2. Pain and Chemical Dependency Not an “Either – Or” proposition Douglas Gourlay, MD, FRCPC, FASAM Wasser Pain Centre, Toronto ON

3. DL Gourlay, MD, FRCPC, FASAM2 The Problem Pain and Addiction CAN coexist Addiction in General Population –Varies 3 – 16% prevalence –Varies with the drug, gender, economic status, race, age… Addiction in the Chronic Pain Population –We really have no idea –We use the same terms, with different meaning Lack of precision in definitions around abuse/dependency/addiction

4. DL Gourlay, MD, FRCPC, FASAM3 Definitions Addiction: Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. (LCPA)

5. DL Gourlay, MD, FRCPC, FASAM4 Definitions Physical Dependence: Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (LCPA)

6. DL Gourlay, MD, FRCPC, FASAM5 Definitions Tolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time. Tolerance develops at different rates, in different people, to different effects

7. DL Gourlay, MD, FRCPC, FASAM6 Definitions Pseudoaddiction: Iatrogenic, maladaptive behavior resulting from inadequate pain control Not to be used “instead of” addiction Unwise to diagnose in patient with history of addictive disorder, even in other substance

8. DL Gourlay, MD, FRCPC, FASAM7 Addiction * Biology Environment Drug *

9. DL Gourlay, MD, FRCPC, FASAM8 Diagnosis DSM-IV criteria - dependence –Maladaptive behavior having at least three of the following in a 12 month period Withdrawal Tolerance Use in larger amounts or over longer period than intended Persistent use, or unsuccessful attempts to cut-down or control use XS time spent using or recovering from use Narrowing of focus due to substance use Continued use despite harm

10. DL Gourlay, MD, FRCPC, FASAM9 Pain and Addiction as Co-morbid Conditions Pain often complicate the Dx of Addiction Pain and Addiction can coexist –Pain plus Alcoholism Cocaine Cannabis –Relatively simple to use current tools to assess addiction i.e. DSM-IV

11. DL Gourlay, MD, FRCPC, FASAM10 Pain and Opioid Addiction What happens when the ‘drug of choice’ is both the problem AND the solution, depending on point of view? –Addiction Specialist Aberrant behavior is due to opioid abuse/addiction –Pain Specialist Aberrant behavior is due to inadequate treatment of pain (pseudoaddiction)

12. DL Gourlay, MD, FRCPC, FASAM11 Pain-Addiction Continuum Pain Addiction Patient Patient Patient

13. DL Gourlay, MD, FRCPC, FASAM12 Boundary Setting 90%+ of patients don’t need strict boundary setting –Most patients have their own internal set For remaining ~10%, strict boundary setting is essential Treatment Agreements, Urine Testing, interval / contingency dispensing

14. DL Gourlay, MD, FRCPC, FASAM13 Boundaries – Identification and Enforcement Discharge Patient

15. DL Gourlay, MD, FRCPC, FASAM14 Boundaries – Identification and Enforcement Consultation with Addiction Medicine

16. DL Gourlay, MD, FRCPC, FASAM15 Aberrant Drug-Related Behaviors Selling prescription drugs Prescription forgery Stealing or “borrowing” drugs from another patient Injecting oral formulations Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Repeated episodes of lost prescriptions Aggressive complaining about the need for higher doses Drug hoarding during periods of reduced symptoms Requesting specific drugs Prescriptions from other physicians Unsanctioned dose escalation Unapproved use of the drug Reporting psychic effects not intended by the physician More Predictive Less Predictive Jaffee, 1996

17. DL Gourlay, MD, FRCPC, FASAM16 Assessing Aberrant Behavior What does it mean? –Aberrant behavior is a late and often unreliable sign of an addictive disorder –When used to trigger UDT, more often used in punitive fashion Aberrant behavior does NOT equal inadequate pain management in all patients

18. DL Gourlay, MD, FRCPC, FASAM17 Assessment Strategies 1 st address pain complaints –Explore AM pain and role of IR opioids Carefully document medication use –Dosing intervals, what worked, what didn’t –Lost/stolen, early refills, double doctoring, problems with control, withdrawal symptoms Family history of drug/EtOH problems Personal psychiatric history

19. DL Gourlay, MD, FRCPC, FASAM18 Assessment Strategies Personal Substance Use History –Alcohol, tobacco, street drugs –Time of last use Drug Treatment History Legal Issues Social Physical Examination Lab Tests: Liver, Hepatitis, HIV, CBC, UDS

20. DL Gourlay, MD, FRCPC, FASAM19 Pain and Chemical Dependency Program Pain and CD Clinic CAMH –Initially at the AMC –Problems with stigma (many “no show’s”) Pain and CD division at the Wasser –Easier for patients to comfortably attend Very few patients fail to attend appointments But difficult to manage dominant SUD pts –“Easier to teach pain docs about addiction”

21. DL Gourlay, MD, FRCPC, FASAM20 Pain and Chemical Dependency Program Strong bridge between the Wasser Pain Centre and CAMH was needed –Currently fellows and residents from CAMH spend time at the Wasser Clinic on Thursday –Queen Street Lab does UDT for Wasser –Stabilized Pain and CD pts are seen at Wasser But we don’t have a place to manage complex pharmacotherapy problems; we’re not integrated

22. DL Gourlay, MD, FRCPC, FASAM21 Pain and Chemical Dependency Program 2004, Purdue Canada donated $300,000 over 3 yrs for a Pain and CD division at the Wasser Pain Management Centre –We are now discussing possibilities of having a “Rationalization of Pharmacotherapy Unit” at the Donwood Site –Pts will be assessed and medically stabilized before deciding what services might next be offered

23. DL Gourlay, MD, FRCPC, FASAM22 Conclusions Pain and Addiction can coexist Successful treatment of either often requires assessment and management of both The Pain and CD Division of the Wasser Pain Centre will do what neither CAMH nor Wasser could do alone