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

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Presentation on theme: "NYSAM 2011 Case Presentation Edwin A. Salsitz, M.D. FASAM Beth Israel Medical Center New York City."— Presentation transcript:

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

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

3 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) Physician Clinical Support System

4 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 54 y.o. evaluated on 6/19/09 Headaches major medical problem Headaches major medical problem ? Paternal uncleEtOH ? Paternal uncleEtOH Lives with husband, has 2 adult stepchildren Lives with husband, has 2 adult stepchildren Upper level executive in marketing, 250K Upper level executive in marketing, 250K Through H.S. no drugs or EtOH Through H.S. no drugs or EtOH

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

8 CT 2010 Case Migraines lessened in 30s and 40s Migraines lessened in 30s and 40s frequency and severity post-menopause frequency and severity post-menopause Opioids X 4 yearsoxyCR & oxyIR Opioids X 4 yearsoxyCR & oxyIR Nationally known HA clinicweaned off opioids 2 yrs agosevere HAs opioids(1 mo.) Nationally known HA clinicweaned off opioids 2 yrs agosevere HAs opioids(1 mo.) Neuro and Pain Specialistran out of meds 1 week early ? Inpatient detox--?work Neuro and Pain Specialistran out of meds 1 week early ? Inpatient detox--?work Current meds. Oxy CR 30mg tid OxyIR 5mg qid(NSAID, ondansetron, prednisone, venlafaxine, topiramate) Current meds. Oxy CR 30mg tid OxyIR 5mg qid(NSAID, ondansetron, prednisone, venlafaxine, topiramate)

9 CT 2010 Case Age 17appendectomy1 st opioid felt good, took away my insecurities Age 17appendectomy1 st opioid felt good, took away my insecurities Subsequent heroin--- energized Subsequent heroin--- energized Sobbing and Crying at mention of mother who died 9 mos ago at age 93 Sobbing and Crying at mention of mother who died 9 mos ago at age 93 Felt she was a terrible disappointment to mother Felt she was a terrible disappointment to mother Saw therapist on and off for many years currently not in psychotherapy Saw therapist on and off for many years currently not in psychotherapy

10 Diagnosis and Plan After Initial Consultation Opioid Physical Dependence Opioid Physical Dependence Pain Paradigm Pain Paradigm Husband to Dispense Opioids Husband to Dispense Opioids Attempt to taper opioids Attempt to taper opioids Rx Oxy CR 30mgattempt bid Rx Oxy CR 30mgattempt bid One week later 1.Oxy CR bid 2. D/C venlafaxine, start duloxetine 3. Oxy IR 5 q6h prn 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 vacationhusband not in agreement on chronic opioid paradigm Headaches have markedly increased while on vacationhusband not in agreement on chronic opioid paradigm Neurologist adds gabapentin 300mg tid and topiramate(now 100mg.qd) Neurologist adds gabapentin 300mg tid and topiramate(now 100mg.qd) Continued attempts to taper opioids not successful Continued attempts to taper opioids not successful

12 4 Weeks Later Husband no longer coming in with patient Husband no longer coming in with patient Headaches dailymaking work and home difficult Headaches dailymaking work and home difficult After long discussion, OXY CR d/cd and methadone low dose started and titrated upwards After long discussion, OXY CR d/cd and methadone low dose started and titrated upwards

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

14 April 2010 Present June Rxs given for methadone June Rxs given for methadone October Short Acting Opioids D/Cd October Short Acting Opioids D/Cd October Methadone 30mg bid October Methadone 30mg bid Headaches present, but intensity/frequency Headaches present, but intensity/frequency Stigma issue around methadone continues Stigma issue around methadone continues Marital issue, no psychosocial Marital issue, no psychosocial Random urines negative Random urines negative

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

16 Saper, J. R. et al. Neurology 2004;62: 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)

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

18 Addiction Chronic Pain Somatic Sxs Somatic Sxs Hedonic Tone Hedonic Tone OPIOIDS ? Endorphin Deficiency OPIOIDS ? Endorphin Deficiency Pain Medicine PrescriptionsPharmaciesLegitimate Addiction Treatment Methadone Clinics RegulationsStigmaBuprenorphine Anti-Depressants Anti-Convulsants Mood Stabilizers SUBSETSUBSET

19 * Anterior Cingulate Gyrus * * *

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

21 HCC=Healthcare for Communities 1998, 2001

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

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

24

25 Problematic (Aberrant) Behaviors Problematic (Aberrant) Behaviors Probably more predictive Probably more predictive –Selling prescription drugs –Prescription forgery –Stealing or borrowing another patients 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 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 The ORT Form-Opioid Risk Tool Mark each box that applies 1. Family history of substance abuseFemale Male Alcohol [ ] [ ] Illegal drugs [ ] [ ] Prescription drugs [ ] [ ] 2. Personal history of substance abuse Alcohol [ ] [ ] Illegal drugs [ ] [ ] Prescription drugs [ ] [ ] 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 [ ] [ ] Courtesy of Lynn Webster, M.D.

27 Validation Study Results Low ModerateHigh Aberrant Behavior Displayed (%) ORT Total Score Risk Category 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 Total score risk category Low risk: 0–3 Moderate risk: 4–7 High risk: 8

28 Russell Portenoy, M.D.

29 …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 dont know we dont know. – Donald Rumsfeld

30 MORPHINE IS GODS OWN MEDICINE Sir William Osler MORPHINE IS GODS OWN MEDICINE Sir William Osler

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

32 SUPPORT ASAM!!


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