1. The Linked Epidemics of Prescription Opioid Abuse and Chronic Pain: A Call to Action Marc Fishman MD Johns Hopkins University Dept of Psychiatry Maryland Treatment Centers Baltimore MD MADC May 2013

2. Outline The problem of prescription drug abuse The problem of chronic pain The problem of chronic pain management A more coherent approach to treatment of chronic pain The treatment of co-occurring chronic pain and addiction Speculation about past and future directions in doctoring Therapeutic optimism, and a call to action

3. The problem of prescription drug abuse

6. Trends in Poisoning Deaths In 2008, poisoning became the leading cause of injury death in the United States Nearly 9 out of 10 poisoning deaths are caused by drugs During the past 30 years, the number of drug poisoning deaths increased six fold from about 6,100 in 1980 to 36,500 in 2008. During the past 10 years, the number of drug poisoning deaths involving opioid analgesics more than tripled from about 4,000 in 1999 to 14,800 in 2008. Opioid analgesics were involved in more than 40% of all drug poisoning deaths in 2008, up from about 25% in 1999. Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011.

7. November 2011 www.cdc.gov/homeandrecreationalsafety/rxbrief November 2011 www.cdc.gov/homeandrecreationalsafety/rxbrief

8. Opioid pain reliever supply

9. The problem of chronic pain

10. Chronic pain – Pain has multiple components Sensory experience associated with physical injury Emotional response of distress and anxiety related to the sensory information Loss of functional capacity related to these experiences – Chronic pain may Be provoked by ongoing chronic injury such as malignancy, tissue destruction or chronic infection Continue when the original injury that provoked the initial pain has resolved or improved – Noxious stimuli and pain have an inconsistent relationship

11. PhysicalSocial Anger/ Fear Anger/ Fear Psychological Anxiety/ Depression Anxiety/ Depression Diminished function, ADLs Deconditioning Impaired sleep Impaired relationships Isolation Invalid status

12. Abnormal Illness Behavior The patient expects and pursues a sick role beyond what is reasonable The patient continues his expectation despite being told it is inappropriate The patient’s sick role is reinforced – Issy Pilowsky

13. Examples of reinforcers in abnormal illness behavior Positive reinforcers – Attention from spouses, family, doctors, lawyers – Disability income – Possibility of tort payments – Ability to express prohibited feelings – Access to reinforcing medications Negative reinforcers – Relief from stress, expectations and criticism – Relief from pain and discomfort The sick role is very powerful

14. Opioids not effective as treatment for chronic pain Tolerance to analgesic properties Opioid-induced hyperalgesia Marked inconsistency with fantasy expectations of persistence of peak pain relief Inevitability of dependence as confound – Withdrawal hyperalgesia – Withdrawal as new negative reinforcer Substantial side effect profile

15. Can opiates worsen chronic pain disorders? Extremely powerful reinforcers – Positive reinforcement for use, negative reinforcement for discontinuation Opioid-induced hyperalgesia Positive reinforcement for illness role Set up an unreasonable standard for pain control Allows for ongoing injury during peaks of pain relief Intoxication allows for psychological comfort with worsening disability Iatrogenic addiction can be disordering Side effects that typically exacerbate abnormal illness behavior

16. The problem of pain management

17. Fortuna, R. J. et al. Pediatrics 2010;126:1108-1116 Percentage of visits during which controlled medications were prescribed to adolescents (A) and young adults (B)

18. Aberrant Medication Behaviors requests for higher medication doses early refills requests specific drugs extra medication because of travel or inability to attend more frequent visits lost medication unsanctioned dose escalations unexpected urine tests showing no opiates deterioration in work or social functioning resistance to change or to discontinuation of opiates despite adverse effects refusal to comply with drug screens concurrent abuse of alcohol or illicit drugs use of multiple physicians and pharmacies

19. The failure of pain management The narrow focus on pain as an isolated symptom out of context, without broader doctoring The view of chronic pain patients as opioid receptors with legs The consideration of aberrant medication behaviors as a risk management inconvenience and grounds for dismissal rather than a core feature of illness and grounds for aggressive treatment The hopeless view of patient care as palliative, (analogous to hospice), but for non-terminal illness Deconditioning

20. The failure of pain management There aren’t enough opioids in the world…

21. A more coherent approach to the treatment of chronic pain

22. Reframe the goals of treatment Function is primary Happiness is important The fantasy holy grail of complete analgesia is unrealistic In fact, pain relief is not high on the list at at all “You’re taking all the pain meds known to man, still in pain, with miserable side effects; we can’t possibly do worse This isn’t working; let’s try something different Not necessarily helpful to use the term “addiction”

23. Essential components of chronic pain treatment Re-evaluation and broad medical treatment Evaluation of psychiatric co-morbidity – Depression – Personality – Life circumstances – Addiction Taper opioids and other impairing medications Substitute serial trials of non-narcotic pain medications Reconditioning Purposeful activity, structure, reconnection Motivational contingencies and realignment of positive and negative reinforcers

24. Non-narcotic medications for chronic pain Nortriptyline (pamelor) Duloxetine (cymbalta) Gabapentin (neurontin) Carbamazepine (tegretol) Valproate (depakote) Pregabalin (lyrica) Maxelitine (mexitil)

25. Non-pharmacologic treatment modalities Physical therapy Cognitive behavioral therapy Biofeedback Relaxation training and guided imagery Meditation and self hypnotic techniques

26. Rehabilitation Patients intuitively believe they have to feel well before they can do things In fact the counterintuitive reality is that they have to do things before they can feel well

27. Cognitive behavioral interpretations Can’t means won’t. Need means want. Think means feel. “I can’t get out of bed today” “What if the bed was on fire?” “Well, then I guess I could.” “Then you don’t mean can’t, you mean won’t.” “Oh, fine, trick me.” “I always go to group” “You have missed 7 of the last 12 groups” “That’s practically always” “I needed to take a mental health day yesterday” “No, you took a mental illness day yesterday” -Glenn Treisman

28. The treatment of co-occurring chronic pain and addiction

29. Evidence of co-morbid addiction Pre-existing history of substance problems Concurrent use of other substances Progression of aberrant medication behaviors – lying, stealing, “street” supplies, etc

30. Treatment of co-morbid addiction Role induction Clarity of treatment goals re addiction Consider buprenorphine Consider extended release naltrexone Support recovery (in the broad sense) as a pain treatment strategy

31. Speculation about past and future directions in doctoring

32. Is medical care just another consumer product? Are patients just another variety of customer? Is our goal to sell more widgets? Is our goal to create markets? – You didn’t know you needed an iPad until you saw one – You didn’t know you needed oxycontin until you took it

33. Who’s the grown up? What should doctors do when patients are sure what they “need” Is it sufficient grounds for delivering a treatment that patients are sure they “need” it

34. It’s hard to say no Patients insist on antibiotics when they have a viral illness Patients ask for benzodiazepines when they have anxiety Patients ask for cosmetic surgery in pursuit of fashion Patients ask for opioids when they have pain

35. Reciprocal conditioning The patients condition us as much as we condition them Reinforcers of abnormal doctoring behavior – Pain as a vital sign – Emphasis on speed, efficiency, cost reduction – Emphasis on patient satisfaction

36. Meet the patients where they are? “I’d like a year’s supply of percocet please” “I agree I’m using too much oxycontin. Can you help me cut down, how about weekends only… “Sure I’ll come to group occasionally, when I can make it” “I agree I’ve been using too much heroin, but cocaine is no big deal” “Why can’t I take xanax for my anxiety. Nothing else works…” “I’d like a year’s supply of suboxone please”

37. Treatment misadventures We’ve been here before

38. Is everything on the menu?

39. What have we learned? Doctors have been part of the problem; but we can be part of the solution Parentalism is not a dirty word Beneficence sometimes trumps autonomy These are complicated cases Treatment requires thoughtfulness, patience, flexibility, optimism

40. Therapeutic Optimism Palliative care has a role, but it is nihilistic in non-terminal disease Recovery is a process Expect mischief and monkey business, and address it Firing the patients usually does not cure them Learn to convert “no” into “yes, but…”

41. Who has the necessary expertise? These patients are: – Psychiatrically ill – Medically compromised – Embedded in chaotic lives – Trapped in a role defined by their suffering – Poisoned by but still dependent on intoxicating substances Remind you of any other kinds of patients you know?

42. The role of counseling Learn to engage these patients Do not be afraid of their medical problems Appreciate their burdens Be a missionary for rehabilitation Teach salience of behaviors over feelings Coach them to improved function

43. A call to action These patients need a multi-disciplinary approach – We are the appropriate lead discipline These patients need a new therapeutic home – It should be in our house!

44. If only it were that easy

45. Treatment Works!