Transcript TREATING TWO DISEASES

TREATING TWO
DISEASES
CHRONIC PAIN SYNDROMES
AND THE DISEASE OF
ADDICTION
Bruce C. Springer, M.D.
Pine Rest Addiction Services
PAIN
► Pain
is an unpleasant sensory and emotional
experience that is associated with potential
or actual tissue injury or is described in
terms of such injury.
► (Int’l Assoc for the Study of Pain, 1979)
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An experience influenced by:
culture, temperament
PAIN
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past experience, memory
anticipation, beliefs
emotional factors, co-occurring health
cognitive factors, gender, age
► The
experience of pain is different from
individual to individual and within the same
person at different times
PAIN
► The
pain signal is transmitted from
nociceptors along peripheral nerves to the
dorsal root ganglion and then to the dorsal
horn of the spinal cord.
► The
spinothalamic tract carries the impulse
up to the thalamus and to the somatosensory cortex and limbic system to be
experienced and interpreted.
CHRONIC PAIN
► Tissue
damage releases chemicals which
sensitize nerve fibers and alter gene
expression.
► Regeneration of nerve fibers into a neuroma
which generates pain signals.
► Injury to and degeneration of pain inhibitory
pathways.
► Sleeplessness, anxiety and depression
trigger more pain
PAIN MODULATION
► Descending
pathways originating in the
ventral medulla, periaqueductal and
periventricular gray matter are stimulated
by endogenous and exogenous opioids.
PAIN MODULATION
► These
pathways interact with sensory spinal
neurons inhibiting pain impulse
transmission. This involves numerous
chemicals and neurotransmitters, including
endorphins, GABA, norepinepherine,
serotonin, enkephalins, and oxytocin.
PAIN MODULATION
► Increases
in inhibitory input on sensory
neurons in the spinal cord is in response to
opioid binding to receptors on neurons in
the midbrain and medulla.
► This
gives us insight into how opiates
function in the CNS to alleviate pain.
PAIN MODULATION
► This
pain modulation system may not work
well in patients with the disease of
addiction to opiates.
► Indeed
addicted patients may well have a
more intense pain experience.
ADDICTION
►A
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DISEASE
primary
neurophysiologic
chronic
FACTORS
genetic
psychosocial
environmental
ADDICTION
► Affects
about one in ten Americans
► Loss
of control over a substance or behavior
and inability to stop despite negative
consequences
► Mesolimbic
dopamine system is home
to the reward and reinforcement of
behaviors essential to survival
WWW.DRUGABUSE.GOV
ADDICTION
► Opiates
bind to mu receptors in the
periaqueductal gray and other areas
described above and help modulate pain.
also bind to mu receptors in the VTA
and increase dopamine release in the NA.
► They
ADDICTION
► Thus
opiates are rewarding and reinforcing.
► Tolerance
produced by neuroadaptation to
a substance where the individual must use
more to achieve the desired result or no
longer benefits from the original effective
dose.
ADDICTION
► Physical
Dependence is a result of neuroadaptation where there is experienced a
characteristic abstinence syndrome when
the drug is stopped, decreased abruptly or
when an antagonist of this drug is given.
can develop both of these and not
have the disease of addiction.
► Patients
CONSEQUENCES
► More
people die from prescription drug
overdoses than in car accidents in Michigan.
► In 2007 someone died of an overdose every 19
minutes.
► Prescription drug abuse is the fastest growing
substance abuse problem in the U.S.
► For every OD death, 9 people are admitted to
treatment facilities, 35 visit ER’s, 161 report
abuse or addiction and 461 report non medical
use of opiates.
PAIN IN ADDICTED PATIENTS
► Increased
pain sensitivity in opiate addicted
patients on methadone maintenance.
► Evidence
supports an opiate-induced
hyperalgesia.
► This
hypersensitive state improves with
opiate detoxification.
PAIN IN ADDICTED PATIENTS
► Addiction
may serve to facilitate the pain
experience
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Inability to experience pleasure
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Chaotic lifestyle
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Sleep disorders
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Anxiety, irritability,
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Loss of social support, interpersonal conflicts
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Noncompliance with past treatment plans
PAIN IN ADDICTED PATIENT
► Addicted
patients alternate between
intoxication and withdrawal states thus
activating the neurochemical stress
response, chronic negative emotional state
and increasing the pain experience
► Anhedonia
► Irritability
► Dysphoria
PAIN IN ADDICTED PATIENTS
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Dopamine depletion and perhaps
decreased dopamine receptors in reward
pathways.
► Depression.
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Pain assessment in patients with
substance use disorders is complicated.
ASSESSMENT of PATIENTS
Look for a recent history of substance use
disorder,
► prescription abuse, problems with opiates
► non involvement in AA or NA,
► little or no family support or too much
support
► Allergies to multiple opiate and non-opiate
analgesics
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ASSESSMENT of PATIENTS
► Be
aware of patients at higher risk for
addiction:
► family history of addiction,
► smokers,
► current problems with drugs,
► other compulsive behaviors,
► gambling addiction
► cannabis use “legal” vs. illicit
ASSESSMENT of PATIENTS
► The
addicted patient (vs. the legitimate
chronic pain patient) will:
► crave drugs, use opiates compulsively,
► increase the dose on their own,
► have social and relational problems,
► severe withdrawal symptoms, be
intoxicated,
ASSESSMENT of PATIENTS
► use
other substances,
► often use higher doses
► seek early refills
► shun personal responsibilities.
ASSESSMENT of PATIENTS
► Decreasing
function and increased
complaints of pain despite medication
titration
► Persistent
negative affective states,
anxiety, depression and irritability
RED FLAGS
► Reports
of lost or stolen prescriptions
► Appearance at office without appointment
and in distress
► Frequent visits to ERs to request drugs
► Family reports overuse or intoxication
► Failure to comply with non-drug pain
therapies
► Fails to keep appointments
RED FLAGS
► Not
interested in rehabilitation
► Reports no effect of non-opiate
interventions
► Seeks prescriptions from other providers
► In Michigan you may use the MAPS form to
get prescription information from the MI
Dept. of Community Health
PAIN PATIENT
► History
and physical; rule out a worsening
organic lesion as the cause of worsening
pain.
► Look for pain facilitating problems such as
sleep disturbance, mood disorders,
disability, stress, drug addiction or abuse.
► What studies are needed?
► Get as many old records as possible.
► Communicate with previous health care
providers.
PAIN PATIENT
► Rule
out a worsening organic lesion as the
cause of worsening pain.
► Be open to potential signals of addiction or
pseudo-addiction.
► Substance abusing patients may over report
pain out of fear or desire to divert drugs.
► Recovering addicted patients may under
report pain over fear of relapse
APPROACHING the ADDICTED
PATIENTS
► Be
matter-of-fact in your questions about
your “worried about your relationship with
some of these medications and what it is
doing to your life and your pain treatment.”
► Ask
about nicotine, caffeine then alcohol
next before asking more about opiates, etc.
APPROACHING the ADDICTED
PATIENT
► “Honest
answers are vital for us to make a
good treatment plan for your pain and your
life better.”
► “You
did not volunteer for chronic pain and
you did not volunteer to lose control over
these drugs.”
► “I
hope you will volunteer to treat both.”
SOAPE GLOSSARY
Summary
Reinforce the patient-physician relationship
in the midst of this chronic illness.
► “We
need to work together on this.”
► “This
requires a team effort and you and I are
two members of the team.”
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SOAPE GLOSSARY
Optimism
Remember the patient may well expect failure
► “People with these diseases can’t do all this by
themselves.”
► “… with help you will do well…”
► “… no one deserves the pain and humiliation
these diseases bring…”
► “… treatment works…”
► “… you can expect improvement in most areas
of your life…”
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SOAPE GLOSSARY
Absolution
Guilt, shame and weakness are paralyzing and can lessen
the patients ability to take on sobriety.
 “Your pain and addiction problem are not your fault.
They are diseases and it is our responsibility to work
together toward your recovery from both.”
 “Recovery is likely.”
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Plan cont…
What will their insurance cover?
What is the patient ready for?
“What
do you think you can do at this point”
“There are many things we can do to pursue
recovery from addiction and pain”
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SOAPE GLOSSARY
Explanatory Model
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Ask the patient, “What is your idea of a person with
addiction?”
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Try to understand what the patient understands about
addiction.
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“This is an illness that responds to medical intervention and
treatment, but not to willpower alone.”
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PAIN PATIENT
► Patient
must sign release forms to other
care providers including PT/OT, counselors,
psychologists, psychiatrists, pain specialists
and PCP etc.
► Encourage
free exchange of information
among all providers and with the patient.
PAIN PATIENT
► Establish
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clear treatment goals
Analgesia
Improvement in other symptoms
Restoration of function
ADDICTION
► The
diagnosis of addictive disease is made
by yourself or another provider.
► It
► It
is a prospective diagnosis made over time
is important for the patient to realize that
without treating addiction their pain will
never be adequately treated.
ADDICTION
► Institute
a Recovery Program
► Discuss with an addiction specialist
► Introduce to a treatment program
► Keep a list of local NA meetings
► Be willing to stay engaged with the patient
► Formulate a treatment agreement with the patient
that has at its core the patients continued
steadfast recovery from addiction while pain is
treated.
ADDICTION RECOVERY and PAIN
TREATMENT AGREEMENT
► Treatment
► Pill
agreement
counts
► Urine drug screens
► One provider for opiates (if needed)
► One pharmacy
► No missed appointments
► No lost scripts.
► Attendance of 12-step meetings
ADDICTION RECOVERY and PAIN
TREATMENT AGREEMENT
► Complete
cooperation with non
pharmacologic treatment and non opiate
treatments.
► Cooperation with counseling, physical
therapy, treatment of mood disorders.
► Complete abstinence from other addictive
substances.
► Strict use of meds as prescribed and no use
of other peoples meds.
ADDICTION RECOVERY
► The
patient must consent to be held
accountable by a team of people including
possibly a Narcotics Anonymous sponsor.
12-STEP PROGRAMS
► Founded
in 1935 by two hopeless alcoholics
Bill Wilson and Robert Smith M.D.
► Discovered that by talking to others with the
same disease they could stay sober.
► AA meetings found in most countries.
► AA Big Book published in many languages.
PSYCHOLOGICAL
INTERVENTIONS
► Deep
relaxation
► Biofeedback
► CBT
► Guided Imagery
► Treat mood disorders, antidepressants tx
► Family/Relationship therapy
► Functional Rehabilitation
ON GOING CARE
► The
goal should be to remain engaged with
the patient regarding pain while continuing
to encourage and support their recovery
from addiction.
► Must constantly reinforce the patients active
role in their treatment.
► Move gently to eliminate unnecessary
dependence on medications: tapering,
replace opiates with buprenorphine, detox.
DISCONTINUING OPIATES
► Pain
has resolved.
► Side effects are unmanageable.
► Opiates are not stabilizing the patient or
improving function.
► Patient loses control over the opiate pain
med.
► Patient using other substances such as
ETOH, benzodiazepines, cannabis, etc.
► Patient is diverting the opiates.
WITHDRAWAL SIGNS AND
SYMPTOMS
► Dysphoria
craving
► Irritability
and vomiting
► Diarrhea
► Cramping abdominal
pain
► Lacrimation
► Joint
► Insomnia
► Severe
► Dilated
pupils
► Rhinorrhea
► Nausea
aching
► Muscle cramping
► Hot and cold flashes
WITHDRAWAL SIGNS AND
SYMPTOMS
► Sweating
► Goose
flesh
► Yawning
► Elevations
of blood
pressure
► Tachycardia
► Mild fever
PAIN IN ADDICTED PATIENTS
OPIATE INDUCED
HYPERALGESIA
► Increased
pain sensitivity in opiate addicted
patients on methadone maintenance.
► Evidence
supports an opiate-induced
hyperalgesia.
► This
hypersensitive state improves with
opiate detoxification.
► Receptor
OPIATE INDUCED
HYPERALGESIA
desensitization. Uncoupling of
intracellular G protein from receptor.
► Up-regulation
► Facilitation
of pain by descending pathways.
► Hyperactivity
receptors.
of cAMP pathway.
of the stimulating NMDA
NON-OPIOID ANALGESICS
► ACETAMINOPHEN
► NSAIDs
► SNRIs
► TRICYCLIC
ANTIDEPRESSANTS
► ANTICONVULSANTS
► TOPICAL AGENTS
► MUSCLE RELAXANTS (avoid Soma)
BUPRENORPHINE
Suboxone for chronic pain
buprenorphine and naloxone
► Consider
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a partial agonist, harder to O.D.
binds strongly to mu opiate receptor.
good analgesic.
safer than other full opiate agonists.
milder withdrawal symptoms.
FDA approved for opiate addiction
maintenance therapy.
► Decide
THE TEAM
who needs a copy of the medication
agreement.
► Decide who will help hold the addicted pain
patient accountable. Case workers,
addiction specialists, addition counselors,
pain specialists, primary care physicians,
physical therapists, pharmacists, etc.
► All health care professionals involved must
be constantly vigilant with the addicted
pain patient.
ADDICTION TREATMENT
► Medicare
Patients: Sparrow/St. Lawrence in
Lansing or Brighton Hospital in Brighton.
► In
the case of noninsured and Medicaid you
must call Network 180. Kent County
residents must go through them
(Gatekeeper). If from another County, call
that counties CMH.
ADDICTION TREATMENT
► For
patients addicted to other substances
and behaviors, refer to Addiction Therapists
at Pine Rest (281-7500), Arbor Circle (4597215), Network 180 (336-3909), Project
Rehab (776-0891).
the Find Treatment Website at
SAMHSA.
► Use
ADDICTION/PAIN TREATMENT
► SPECTRUM
HEALTH Corey Waller, M.D.
► The Center for Integrative Medicine
►75
Sheldon Blvd SE, Suite 100
Grand Rapids, MI 49503
616-391-6120
Case workers, Physical
Therapists, Nursing Staff,
Addiction Counselors,
Pharmacists
► Very
important role in keeping the patient
engaged in their own care
► Opportunities and needs of the addicted
pain patient missed by others may be
recognized by these providers
► The addicted pain patient may be held
accountable for many aspects of their lives.
THE ADDICTED PAIN PATIENT
► THANK
YOU!
► QUESTIONS?
►
Principles of Addiction Medicine, ASAM, 4th
Edition
► TIP 54: Managing Chronic Pain in Adults
With or in Recovery From Substance Use
Disorder, SAMHSA, Rockville, MD 20857