Controlled Substance Management or “Doctor I need Oxy” Tony Tommasello, Ph.D. University of Maryland School of Pharmacy Office of Substance Abuse Studies 410 706-7513 atommase@rx.umaryland.edu

Program Objectives At the end of this program participants will be better able to: Screen for substance abuse Assess the severity of a patient’s involvement with alcohol or illicit drugs Determine the legitimacy of a patient’s request for opioid analgesics Justify and document the decision to prescribe or refuse to prescribe CDS

Lawnmower Addict L.A. is a 42 Y.O. male who broke his ankle while mowing wet grass across an incline. After several surgical attempts including failed pinning operations, his foot is rotated 60 degrees out of alignment and he has chronic pain. Prior to this injury L.A. had a history of opioid addiction. He states that he is committed to recovery and participates in 12-step N.A. meetings but he abused his last oxycodone prescription and experienced a relapse. His goal is to achieve pain relief without relapse to opioid abuse.

Enduring pain to avoid relapse E.P. is a 40 y.o. married male with 4 children, He has been in opioid addiction recovery for over 9 years. I received a tearful midnight call from his wife stating the E.P. was lying in bed in a fetal position, moaning in pain and refusing to take opioid analgesics after incurring a back injury while wrestling with his son who is a star member of the high school wrestling team. His goal is to never relapse to active opioid addiction.

Scope of the Public Health Problem An estimated 2.4 million people have used heroin at some time in their lives (NHSDA, 1998) During 1996 through 1998, an estimated 471,000 persons used heroin for the first time. Of them, 25% were under age 18 and another 47% were age 18 - 25 (NHSDA, 1999)

Heroin Price Falls, Purity Increases 1980 through 1998 Purity (% heroin) Purity (% heroin) Price in $US Price in $US Data from U.S. Department of Justice: Drug Enforcement Administration

What about abuse? According to the National Institute on Drug Abuse (NIDA), in 1999 Four million Americans reported current use of prescription drugs for non-medical purposes The most dramatic increases were found among the 12 to 25 year olds Oxycontin® and Ritalin® were among the most cited abused medications

Oxycontin 80mg sustained release tablet

Number of U.S. Narcotic Analgesic-Related ED Visits, 1994-2001 Source: www.samhsa.gov/oas/2k3/pain/dawnpain.pdf

Narcotic Abuse Taxes ED Resources In 2001 there were an estimated 90,232 ED visits, a 117% increase since 1994 “Dependence” was the most frequently mentioned motive for abuse (44% of cases) Between 2000 and 2001 Oxycodone mentions increased 70% and accounted for 53.7% of the overall increase in narcotic abuse cases during that year. Source: The DAWN report January 2003. http://www.samhsa.gov/oas/2k3/pain/DAWNpain.pdf

Teen Abuse of Rx Drugs National figures Curran JJ: Prescription for Disaster – The growing problem of prescription drug abuse in Maryland. Sept 2005.

Access to treatment is limited Of the estimated 810,000 opioid dependent persons in the U.S. only 170,000 maintenance treatment slots exist.

The Journey Matters

Therapeutic drug use: Drug use to treat or diagnose illness. Almost everyone has taken a drug at one time or another because they were sick. A direct and reliable drug effect is expected. Antibiotics kill bacteria regardless of the sick person’s belief in the medicine. The drug is a known entity. There are rules. The prescription tells: what to take, how much to take, and when to take it. A person who violates the rules must own the consequences.

Social Drug Use Drugs are used to increase social interactions. Rules are vague or non-existent. Drug supply is uncertain Most cases of addiction result from social drug use that gets out of control.

A Basic Distinction High seeking = Pain relief seeking “Because 6 to 15% of the U.S. population abuses drugs, the history of pain management is marked by the undertreatment [of pain in] the other 85 to 94%.” Passik SD quoted in: Gilson AM and Joranson DE (2002) U.S. Policies Relevant to the Prescribing of Opioid Analgesics for the Treatment of Pain in Patients with Addiction Disease Clinical Journal of Pain 18:S91-S98. available at http://www.medsch.wisc.edu/painpolicy/

Pain Statistics Most common reason that people seek medical care 50 million Americans are partially or totally disabled due to pain Annual cost to U.S. society estimated to exceed $100 billion 50-80% of patients with pain report that their pain is inadequately managed Risk of undertreatment is increased among those with a history of substance abuse

Addiction Defined Addiction is compulsive use with loss of control and continued use despite adverse consequences.

Elements of Compulsivity: Constant thought of drug acquisition Anticipation of opportunities to use Defer other priorities of life Unable to resist desire to use

Aspects of Loss of Control Inability to use in moderation consistently Easier to abstain completely Frequent episodes of excessive use

Continued use despite problems Loss associated with use Multiple crisis not seen as drug-related Sincere promises to self and others to quit

Signs of Psychological Dependence Carrying Drugs Using Drugs alone Stockpiling Drugs Concern over supply Changing friends Finding excuses to use Using at inappropriate times Willingness to take increasing risks

The Memory of Drugs Nature Video Cocaine Video Amygdala not lit up Amygdala activated Front of Brain Back of Brain Slide 10: The memory of drugs. This slide demonstrates something really amazing—how just the mention of items associated with drug use may cause an addict to “crave” or desire drugs. This PET scan is part of a scientific study that compared recovering addicts, who had stopped using cocaine, with people who had no history of cocaine use. The study hoped to determine what parts of the brain are activated when drugs are craved.   For this study, brain scans were performed while subjects watched two videos. The first video, a nondrug presentation, showed nature images—mountains, rivers, animals, flowers, trees. The second video showed cocaine and drug paraphernalia, such as pipes, needles, matches, and other items familiar to addicts. This is how the memory of drugs works: The yellow area on the upper part of the second image is the amygdala (a-mig-duh-luh), a part of the brain’s limbic system, which is critical for memory and responsible for evoking emotions. For an addict, when a drug craving occurs, the amygdala becomes active and a craving for cocaine is triggered. So if it’s the middle of the night, raining, snowing, it doesn’t matter. This craving demands the drug immediately. Rational thoughts are dismissed by the uncontrollable desire for drugs. At this point, a basic change has occurred in the brain. The person is no longer in control. This changed brain makes it almost impossible for drug addicts to stay drug-free without professional help. Because addiction is a brain disease. Photo courtesy of Anna Rose Childress, Ph.D. Nature Video Cocaine Video

DSM IV: Substance Dependence 3 of following in 12 month period: Tolerance Withdrawal Difficulty cutting down (loss of control) Time spent drug seeking (compulsive use) Decrease in activities Continued use despite knowledge of persistent physical or psychological problems

Addiction Characteristics First priority is drug acquisition and use Negative consequences occur in order 1) Interpersonal relationships suffer 2) Productivity declines 3) Self-Esteem plummets 4) Health problems emerge or worsen Note: Legal problems can occur at any time.

Why Treatment ? Rewards Negative consequences Utility Theory Dysfunctional lifestyle of opioid addiction makes treatment a desired alternative Oral methadone and buprenorphine sublingual tablets are approved for both medical withdrawal and medical maintenance

Addictive Behaviors Selling prescription drugs Prescription forgery Stealing drug from others Injecting oral formulations Buying drugs on the street Resistance to change therapy despite evidence of adverse effects from the drug

Pseudo-addiction Drug-seeking behavior misidentified by health providers as addictive behavior, when it is actually relief-seeking behavior Behaviors resembling those of drug addiction disappear when patient is given adequate doses of analgesia

Pseudoaddiction Behaviors Complaints for more drug Hoarding drug during pain free periods Specific drug requests Openly seeking other sources of help Occasional unsanctioned dose increases Resistance to change in therapy

Ambiguous Behaviors Complaints for more drug Hoarding drug during pain free periods Specific drug requests Openly seeking other sources of help Occasional unsanctioned dose increases Resistance to change in therapy

Principles Physical Dependence = Addiction Pain Management with opioids Addiction (<3%)* Physical dependence (common) * Brushwood et al. (2002) Pharmacists’ Responsibilities in Manageing Opioids: A Resource APhA Special Report American Pharmacists Association.

Summary Differentiating factors Motivation for use Route of administration Frequency of use and dose Pseudo-addiction? Continued use despite problems

Types of Pain Nociceptive Neuropathic Pain resulting from actual or potential tissue damage Results from ongoing activation of primary afferent nociceptive neurons by noxious stimuli Neuropathic Results from a disturbance in function or pathologic change in a neuron Can be peripheral or central

Pain Characteristics

Non-Verbal Signs of Pain Aggressive behavior Changes in daily activities Facial expression Bodily movements Vocal Mood Physical Assessment Values Change in vital signs

Symptom Analysis Precipitating events Palliating events Quality Severity Pain location and radiation Temporal relationships Associated symptoms Previous treatments and their effects

Pain Scales Numerical Pain Scale Faces Pain Scale

Pain Assessment Accept the patient’s description Thorough assessment of each pain History, examination, investigation Assess impact of pain on ADLs and functional status Assess other factors that influence pain Physical, psychological, social, cultural, spiritual Reassessment

WHO-Step Ladder Severe Moderate Mild Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants Moderate APAP/Codeine APAP/Hydrocodone APAP/Oxycodone APAP/Dihydrocodeine Tramadol ± Adjuvants Mild Aspirin Acetaminophen NSAIDs ± Adjuvants Adapted from: World Health Organization. Cancer Pain Relief. 1996.

Patient Centered Treatment Goals “What would you like to do that you can’t do because of your pain?” “I’d like to be able to do my needlework” “I’d like to walk to the bathroom – alone” “I want to sleep through the night” “I want to go back to work” “I want to be able to play with my children”

With Uncontrolled Pain … Emotional Effects Depression, anxiety, anger Cognitive Effects Somatic focus, helplessness, “catastrophization” Behavioral Effects Inacitvity, social/sexual dysfunction, poor sleep, loss of productivity Physical Changes Muscle tension, poor posture, circulatory impairment, obesity Increased PAIN and Dysfunction PAIN

Four kinds of patients Two kinds of pain No History of Abuse (Group 1)* Substance abuser in the past (Group 2)* Addict in recovery including opioid maintenance patient Active substance abuser (Group 3)* Nociceptive pain Acute Chronic Somatic Visceral Neuropathic pain * Gourlay et al. (2005) Pain Medicine 6(2) 107-112

The CAGE Screen Have you ever felt the need to Cut Down on your drinking Have you ever been Annoyed by criticism of your drinking Have you ever felt Guilty about your drinking Have you ever needed an Eye Opener to get going in the morning.

CAGE 4 yes/no questions (1 yes = positive) Administered by interview Alcohol only Screens for abuse and dependence Add quantity and frequency questions to screen for at-risk drinking Sens: 43% - 94% Spec: 78% - 96%

Toxicology Screening Tests Qualitative results Purposes To identify surreptitious use To monitor known users Clinical Examples Prenatal Care Impaired Professionals Trauma/ER

Legitimate patient with no Hx of addiction (Group 1*) Manage pain (analgesic ladder) Recognize low addiction risk Differentiate physical dependence from addiction Don’t mistake pain relief seeking for drug seeking - pseudoaddiction * Gourlay DL et al. (2005) Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 6(2), 107-112.

Pain Management and Addiction Confusion over the distinction between physical dependence (a state of adaptation that produces withdrawal signs upon abrupt drug discontinuation) and addiction (DSM-IV Substance Dependence) has confounded approaches to the patient in pain.

Misconception regarding pain management with opioids Misconception: Therapeutic use of opioids is commonly associated with substance abuse or addiction Reality: In patients with no history of substance abuse the risk of addiction following therapeutic use appears to be less than 3%

Clinical Features Distinguishing Opioid Use in Patients With Pain Versus Patients Who Are Addicted to Opioids (TIP 40) Clinical features Pain Pt. Addicted Pt. Compulsive drug use Crave drug (when not in pain) Obtain or purchase drugs from nonmedical sources Procure drugs through illegal activities Escalate opioid dose without medical instruction Supplement with other opioid drugs Demand specific opioid agent Cease use when effective alternatives are available Prefer specific routes of administration Can regulate use according to supply Rare Absent Unusual Usually No Usually (break through pain) Common Frequent Not usually Yes

Patient populations under-treated for pain Elderly Minorities Children Terminally ill patients with HIV/AIDS Chronic non-cancer pain Perceived as high addiction risk Gilson AM and Joranson DE (2002) U.S. Policies Relevant to the Prescribing of Opioid Analgesics for the Treatment of Pain in Patients with Addiction Disease Clinical Journal of Pain 18:S91-S98. available at http://www.medsch.wisc.edu/painpolicy/

Addict in solid recovery (Group 2*) May refuse adequate pain pharmacotherapy Use of buprenorphine Suggest increased support group work while on analgesic pharmacotherapy Conduct urine or saliva screens for unauthorized substances Utilize pain management contract * Gourlay DL et al. (2005) Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 6(2), 107-112.

Misconception regarding pain management with opioids Misconception: it is illegal to prescribe or dispense opioids for a patient with a history of substance abuse Reality: It is not illegal and the regulatory agencies do not intend to restrict appropriate therapeutic use

Management Guideline for Recovering Addicts Relapse prevention: “Relapse occurs most often when practitioners are unaware of their patients’ opioid addiction history” (TIP43 p174) Education regarding the need for drug Patient’s fear and staff reluctance may conspire to under-medicate “A patient’s previous drug of abuse should not be prescribed for pain treatment” (TIP 43 p176) TIP 43 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs DHHS Publication No. (SMA) 05-4048 Rockville, Md.

Undiagnosed substance abuse or addiction – active users (Group 3*) Screen all patients for substance use disorders with CAGE Ask Make pain management contingent on thorough assessment and treatment if warranted Utilize pain management contract * Gourlay DL et al. (2005) Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 6(2), 107-112.

Management Guidelines for High Risk (Group 2) and Active User (Group 3) Identify and treat underlying medical problem(s). Use appropriate drug, dose, and route Employ non-opioids when possible Recognize abuse behaviors Don’t negotiate Refer to substance abuse and pain services Disclose plan for prescription abuse (Pain management contract)

Drug Diverter – Not a patient Medico-legal nightmare Do a thorough pain assessment Document, document, document First time patients who request specific agents Abide by pain management ladder – don’t trade off good medical practice for convenience

Policy Barriers to Effective Pain Management Lack of training or expertise by healthcare practitioners and limited access to pain specialists Regulatory steps to prevent drug diversion may also impede pain management (Electronic CDS prescriptions) Perceived risk by physicians that sanctions may be imposed by regulatory boards for over prescribing opioids for non-malignant conditions (Chilling Effect) Poor communication

Federal Food Drug Cosmetic Act and the Controlled Substances Act CSA FFDCA “Pain specialists may treat a chronic pain patient currently enrolled in a narcotic treatment program with narcotics. The CSA does not set standards of medical practice. It is the responsibility of individual practitioners to treat patients according to their professional judgment for a legitimate medical purpose in accordance with generally acceptable medical standards.” P. Good (2000) Chief; Liaison and Policy Section, Office of Diversion Control DEA.

The Pharmacist’s Dilemma To fill or not to fill Therapeutically Appropriate Yes No OK Dispense Resolve problem (dose, route interaction) Resolve document problem Don’t dispense Legally Valid

Corresponding Responsibility Rule 21 CFR 1306.04 A prescription for a CDS to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice. The responsibility for the proper prescribing and dispensing of CDS is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a prescription and the person knowingly filling such a purported prescription as well as the person issuing it shall be subject to the penalties provided for violations of the provisions of law relating to CDS.

Federal CDS schedules I High abuse potential No current accepted medical use May be used in research Heroin, LSD, MDMA II Accepted medical uses Morphine, hydromorphone, methadone, oxycodone, cocaine, amphetamines III Less abuse potential than I and II Opioid combined with non-opioids, anabolic steroids, buprenorphine IV Less abuse potential than III Benzos, Chloral hydrate, phenobarb, fenfluramine. V Less abuse potential than IV Antitussives with limited amounts of codeine

CDS Requirements II Signed prescriptions*; no refills; prescriber must be registered with DEA III & IV Written, oral, or faxed prescription; refill 5 times in 6 months; prescriber must be registered with DEA V Written, oral, or faxed prescription; refill as authorized; prescriber must be registered with DEA * - Emergency prescriptions require follow up prescription, Fax may be used for home infusion/intravenous therapy, long term care facility, and hospice patients

Model Prescription Schedule II medication Physician name, address, and DEA number Ralph Amado, M.D. 3862 North Hampton Lane Rudolph, PA 38216 AA620395 Patient: Patient name and address Roger Bacon 1063 Eastlight Dr. Essex, PA 38604 Drug name and strength Dosage form and quantity Oxycontin 20mgs Tablets #60 (sixty) SIG: for pain take one tablets every 12 hours. Refill x 0 (none) Physician signature: Ralph Amado Date issued: 4/18/06

Red Flags for Prescription Forgery The prescription is “too legible” Standard abbreviations are not used The prescription appears to be photocopied More that one ink color or handwriting used Erasure marks visible Paper appears to have been wet. (acetone) Odd combinations of medications Someone other than the patient presents the prescription for dispensing\

Prescription Drug Monitoring Programs Electronic PDMP passed in 2006 Maryland general session (SB 333 & HB 1287) and was vetoed by Gov. Ehrlich on May 26, 2006. As of April 2005, 22 states already adopted electronic PDMPs Of the various PDMP approaches (serial Rx, triplicate) electronic systems are the least intrusive and “chilling” on prescribing practices. Brushwood DB, Hahn KL and Rickert ED (2005) Pharmacists’ Responsibilities in Managing Opioids: 2005 update. American Pharmacists Association CE Monograph

Federation of State Medical Boards “The board will judge the validity of prescribing on the physician’s treatment of the patient and on available documentation, rather than on the quantity and chronicity of prescribing” Evaluation of patient, treatment plan, informed consent and agreement for treatment, periodic review, consultation,medical records, compliance with regulations

Case: Acute Pain Patient with hx of heroin addiction who is currently receiving buprenorphine sublingual tablets (Suboxone®) comes to Acute Care Center with compound fracture of the right femur.

Case: Acute Pain - Issues Ability to control pain in patient receiving chronic partial antagonist therapy Risk of relapse Uncontrolled pain may delay/impair rehabilitation and recovery

Case: Acute Pain- Strategies Non-pharmacologic and non-opioid interventions should be optimized first Engage patient in strategies that have aided in their recovery as soon as possible Consult addiction medicine specialist When opioids are necessary, use long-acting, slower onset formulations when possible Must D/C buprenorphine in order to obtain full agonist effect of mu agonists.

Examples of Nonpharmacologic Interventions for Pain Cognitive-Behavioral education/instruction relaxation imagery music distraction biofeedback Physical Agents heat or cold compress massage, exercise, immobilization transcutaneous electrical nerve stimulation

Mechanistic stratification of antineuralgic agents Mechanistic stratification of antineuralgic agents. PNS = peripheral nervous system; CBZ = carbamazepine; OXC = oxcarbazepine; PHT = phenytoin; TPA = topiramate; LTG = lamotrigine; TCA = tricyclic antidepressant; NE = norepinephrine; SSRI = selective serotonin re-uptake inhibitor; SNRI = serotonin and norepinephrine re-uptake inhibitor; GBP = gabapentin; LVT = levetiracetam; NMDA = N-methyl-D-aspartate; NSAID = nonsteroidal anti-inflammatory drug. Beydoun A. Neuropathic pain: from mechanisms to treatment strategies. [Journal Article] Journal of Pain & Symptom Management. 25(5 Suppl):S1-3, 2003

Case: Acute Pain- Strategies Begin tapering of opioids as soon as possible but gradually to avoid any withdrawal symptoms Treat relapse if it occurs Re-start buprenorphine therapy

Misconception regarding pain management with opioids Misconception: patients on methadone maintenance therapy should not be experiencing pain Reality: “Reluctance to provide adequate pain treatment to patients on medication assisted therapy usually is based on the mistaken belief that a maintenance dose of opioid addiction treatment medication also relieves acute pain” (TIP43 p174) TIP 43 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs DHHS Publication No. (SMA) 05-4048 Rockville, Md.

Guidelines for Methadone Patients Don’t expect the patient’s methadone maintenance dose to provide analgesia Continue patient’s maintenance dose Add analgesic (opioid and otherwise) starting with usual doses Anticipate tolerance and the need for higher dose requirement

Sample Adult Screening Protocol Transition: Stresses and ways of coping “Do you use tobacco?” (if so, “Are you interested in quitting?”) “Do you drink alcohol?” “Have you ever experimented with any drugs?” Ask CAGE or CAGE-AID questions Ask Q/F questions on alcohol Usually takes less than one minute

For Especially Sensitive Situations Ask about friends first Ask about prior use first Make normalizing statements before asking questions

Review of Pain Classifications Acute Pain Warning that tissue injury (or disease) has occurred Subsides as healing takes place (usually less than 3 months) Often accompanied by autonomic responses – tachycardia, tachypnea, hypertension, diaphoresis, mydriasis Goal: relieve pain and allow healing to occur  CURE evidence supports that pain relief may hasten healing following many types of injuries

Review of Pain Classifications Chronic Nonmalignant Pain May initially be elicited by injury but may persist long after healing has taken place and change in characteristics and location May occur following injury, chronic disease, or have no definable cause Examples: diabetic neuropathy, radicular or low back pain Typically persists for months to years and may be continuous (persistent) or cyclic (chronic) Goal: relief and management as cycles occur

Review of Pain Classifications Chronic Nonmalignant Pain Not associated with autonomic responses Frequently associated with depression, anxiety, fear, sleep disorders, anorexia, disability Likely to develop physical dependence and tolerance to analgesics Use of opioids has been controversial but becoming more widely accepted in specific circumstances Evidence that functionality improves Cognitive and motor impairment are not problems associated with chronic use Goal: relief and rehabilitation (not cure)

Review of Pain Classifications Malignant Pain Associated with cancer or some similar progressive, ultimately fatal disease Frequently worsens in intensity and spreads to other areas of the body as the disease progresses Not associated with autonomic responses Frequently associated with depression, anxiety, fear, sleep disorders, complications of the cancer and other symptoms including hiccups, cough, chronic nausea, shortness of breath, myoclonus, delirium as patient enters final days to weeks of life Physical dependence is assumed and patients usually require higher and higher doses of opioids due to tolerance and disease progression Goal: relief, maintain function, quality of life, palliative care

American Academy of Pain Medicine and American Pain Society Joint Statement 1997 Good medical practice for patients receiving chronic opioid therapy involves: Complete patient evaluation including coexisting diseases and conditions Treatment plan: inform patient of risks and benefits of opioids and conditions for prescribing. Consultation with specialists Periodic review of efficacy, AEs, functional status, QOL, medication misuse Thorough documentation

The VIGIL System Verification: that the pt. can take the medication responsibly and that the Rx is genuine Identification: driver’s license or other ID Generalization: establish the general parameters of the provider-pt relationship Interpretation: the decision to dispense is made Legalization: ensuring adherence to legal requirements for treatment While this process takes time – most bona fide patients will accept or welcome it because it acknowledges their need for ongoing treatment with controlled substances and provides “rules” for safe conduct with these agents. Bogus “patients” will not be willing to meet these requirements.

Case: Chronic Nonmalignant Pain Patient with diabetic neuropathy, degenerative spinal disease, and history of cocaine (nasal) dependence. Pain described as shooting up right leg, dysesthesias, burning and numbness in both feet. Recurrent diabetic foot ulcers that required amputation of several toes. Frequently misses work due to pain. Receiving maximum doses of gabapentin and SSRI. Previously has failed trials of imipramine and carbamazepine. A trial of oxycodone 10 mg Q 4 H improves pain significantly, however his clinician feels that he should decide whether he wants to take the risk of addiction.

Case: Chronic Nonmalignant Pain- Issues Past substance abuse places him at greater risk for opioid abuse and dependence (10-25%) Patient seeking medical attention has a right to treatments that he may benefit from Clinicians have ethical responsibility to intervene and relieve suffering (beneficence) but should exercise knowledge, skills and experience in making intervention decisions Clinicians should not knowingly cause unwanted injury or suffering Inadequate treatment of pain has been found to be criminal negligence and malpractice in courts

Case: Chronic Nonmalignant Pain- Issues If patient is impaired, does he have the capacity to understand risks and make judgment? Determining etiology and pathophysiology of chronic pain syndromes if often difficult Chronic pain is often complicated by depression and anxiety which may limit patient’s ability to make balanced decision and other complications of unrelieved pain

Case: Chronic Nonmalignant Pain- Issues Unrelieved or undertreated pain may: provoke drug abuse in patients with substance abuse prevent patient from fulfilling responsibilities that impact others – salary, benefits

Case: Chronic Nonmalignant Pain- Strategies Non-opioid strategies should be evaluated prior to initiation of opioids including co-analgesics Individuals caring for patient should be experienced in chronic pain, substance abuse and use of opioids in patients with history of substance abuse

Case: Chronic Nonmalignant Pain- Strategies When opioids are considered: Patient should be informed (in writing) of potential risks and benefits and conditions of treatment and given opportunity to accept or reject opioid trial Pain Management contract

Case: Chronic Nonmalignant Pain- Strategies Special monitoring and clear limits regarding opioid use should be set (to avoid secondary harm of substance abuse) Prescriptions are for fixed amounts, clinicians should see patients more frequently than other patients Single pharmacies Pharmacy will not accept opioid prescriptions from other than contracted prescriber Inappropriate behavior, accelerated use of opioids etc will result in screening

Case: Chronic Nonmalignant Pain- Strategies Treatment goals should be clearly established – pain relief, function, quality of life Pain should be adequately treated using standardized guidelines (including use of breakthrough medications) – may lead to pseudoaddiction or abuse Opioid doses in patients with history of substance abuse frequently are higher than “typical” doses Underdosing may provoke or exacerbate abuse

Case: Chronic Nonmalignant Pain- Strategies Due to prior history of abuse, patient should connect (if not already) with AA or NA, etc or formal treatment program – some clinicians may require participation for prescriptions

Pharmacotherapy General Principles Around-the-clock dosing and long-acting formulations for continuous pain As-needed immediate-release analgesic supplementation for breakthrough pain Observe for end-of-dose failure Incident pain “prophylaxis” Spontaneous pain suggestive of visceral/neuropathic etiology Anticipate, prevent, and treat predictable SEs Constipation

Conclusions There is no easy formula for dealing with this common yet complex area of patient care Engage addiction specialists sooner rather than later

Conclusions Consider referral to pain management specialist when standard approaches fail and discomfort sets in – before the situation has escalated out of control. Employ the assistance and cooperation of a competent pharmacist who maintains a patient centered pharmacy practice.

Recommended Readings and Websites Gilson AM and Joranson DE. (2002) U.S. Policies Relevant to the Prescribing of Opioid Analgesices for the Treatment of Pain in Patients with Addictive Disease Clin J Pain 18: S91-S98. Brushwood DB, Finley R, Giglio JG and Heit HA (2002) APhA Special Report: Pharmacists’ Responsibilities in Managing Opioids: A Resource. (American Pharmacists Assocition) Gilson AM, Ryan KM, Joranson DE and Dahl JL (2004) A Reassessment of Trends in the Medical Use and Abuse of Opioid Analgesics and Implications for Diversion Control: 1997-202. J. Pain and Symptom Management 28(2) Websites of interest: http://www.medsch.wisc.edu/painpolicy/ http://www.deadiversion.usdoj.gov/ Brushwood DB (2002): The Pharmacist’s Duty to Dispense Legally Prescribed and Therapeutically Appropriate Opioid Analgesics. Pharmacy Times January 2002 C.E. program. Gourlay DL et al. (2005) Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain. Pain Medicine 6(2) 107-112.

Recommended Readings and Websites TIP 43 Center for Substance Abuse Treatment. (2005) Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs DHHS Publication No. (SMA) 05-4048 Rockville, Md TIP 40 Center for Substance Abuse Treatment. (2004) Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction DHHS Publication No. (SMA) 04-3939 Rockville, Md

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