Chronic Pain and Drug Seeking Patients - CME Conferences

3 rd Annual Essentials in Primary Care 

Summer Conference: Session 1 

Tuesday, July 24, 2012 

“There’s no pain that’s so easy to bear than 

that of someone else.” 

Leriche 

Chronic Pain and 

Drug Seeking Patients 

Grace Forde, M.D. 

Director of Neurological Services 

North American Partners In Pain Management 

Van Gogh: 

“Old Man in Sorrow” 

“We all must die. But 

if I can save him from 

days of torture, that is 

what I feel is my great 

and ever new 

privilege. Pain is a 

more terrible lord of 

mankind than even 

death himself.” 

Albert Schweitzer 

Grace Forde, MD 

Chronic Pain & the Drug Seeking Patient




Opioid Therapy 

Opioid therapy have a recognized role in pain 

management . For chronic pain, opioids are often 

effective when prescribed and used appropriately as 

part of a structured pain management plan. 

One 2010 report indicated that nearly 105 of patients 

admitted for substance abuse treatment in 2008 

reported prescription pain reliever abuse – an 

increase from 2% among admissions in 1998 

Opioid Therapy (cont) 

The 2008 National survey on drug use and health 

reported that among Americans aged > 12 years, the 

prevalence of nonmedical use of prescriptions ( i.e. 

pain relievers, tranquilizers, stimulants, sedatives) 

was second only to marijuana use among types of 

illicit drud use 

There was also a parallel increase in hospitalization 

for poisoning by prescription opioids 






Opioid Therapy (cont) 

Non adherence to treatment includes taking too much 

of the prescribed medication, diverting medication to 

other individuals, self medicating with un prescribed 

or illicit drugs or taking medication inconsistently 

Urine toxicology is one very important way to monitor 

opioid adherence 

Another way is through REMS 

Risk Evaluation and Mitigation 

Strategy (REMS) 

Two main goals 

• Mitigate the risk of accidental overdose, 

misuse and abuse 

• Inform patients of the potential serious risk 

of addiction with the use of opioids 






Assessment Challenges 

Pain is subjective 1,2 No satisfactory objective measures 1,2 

Pain is 

multidimensional 

Gold standard for pain assessment 

– Patient’s self-report 2 

Clinician must consider multiple aspects 

of the pain experience 

– Sensory, affective, cognitive 3,4 

1. APS. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 5th ed. Glenview, Ill: American Pain Society; 

2003. 2. McCaffery M, Pasero C, eds. Pain: Clinical Manual. 2nd ed. St. Louis, Mo: Mosby, Inc; 1999:36-102. 3. NPC/JCAHO. 

Pain: Current Understanding of Assessment, Management, and Treatments. December 2001. 4. Galer BS et al. Clin J Pain. 

2002;18:297-301. 5. Ramelet A-S et al. Aust Crit Care. 2004;17:33-45. 6. Craig KD et al. Clin Perinatol. 2002;29:445-457. 

7. Davis MP, Srivastava M. Drugs Aging. 2003;20:23-57. 

Clinical Assessment: 

Psychosocial History 

Current psychiatric symptoms 

History of addictive disease 

Medical Records and Speak to previous 

treating physician 

Change in social function 

– work 

– family and relationships 

– recreation 

Medical-legal status 






Trial of Opioid Therapy 

Document realistic goals 

Patient education 

Treatment agreement and informed consent 

forms 

Begin with short-acting agents 

Titrate to optimal effect 

Aggressively manage side effects 

Document exit strategies 

Creating an Exit Strategy 

Upon initiating opioid therapy, agree with 

patient on criteria for failure of the trial 

Common failure criteria include: 

– lack of significant pain reduction 

– lack of improvement in function 

– persistent side effects 

– persistent noncompliance 

Document method for tapering off opioids 

if trial is not successful 






Patient Care Agreement/ 

Informed Consent Components 

Reminder: opioids are one modality in multifaceted 

approach to achieving goals of therapy 

Detailed outline of procedures and expectations 

between patient and doctor 

Prohibited behaviors and grounds for tapering or 

discontinuation 

Limitations on prescriptions 

Refill and dose-adjustment procedures 

Exit strategy 

Patient Care Agreement / Informed 

Consent Components (cont) 

They will not use Illegal drugs ( including Marijuana) 

They will not change their dose without prior discussion 

with the provider 

They will not obtain scheduled substances from another 

provider without notifying the pain physician (including 

the ER doc) 

They will get their prescription filled at a single pharmacy ( 

of their choosing) 

They will obtain consultations or go to PT if asked to 

They will NOT be given early refills if the medications are 

used up early, lost or stolen 

They agree to random urine drug screening 






Opioid Dependence, Tolerance, 

Pseudoaddiction, and Addiction 

What are the differences 

Physical dependence: Withdrawal syndrome would occur if the 

medication is discontinued abruptly, dose is reduced rapidly, or an 

antagonist is administered 1,2 

Tolerance: A greater amount of medication is needed to maintain 

therapeutic effect, or loss of effect over time 2 

Pseudoaddiction: Behavior suggestive of addiction caused by 

undertreatment of pain 2 ; can be a major barrier to appropriate 

treatment of patients in pain 

Addiction (psychologic dependence): A biopsychosocial disorder 

characterized by continued compulsive use of a substance despite 

harm 2,3 

1. APS. Guideline for the Management of Cancer Pain in Adults and Children. Glenview, Ill: American Pain Society; 2005. 

2. Savage SR et al. APS Consensus Statement. Glenview, Ill: American Pain Society; 2001. 3. Fishbain DA et al. Clin J Pain. 

1992;8:77-85. 

Patient Reassessment Model 

The "Four A's of Pain" 

Analgesia 

Activities of daily living 

Adverse effects 

Aberrant drug-taking behaviors 

Important to remember two other “A’s” 

Assessment 

Action (treatment plan) 






Assessing Patients at Risk for 

Opioid Addiction: Screening for 

Substance-Abuse Potential 

Predictive of Aberrant Behavior Use Caution With 

Alcohol consumption 

Drug use 

Men who drink >4 alcoholic beverages 

per day or >16 per week 

Women who drink >3 alcoholic 

beverages per day or >12 per week 

Persons who admit to recreational 

use of marijuana or hashish in the 

previous year 

History of addictive disease 

Smoking 

Persons who are




Urine Drug Screen 

The current recommendation 

is to do a urine drug screen 

initially before any opioid is 

prescribed and then 

subsequently on a random 

basis 

Urine Toxicology 

Detection time of most drugs in urine is 1-3 days; longer 

if drug is lipophilic 

Types of urine drug test 

– immunoassays and gas chromatography/mass 

spectrometry 

– high-performance liquid chromatography 

Before ordering a test, ascertain 

– if patient is taking any prescribed, OTC, or herbal drugs 

– when the last dose/quantity was 

– drug abuse/addiction history 

Make sure laboratory knows what you are looking for 

and how to look for it 






Predictive Variable for an Abnormal 

Urine Drug Screen 

Younger age 

Type of medication and dose 

were poor predictors 

Urine Toxicology 

Standard urine screening tests only report whether 

various classes of drugs are present or absent based 

on an arbitrary cut off level. Therefore need to ask 

when the last dose was taken and how much. 

The standard immunoassay reacts only with natural 

opiates (such as morphine, codeine, hydrocodone 

and hydromorphone 

Semi –synthetic and synthetic opioids (such as 

fentanyl, oxycodone and oxymorphone) are likely to 

be missed. Although very high doses of 

semisynthetic opioids such as oxycodone maybe 

picked up 






Urine Toxology (cont) 

To identify specific drugs and their CONCENTRATION 

in the urine, gas chromatography / mass spectometry 

(GC/MS) or high performance liquid chromatography 

(HPLC) is used. Therefore, unexpected positive and 

negative immunoassay results should be confirmed 

by one of these more specific techniques. 

Urine Drug Screen (Cont) 

Codeine is metabolized to morphine, but not vice 

versa 

Hydrocodone is metabolized to hydromorphone, but 

not vice versa 

Oxycodone is metabolized to oxymorphone, but not 

vice versa 

In addition some patients treated chronically treated 

with morphine can have relatively small quantities of 

hydromorphone in their urine as a result of a minor 

pathway 






Cannabinoids 

Recent studies have shown that Cannabinoids 

alleviate Multiple Sclerosis related pain and other 

Neuropathic pain states, and have an opioid spearing 

effect in pain relief. 

In Canada and the UK, a plant derived Cannabinoid 

nasal spray ( Sativex) is approved for pain and 

spasticityof MS. 

However, since marijuana cannot be purchased 

legally in the US, we cannot knowingly prescribe 

opioids to anyone who is using marijuana 

Methadone 

Methadone pose a unique problem, since the urine 

drug concentration can vary by hydration and urine 

output 

There is some evidence that measuring creatinine 

levels and the metabolite of methadone 2-ethylidene- 

1,5-dimethyl 1-3,3-diphenylpyrrolidine (EDDP) can 

give more accurate results. 

Currently no quantitative screening method is 

available that accurately identifies dosage regiment 

through over or under use 






Treatment Guidelines for Opioid 

dependence fro the american Society 

of addiction medicine (ASAM) 

Consider acute intoxication and / or withdrawal 

potential 

Biomedical conditions and complications 

Emotional , behavioral, or cognitive conditions and 

complications 

Readiness to change 

Relapse, continued use, or continued problem 

potential 

Recovery / living environment 

The American Psychiatric 

Association Guidelines 

The APA identified the following three treatment 

modalities to be effective strategies for managing 

opioid dependence and withdrawal 

• 1 

• 2 

• 3 

Opioid substitution with Methadone or buprenorphine, 

followed by a gradual taper 

Abrupt opioid discontinuation with the use of clonidine to 

supress withdrawal symptoms 

Clonidine-Naltrexone detoxification 






Medications used in the treatment of 

Opioid Addiction 

Buprenorphine ( Buprenex, Subutex) 

• Can be used for moderate to severe pain and / or opioid 

dependence 

Buprenorphine / Naloxone (Suboxone) 

Naltrexone ( ReVia, Vivitrol, Depade) 

• Indicated for the prevention of relapse to opioid dependence 

following opioid detoxification 

• Also indicated for the treatment of alcohol dependence 

Naloxone (Narcan) 

Clonodine (Catapres) 






Treatment of the patient with chronic 

pain and a history of Addiction 

Reassure patient that their addiction history will not 

prevent adequate pain management 

Verify Methadone or buprenorphine dose with the 

clinic or prescribing M.D. 

Aggressively treat pain with conventional opioids. 

Opioid cross tolerance often necessitates higher 

doses at shorter intervals 

Use adjuvant medications liberally 

Use long acting opioids instead of PRNs, except for 

patients on methadone 

For patients on buprenorphine therapy refer to an 

addiction specialist 

Medico-legal 

Considerations 






Regulatory Issues 

Risk of regulatory censure low if 

procedures are followed and documented 

Relevant regulations include: 

– federal (DEA) 

– state policies 

Useful model guideline from Federation of 

State Medical Boards. Available at: 

www.fsmb.org

Chronic Pain and Drug Seeking Patients - CME Conferences

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?