3 The Perfect Storm n Liberalization of opioid therapy for chronic pain. n Newer, more potent opioid drugs. Smorgasbord of choices. n Demands on Primary Care n Societal Attitudes n Parents, healthcare providers often naïve n Minimal Screening for Addiction
4 Red Flags n Smoking n Family history of addiction n Psychiatric disorder n The patient insists on being on multiple classes of controlled substances n Allergic of cant tolerate non-addictive medications and approaches n Lots of chaos, never seem to really improve, pain and anxiety always high n Reports or appearance of intoxication
5 What are prescription Opioids? n Hydrocodone – Vicoden, Lortab, Norco –tabs, vikes, hydros n Oxycodone – OxyContin, Percocet –Oxys, OCs, Percs n Codiene n Morphine n Methadone n Fentanyl – Duragesic n Propoxyphene – Darvocet, Darvon n Tramadol - Ultram
6 Potential problems with long-term use of Opioids: n Addiction n Tolerance n Hyperalgesia (abnormal pain sensitivity) n Hormonal side effects (decreases testosterone levels, decreases sex drive and irregular menses) n Suppression of the immune system n Depression n Interference with endorphin system
7 Addiction : A Definition Addiction is a primary chronic disease with genetic psychological and environmental factors contributing to its development and manifestations. The disease is often Progressive and Fatal. It is characterized by impaired control over drugs, preoccupations with the drug, use of drugs despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic
8 Six of the top ten drug claims paid in the 1 st quarter of 2009 were addictive pharmaceutical drugs Drug Total Claims Total Paid Hydrocodone/APAP44,268$3$346,726.46 Aspirin39,556$34,788.72 Docusate Sodium 35,707$72,660.41 Alprazolam33,106$190,029.25 Calcium Carb/Vit D 32,124$65,822.51 Acetaminophen31,011$77,153.23 Multivitamins27,664$39,106.64 Loratadine25,423$237,272.83 Clonazepam23,620$109,086.56 Lorazepam20,501$112,722.04
9 Statistics n Substance abuse treatment admissions reporting primary pain reliever abuse increased from 18,300 in 1998 (1.1 percent of all admissions) to approximately 105,680 (5.6 percent) in 2008
10 Alcohol and Other Drug Dependence in America are Thought to be Causative Factors in: n Up to 50% of Divorces n 65% of Domestic Violence Cases n 70% of Childhood Sexual Abuse Cases n Impaired Job Performance and Loss of Employment in Individuals between the ages of 20-50 n Fetal Alcohol Syndrome and Fetal Alcohol Affect (Number One Preventable Cause of Birth Defects) n High Mortality Rate (Nicotine Dependence is the Nations #1 Killer)
11 n A key neurophysiologic lesion of alcoholism and other addictions occurs in the mesolimbic dopaminergic neural pathway in the brains ventral tegmentum. In normal individuals, this pathway provides pleasurable reinforcement when hunger or sex drives are satisfied. In addicted individuals, neuronal function in this pathway is regulated by different DNA sequences. Thus the neurophysiologic basis of the disease of addiction involves a hijacking of the mesolimbic pathway such that it drives addictive behaviors along with or instead of adaptive eating and sexual behaviors. For alcoholics, the resulting cravings and impulses to drink make it difficult to avoid alcohol.
12 Characteristics of Addictive Illness n Compulsion n Loss of Control n Continued Use Despite Adverse Consequences n Distorted Thinking
13 1.2 million 10Opioids 5-6 million 60Marijuana 3.1 million 35Cocaine 12-18 million 180Alcohol Chemical Dependence Use(Millions)Substance
14 Common denominator in at least the acute effects of all drugs of abuse is activation of the brains Mesolimbic dopamine system.
17 Problems for Pain Management n Over the past 30 years we have seen major advances in understanding the neurobiology of pain leading to: –new medications –improved surgical options and other intervention –better management of acute and post surgical pain.
19 n We have seen NO reduction in the prevalence of chronic pain and its associated disability n Far greater resources devoted to the problem and worse functional outcomes
20 n This is likely due to our failure to address the psychological and behavioral components of chronic pain. n Numerous studies have demonstrated that psychological variables predict onset, chronicity and outcomes in back pain more than do somatic variables.
21 n Chronic Pain has always been common but back related disability has increased exponentially. n Pain Specialists typically believe that addiction is rare in their patient population.
22 n Dr Edward Covington, Director of Pain Management of the Cleveland Clinic, feels that low estimates of addiction prevalence among chronic pain patients are difficult to accept for several reasons
23 n Low back pain is more common in individuals with nicotine and alcohol dependence n Nicotine worsens fibromyalgia n Chronic pain often follows accidents (more common in those with chemical dependence)
24 In a survey of 414 patients in a Swedish Rehabilitation Hospital n 1 in 4 had an active addiction n 1 in 3 had a lifetime history of addiction
25 Addiction disorders are of epidemic proportions in healthcare settings. n Johns Hopkins Hospital –Positive screens for alcoholism found in: n 25% of admissions to Internal Medicine n 30% of admission to Psychiatry n 14% of admission to Neurology n 12.5% of admission to OB/GYN n 23% of admission to Surgery –Detection rates: n Less than 25% in Surgery and OB/GYN n 25-50% in Neurology and Internal Medicine