulness meditations will begin to make sense.
35What Are We? Unique or Random? Thank you Thank you Thank youYou are either a unique special being endowed with the dimensions of consciousness –your mind– and moral capacity, or are a random, accidental collections od DNAs and Genes with no purpose other than the biological imperative of reproduction. Your contribution to humanity, if any, is at best an acciedent waiting to happen—a mutaton--; and when it happens, what will you do? Chances are you wouldn’t matter but someone will try to pattern it and make a profit. Only you can decide, but whatever you decide will impact on the way you see yourself and treat others.To the Dalai Lama, some how it doesn’t make sense that the brightest of us who have learned and know so much about the mysteries of our brains and minds can accommodate the life view that things like the meaning of life and good and evil don’t matter. As we the Thais embark on a mission of helth reform. I hope we will remember that understanding of addiction as a brain disease should not just inform us, but should change us. In that respect I believe our tradition of humanistic aprroach to care based oncontemplative science has aleady put us ahead of the curve. I very much look forward to be part of that enterprise. Again, thank you for the opportunity to share with you a few of my thoughts.