Aberrant Drug-taking Aberrant Drug-taking Behaviors in Medically Behaviors in Medically Ill Pain Patients Ill Pain Patients Steven D. Passik, PhD Steven D. Passik, PhD Director, Symptom Management and Palliative Care Director, Symptom Management and Palliative Care Program - Markey Cancer Center Program - Markey Cancer Center Associate Professor of Medicine and Behavioral Associate Professor of Medicine and Behavioral Sciences Sciences University of Kentucky University of Kentucky Lexington, KY Lexington, KY APA, NYC, 05/03/04 APA, NYC, 05/03/04
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Aberrant Drug-taking Behaviors in Medically Ill Pain Patients Aberrant Drug-taking Behaviors in Medically Ill Pain Patients Steven D. Passik, PhD Director,
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Steven D. Passik, PhDSteven D. Passik, PhDDirector, Symptom Management and Palliative Care Program - Director, Symptom Management and Palliative Care Program -
Markey Cancer CenterMarkey Cancer CenterAssociate Professor of Medicine and Behavioral SciencesAssociate Professor of Medicine and Behavioral Sciences
University of KentuckyUniversity of KentuckyLexington, KY Lexington, KY
APA, NYC, 05/03/04APA, NYC, 05/03/04
Indiana/UK Studies on Aberrant Drug-Indiana/UK Studies on Aberrant Drug-taking in Pain Managementtaking in Pain Management
Attitudes and behaviors in cancer patients and women Attitudes and behaviors in cancer patients and women with AIDS, Passik, et al., JPSM,1998with AIDS, Passik, et al., JPSM,1998UTS in pain management, Passik et al, JPSM, 1998UTS in pain management, Passik et al, JPSM, 1998Survey of clinicians’ perceptions of ADTB, Passik et al, Survey of clinicians’ perceptions of ADTB, Passik et al, JPSMPC, 2002JPSMPC, 2002Development of a tool to assess pain outcomes in Development of a tool to assess pain outcomes in chronic opioid therapy, Passik et al submittedchronic opioid therapy, Passik et al submittedAberrant drug taking in cancer and AIDS patients, Aberrant drug taking in cancer and AIDS patients, Passik et al, in prepPassik et al, in prepRetrospective Characterization of abusers of Retrospective Characterization of abusers of OxyContin seeking drug treatment in Kentucky, Hays, OxyContin seeking drug treatment in Kentucky, Hays, et al., JNCCN, 2003; Preliminary prospective data et al., JNCCN, 2003; Preliminary prospective data
Aberrant Drug-taking Behaviors: Aberrant Drug-taking Behaviors: The ModelThe Model
Probably more predictiveProbably more predictive– Selling prescription drugsSelling prescription drugs– Prescription forgeryPrescription forgery– Stealing or borrowing another Stealing or borrowing another
Probably less predictiveProbably less predictive– Aggressive complaining about Aggressive complaining about
need for higher dosesneed for higher doses– Drug hoarding during periods of Drug hoarding during periods of
reduced symptomsreduced symptoms– Requesting specific drugsRequesting specific drugs– Acquisition of similar drugs from Acquisition of similar drugs from
other medical sourcesother medical sources– Unsanctioned dose escalation 1 Unsanctioned dose escalation 1
– 2 times– 2 times– Unapproved use of the drug to Unapproved use of the drug to
treat another symptomtreat another symptom– Reporting psychic effects not Reporting psychic effects not
intended by the clinicianintended by the clinician
Passik and Portenoy, 1998
Differential Diagnosis of Aberrant Drug-Differential Diagnosis of Aberrant Drug-Taking Attitudes and BehaviorTaking Attitudes and Behavior
Physician-Ranking of Ab. Behs.Physician-Ranking of Ab. Behs.(Passik, Kirsh, et al, J Pain Pall Care Pharm, 2002)(Passik, Kirsh, et al, J Pain Pall Care Pharm, 2002)
Rank Aberrant Behavior: Mean (SD)
1 Selling prescription drugs 4.0 (3.5)
2 Forging Prescriptions 4.4 (3.6)
3 Altering route or drug delivery system (i.e., crushing sustained release tablets for snorting or injecting)
4.7 (3.6)
4 Concurrent abuse of related illicit drugs 5.1 (2.9)
5 Stealing or borrowing medications from others 5.2 (2.9)
6 Obtaining drug from non-medical source 5.8 (3.0)
7 Frequent Prescription losses 6.2 (2.7)
8 Multiple unsanctioned dosing 7.4 (2.9)
9 Aggressive demand for more drug 7.6 (3.4)
10 Unapproved use of drug to treat non-pain symptoms 7.7 (3.1)
11 Drug hoarding 8.6 (3.3)
12 Unsanctioned dose escalation once or twice 9.8 (3.6)
13 Unkempt appearance 11.0 (3.2)
Aberrant drug-taking in cancer and Aberrant drug-taking in cancer and AIDSAIDS
73 patients with AIDS - 100% with reported past or current 73 patients with AIDS - 100% with reported past or current history of substance abuse (42% of total sample)history of substance abuse (42% of total sample)
100 patients with cancer -18% reported past or current 100 patients with cancer -18% reported past or current history of substance abuse (58% of total sample)history of substance abuse (58% of total sample)
101 men (58% ), 72 women (42%)101 men (58% ), 72 women (42%)
118 Caucasian (68%), 50 African-American (29%) 5 118 Caucasian (68%), 50 African-American (29%) 5 “Other” (3%); Mean age = 51.6 (SD = 15.2)“Other” (3%); Mean age = 51.6 (SD = 15.2)
Compared to cancer patients , patients with AIDS Compared to cancer patients , patients with AIDS were significantly more likely towere significantly more likely to : :
-Be single-Be single
-Be male-Be male
-Be of a minority ethnic group-Be of a minority ethnic group
-Be younger -Be younger
-Report past or present psychiatric problems-Report past or present psychiatric problems
-Report being inadequately medicated for pain-Report being inadequately medicated for pain
Average # of aberrant behaviorAverage # of aberrant behavior 3.413.41 1.421.42 6.146.14
Total # of “aberrant behaviors Total # of “aberrant behaviors 423 423 122122 301301““probably less predictive of probably less predictive of (72%)(72%) (86%)(86%) (67%)(67%)addiction” addiction”
Total # aberrant behaviors Total # aberrant behaviors 167167 2020 147147““probably more predictive probably more predictive (23%)(23%) (14%)(14%) (33%)(33%)of addiction”of addiction”
Numbers of Aberrant BehaviorsNumbers of Aberrant Behaviors
Total # aberrant behaviorsTotal # aberrant behaviors 305305 152152(6.2)(6.2) (6.3)(6.3)
Aberrant behaviors “probablyAberrant behaviors “probably 239239 116116less predictive of addictionless predictive of addiction ““ (78%)(78%) (74%)(74%)
Aberrant behaviors “probablyAberrant behaviors “probably 6666 4040more predictive of addiction”more predictive of addiction” (22%)(22%) (26%) (26%)
The Four “A’s” of Pain The Four “A’s” of Pain Treatment OutcomesTreatment Outcomes
Analgesia – modest but meaningfulAnalgesia – modest but meaningful
Activities of Daily Living (psychosocial Activities of Daily Living (psychosocial functioning) – 80% rated as improved overallfunctioning) – 80% rated as improved overall
Adverse effects (side effects) – common but Adverse effects (side effects) – common but tolerable tolerable
Aberrant drug taking (addiction-related Aberrant drug taking (addiction-related outcomes)outcomes)
Passik & Weinreb, 1998
Aberrant BehaviorsAberrant Behaviors (Passik, Kirsh et al, in prep, 2004)(Passik, Kirsh et al, in prep, 2004)
55.4
25.3
8.5 6.7
4.1
0
10
20
30
40
50
60
0 2 to 3 3 to 4 5 to 7 8+
% of Patientsexhibiting behs.
(n = 215)
(n = 98)
(n = 33) (n = 26) (n = 16)
Number of Behaviors Reported
Characterization of OxyContin abusers Characterization of OxyContin abusers seeking drug abuse treatment in KYseeking drug abuse treatment in KY
Chart review survey of admissions to drug Chart review survey of admissions to drug treatment center in Lexington at height of media treatment center in Lexington at height of media coverage of the epidemiccoverage of the epidemic
195 admissions for OxyContin abuse195 admissions for OxyContin abuse
SCID diagnoses and other SCID diagnoses and other medical/demographic data recordedmedical/demographic data recorded
Characterization of OxyContin abusers Characterization of OxyContin abusers seeking drug abuse treatment in KYseeking drug abuse treatment in KY
OxyContin abusers were:OxyContin abusers were:– Using on average, 180mgs per dayUsing on average, 180mgs per day– History of other DSM IV, nonsubstance abuse Dx History of other DSM IV, nonsubstance abuse Dx – History of poly-substance abuseHistory of poly-substance abuse– History of other prescription drug abuseHistory of other prescription drug abuse
OxyContin abusers compared to other opioid abusers:OxyContin abusers compared to other opioid abusers:– YoungerYounger– MaleMale– RuralRural
Characterization of OxyContin abusers Characterization of OxyContin abusers seeking drug abuse treatment in KYseeking drug abuse treatment in KY
The 60 patients who ostensibly began using in The 60 patients who ostensibly began using in pain treatmentpain treatment– Treated mainly by primary care and other non pain Treated mainly by primary care and other non pain
expertsexperts– Similar med/demos to other OxyContin abusersSimilar med/demos to other OxyContin abusers– Equally likely to alter route of administration, with Equally likely to alter route of administration, with
13% reporting crushing and injecting13% reporting crushing and injecting
Characterization of OxyContin abusers Characterization of OxyContin abusers seeking drug abuse treatment in KYseeking drug abuse treatment in KY
The 60 patients who ostensibly began using in The 60 patients who ostensibly began using in pain treatmentpain treatment– Treated mainly by primary care and other non pain Treated mainly by primary care and other non pain
expertsexperts– Similar med/demos to other OxyContin abusersSimilar med/demos to other OxyContin abusers– Equally likely to alter route of administration, with Equally likely to alter route of administration, with
13% reporting crushing and injecting13% reporting crushing and injecting
Rx Drug Abusers Entering TreatmentRx Drug Abusers Entering Treatment(Passik, Kirsh, et al, in process)(Passik, Kirsh, et al, in process)
DrugDrug # of instances# of instances (of n = 89)(of n = 89)
Rx Drug Abusers Entering TreatmentRx Drug Abusers Entering Treatment(Passik, Kirsh, et al, in process)(Passik, Kirsh, et al, in process)
DrugDrug Altered Altered deliverydelivery
Snort*Snort* Crush*Crush* I.V.*I.V.*
OxyContinOxyContin 55/5755/57 5353 2727 1414
LortabLortab 17/3117/31 1515 99 44
PercocetPercocet 11/1311/13 1010 44 33
MorphineMorphine 4/44/4 22 11 33
MethadoneMethadone 1/31/3 11 00 00
DilaudidDilaudid 2/22/2 11 11 22
DuragesicDuragesic 0/20/2 00 00 00
* Not mutually exclusive
ConclusionsConclusions
Patients of all types engage in some ambiguous Patients of all types engage in some ambiguous drug-taking behaviordrug-taking behavior
Substance abuse history is associated with Substance abuse history is associated with increased number of aberrant behaviors and increased number of aberrant behaviors and types of aberrant behaviorstypes of aberrant behaviors
Provision of adequate analgesia may not be Provision of adequate analgesia may not be enough to limit aberrant behaviors in complex enough to limit aberrant behaviors in complex patients who have a history of drug abusepatients who have a history of drug abuse
Assessment should be multimodal – 4A’sAssessment should be multimodal – 4A’s