Co-occurring Disorders: Pain, Depression and Substance Abuse Walter Ling MD Integrated Substance Abuse Programs UCLA [email protected]www.uclaisap Fifth Annual Statewide Conference on Co-Occurring Disorders October 3, 2006 Long Beach Convention Center Long Beach, California
69
Embed
Co-occurring Disorders: Pain, Depression and Substance Abuse Walter Ling MD Integrated Substance Abuse Programs UCLA [email protected] Fifth.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Co-occurring Disorders: Pain, Depression and Substance Abuse
Fifth Annual Statewide Conference on Co-Occurring Disorders
October 3, 2006
Long Beach Convention Center
Long Beach, California
Scope of the Talk
• “What’s the big deal”? “Why bother with it”?
• How big a problem is it?
• How do we go about it?
• What can we do?
• A few specific tricks?
What’s the Big Deal?
• Common clinical problems
• Overlaps in neurobiology
• Confusing diagnosis
• Complicates treatment , presence of one predicts poor
treatment outcome of the other
• Strain on treatment systems and resources
What’s the Problem?
• Estimates of psychiatric co-morbidity among clinical populations in substance abuse treatment settings range from 20-80%
• Estimates of substance use co-morbidity among clinical populations in mental health treatment settings range from 10-35%
Differences in incidence due to: nature of population served (eg: homeless vs. middle class), sophistication of psychiatric diagnostic methods used (psychiatrist or DSM checklist) and severity of diagnoses included (major depression vs. dysthymia).
ECA DSM-III Diagnoses (rates per 100 people)
1 Month Lifetime
Any Alcohol, Drug or Mental Health
Disorder
15.7 32.7
Any Mental Disorder 13.0 22.5
Alcohol Dependence 1.7 7.9
Drug Dependence 0.8 3.5
Regier, et al. (1990)
Lifetime Prevalence and Odds Ratios ECA Study
Alcohol OROtherDrug OR
Any mental 36.6% 2.3 53.1% 4.5
Schizophrenia 3.8% 3.3 6.8% 6.2
Any affective 13.4% 1.9 26.4% 4.7
Anti-social 14.3% 21.0 17.8% 13.4
Alcohol 47.3% 7.1
Regier, 1990
Chronic pain, Depression and Anxiety
• National Co-morbidity Study (8098 15-54 y.o. chronic pain arthritic patients vs general population control)
Mood disorder: 27% patients vs 10% controls
Anxiety disorder: 35% vs 9%
Depression: 20% vs 9%
Generalized anxiety disorder: 7% vs3%
Panic disorder: 7% vs 2%
PTSD: 11% vs 3%
Odds of disability from chronic pain increase: anxiety (2.86); depression (2.8);panic disorder ( 4.27)
The “ideal, but infrequent” patients for the separated service delivery systems
The mental health service system
• The uncomplicated schizophrenic
• The “simple” affective disordered individual
• The “pure” bi-polar patient
The substance abuse service system
• The “plain” alcoholic
• The addict who uses only heroin
• The stimulant dependent individual w/o other psych diagnoses
Drug Induced Psychopathology
Drug States
• Withdrawal
- Acute
- Protracted
• Intoxication
• Chronic Use
Symptom Groups
• Depression
• Anxiety
• Psychosis
• Mania
Rounsaville ‘90
Likelihood of a Suicide Attempt
• Risk Factor
• Cocaine use
• Major Depression
• Alcohol use
• Separation or Divorce
NIMH/NIDA
Increased Odds Of Attempting
Suicide
62 times more likely
41 times more likely
8 times more likely
11 times more likely
ECA EVALUATION
Facts about Suicide:
• 500,000 ER visits for attempts in 1997
• Four times as many US citizens died by suicide during the Viet Nam War period than died as soldiers.
• Rates increase with age ( as do other causes of death) CDC web site
• Suicide rate among addicts is 5-10 times that of non-addicts Preuss/Schuckit Am J Psych 03
Less than than half of the women with interpersonal
trauma and co-morbidity will receive treatment that
addresses their trauma history and co-occurring
conditions
(Timko & Moos, 2002).
49% of social anxiety disorder patients have panic disorder**
50% to 65% of panic disorder patients have depression†
11% of social anxiety disorder patients have OCD**
67% of OCD patients have depression*
70% of social anxiety disorder patients have depression
Comorbidity of Depression and Anxiety Disorders
Depression
OCD
Social Anxiety Disorder
Panic Disorder
HIGHLY COMMON…
HIGHLY COMORBID
The Four Quadrant Framework for Co-Occurring Disorders
A four-quadrant conceptual framework to guide systems integration and resource allocation in treating individuals with co-occurring disorders (NASMHPD,NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002)
Not intended to be used to classify individuals (SAMHSA, 2002), but . . .
Less severemental disorder/
less severe substance
abuse disorder
More severemental disorder/
less severe substance
abuse disorder
More severemental disorder/
more severe substance
abuse disorder
Less severemental disorder/
more severe substance
abuse disorder
High severity
High severity
Lowseverity
DSM and ICD: The “Bibles”
Assessing for addiction in pain patients
Substance Abuse
• One or more within a 12 month
period
- Failure to fulfill major role
obligation
- Recurrent use in hazardous
situations
- Recurrent legal problems
- Recurrent social or
interpersonal problems
Substance Dependence
• Three or more within a 12 month period
- Abuse criteria, plus:
- Tolerance
- Withdrawal
- Larger amount/longer time than intended
- Persistent desire to control use
- Great deal of time spent in activities related to use
Diagnostic and Statistical Manual of Mental Disorders*
*4th ed, APA, 1994
Pain and Depression
• What comes first?
- The antecedent hypothesis
- The consequence hypothesis
- The “scar” hypothesis
- “Pain-prone personality”
- Life experience and personal mastery
• Does it really matter?
Pain and depression make each other worse
Pain and Depression
• Between 30% and 60% of depressed patients have chronic pain
• Chronic pain patients who are depressed are 9 times more likely to
be disabled
- This depression is responsive to treatment
- Treatment lowers pain intensity and improves function and quality of
life
• Treatment needs to be adequate and sustained; combined
pharmacotherapy with behavioral therapy, aim to improve self
management, beware of increased suicide risks
Depression IS Pain
• Pain is second most common somatic symptom in
depression, second only to insomnia.
• Pain occurs in over 50% of depressed patients
• Common pain in depressed patients: headaches, facial
pain, neck and back pain, chest and abdominal pain and
extremity pain
• Pain often dominate clinical picture overshadowing other
depressive symptoms
Pain and Depression
• Pain is depressive equivalent
• Chronic pain leads to depression
• Circular relationship, vicious circle
• Common association and overlapping
• Common neurobiological substrate
• Psychological determinants critical
• Responsive to antidepressants
• Non-pharmacological strategies critical
Pain and Depression
• Two thirds of new neurological patients have pain.
• One third are depressed; 75% of them have pain.
• One quarter have both pain and depression.
• Neuropathy, neuromuscular disease, headaches.
• Sx persist at 3 & 12 mo. follow up
• Pain predicts depression at f/u and vice versa
• Odds of pain increase: female, depressed, NMD
• Odds of depression increase: CVD, Cognitive disWilliams LS et al J Neuro Neurosurg Psych. 2003
Pain IS Depression
• Somatic cyclothymia
• Periodic melancholy
• Vegetative depression
• Masked depression
• Affective equivalents
• Depressive equivalents
• Variant of depressive disease
Pain and Depression
•Co-occurrence makes diagnosis difficult
• Pain patients tend to show more irritability,
anhedonia, loss of interest, reduced capacity to
experience pleasure.
• Depressed patients tend to exhibit more
dysphoria, early morning awakening,
indecisiveness, despair and suicidal ideations
Treating Co-morbid Pain and Depression
• Tricylclic antidepressants
- Efficacy in neuropathic pain
• SSRI’s
- Safety profile
• Dual-acting agents
- Effective for depression and pain
- Detke MJ 2002
Treating Co-morbid Pain and Depression
• Non-pharmacological treatment
- Cognitive behavioral treatment
- Operant behavioral treatment
- Biofeedback training
- Motivational interviewing
- Private emotional disclosure
• Integrating pharmacotherapy and behavioral
treatment
What happen when pain becomes chronic
• The one certain thing: treatment didn’t work
• Patient frustrated and lost faith in doctors
• Patient blamed for not getting better
• Lost “role”; becomes dependent on others
• Others must pick up slack and must provide support
• Patient feels neglected when others can’t do all
• Patient becomes anxious, angry and depressed
• Patient assumes life style of chronic pain
Chronic pain: identifying early risk factors
• Attitude and belief of pain
• Whose fault?
• Behavior and compensation issues
• Dx and Tx issues
• Emotions
• Family
• Work
Early signs of chronic pain
• Not healing as expected
• Perceived neglect or ill treatment
• Perceived management abandonment
• Not adequately treated
• Accident was some one’s fault
• Expanding Sx
• Sleep disturbance, anger fear
Opioid, Pain and Addiction: Confluence of Events
• Under treatment of pain:
• Increasing availability of opioids:
• Rise in abuse of prescription opioids
New Demand:
Core competency in pain and in addiction
From Pain Relief to Addiction: Opioids and the Faces of Janus