Transcript www.nade.org

Drug Seeking, Abuse or Legitimate
Treatment?
Presented to the National Association of Disability Examiners
September 11, 2012
Dr. Michael Bourn DO
The Center For Symptom Relief
Medical Director, Pain and Palliative Medicine, Doctors Hospital,
Columbus Ohio
Objectives
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1. Recognize aberrant drug related behavior
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2. Understand strategies to limit drug abuse
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3. Differentiate between drug seeking and relief
seeking
4. Aknowledge the difficulty in making this
determination
America is in an Opiate Crisis
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4 people die every day in Ohio from prescription
drugs, more than car crashes
Opiate pain medication deaths have overtaken
heroin and cocaine combined
Opiate prescriptions have gone up over 600%
in the last 10 years, deaths are up over 300%
Poor evidence that long term opiate therapy for
chronic pain is effective
Some Definitions First
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Aberrant drug related behavior
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Abuse/Misuse
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Addiction
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Pseudoaddiction
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Diversion
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Physical dependance
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Tolerance
Aberrant Drug Related Behavior
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A behavior outside the boundaries of the
agreed upon treatment plan which is
established as early as possible in the
doctor-patient relationship
Can take many forms
Abuse/Misuse
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Any use of illegal drug
The intentional self-administration of a
medication for a nonmedical purpose such
as altering one’s state of consciousness
Use of a medication (for a medical
purpose) other than as directed or as
indicated, whether willful or unintentional,
and whether harm results or not
Addiction
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Primary chronic, neuro-biologic disease
Genetic, psychosocial, environmental
factors influence development and
manifestations
Characterized by behaviors;
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Craving
Impaired control over use
Compulsive use
Continued use despite harm
Pseudoaddiction Defined
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Iatrogenic syndrome
Misinterpretation of relief seeking behavior as
addiction behaviors
Behaviors resolve when pain is adequately
controlled
Diversion
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The intentional transfer of a controlled
substance from legitimate distribution
and dispensing channels
Physical Dependence
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State of adaptation
Drug class specific signs and symptoms
produced by
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Cessation
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Rapid dose reduction
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Decreasing blood level
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Administration of antagonist
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Not the same as addiction
Tolerance Defined
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Physiologic state resulting from regular use of a
drug
Increased dosage required to produce specific
effect
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Reduced effect seen with constant dose
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Does not equate with addiction
Is Addiction all we are Worried
About?
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Opiate pain medication can be unsafe at any
dosage
Current epidemic of opiate deaths are not
simply due to addiction
Current studies have prompted the CDC to
warn against high dose opiates(greater than
100 OME/day)
Associated with an 8 fold increase in death from
opiate medication
Behavior Predictive of Aberrant
Drug Taking
–Selling prescription drugs
–Prescription forgery
–Stealing or borrowing another patient’s drugs
–Injecting oral formulation
–Obtaining prescription drugs from non-medical
sources
–Concurrent abuse of related illicit drugs
–Multiple unsanctioned dose escalations
–Recurrent prescription losses
More Behaviors
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Getting meds from more than one prescriber
with out their knowledge
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Performed sex for drugs/prostitution
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Stole money for drugs
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Aggressive complaining about need for higher
doses
More Behaviors
–Drug hoarding during periods of reduced
symptoms
–Requesting specific drugs
–Unsanctioned dose escalation
–Unapproved use of the drug to treat another
symptom
–Reporting psychic effects not intended by the
clinician
Options Available in Managing
Chronic Pain
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Physical therapy
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Manipulative therapy(chiropractic/osteopathic)
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Interventional(epidural injections, nerve blocks)
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Surgery
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Adjuvant medications(gabapentin/cymbalta)
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Opiates should be reserved as a last resort
Federation of State Medical Boards
Policy
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FSMB has a sample policy adopted by most
states for use of opiates in cases of chronic
non-cancer pain
Lays out guideline for evaluation, consent,
examination referral and monitoring
Requires regular assessment of goals of caretypically functional goals
Regular assessment of burden of opiate
therapy
Screening Tools Used to Detect
Aberrant Drug Taking
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Tools can be used to help determine risk of
aberrant/dangerous/addicted behavior
Tools should be administered prior to
commencement of chronic opiate therapy
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ORT
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SISAP
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SOAPP-R
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COMM
Opioid Risk Tool(ORT)
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Scoring
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0-3: low risk (6%)
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Webster & Webster. Pain Med.2005;6:432.
Administered prior to
opioid therapy
4-7: modreate risk
(28%)
8 or higher: high risk
(>90%)
Additional Tools
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Prescription monitoring programs
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State run databanks, updated real time
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Pharmacy duty to enter prescribed meds
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VA does not participate
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MAT/methadone/suboxone clinics don't
participate
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Can see number of prescribers, prescriptions
and pharmacies used
Additional Tools Cont.
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Urine Drug Screening
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Confirm they are taking meds prescribed
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Confirm they are not abusing illegal/illicit
drugs
Random Pill Counts
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Confirm patient is taking meds appropriately
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Needs to be done on short notice-can actually
rent pills if they have time