PowerPoint Presentation - uhn.echoontario.ca · •Double doctoring •Functional deterioration seemingly related to drug use •Repeated resistance to change in therapy despite clear

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Aberrant Drug Related Behaviours

Identifying and Managing a Spectrum of Risk

Andrew J Smith, MDCM

Staff Physician, Pain and Addiction Medicine

Centre for Addiction and Mental Health,

Faculty/Presenter Disclosure

Faculty: Andrew J Smith, MDCM

Relationships with commercial interests:

None to report

ADRBs: A Spectrum of Risk Learning Objectives

1. Define aberrant drug related behaviours

2. Describe at least three elements of structured treatment of chronic pain

3. Outline an approach to managing aberrant drug related behaviours

Aberrant Drug Related Behaviours

• Any medication-related behaviours that depart from the agreed-upon therapeutic plan of care

• Problematic behaviors or “red flags” for clinicians

• Watch the language! Culture-bound, but defined by

conventional practice, laws and regulations, guidelines and

TREATMENT AGREEMENT

• Monitoring for ADRB essential part of opioid therapy

• Should be viewed as “data,” which must be interpreted in a

differential diagnosis of addiction

White WL, Kelly JF: Alcohol/drug/substance “abuse”: The history and (hopeful) demise of a pernicious label. Alcoholism Treatment Quarterly. 2011; 29 (3):317-321

Spectrum of Prescription Opioid Use

Nonmedical Users Pain Patients

Passik SD, Kirsh KL. The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse. Experimental and Clinical Psychopharmacology. 2008; 16(5): 400-404.

Aberrant Drug Related Behaviours

• Selling medications / RX Forgery

• “Street” sourcing

• Crushing / Snorting / Injecting

• Multiple dose-escalations or other non-compliance with therapy despite discussions

• Multiple episodes of prescription loss or theft

• Double doctoring

• Functional deterioration seemingly related to drug use

• Repeated resistance to change in therapy despite clear evidence of therapeutic failure or adverse effect

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Aberrant Drug Related Behaviours

• Aggressive requests for dose increases

• Stockpiling during periods of reduced symptoms

• Requesting specific medications

• Unsanctioned dose escalation or other non-adherence on occasion

• Unapproved use of the medication to treat another symptom

• Reporting mood or cognitive effect not intended by the clinician

• Catastrophizing and rumination about return of severe symptoms with change in therapy

Portenoy RK, Payne R. Acute and chronic pain. In Lowinson JH, Ruiz P, Millman RB (eds): Comprehensive Textbook of Substance Abuse, 4t Edition. Baltimore: LWW; 2011. p651

Predictors of Opioid Aberrancy in Patients with Chronic Pain: A Diverse Set of Risk Factors

• Younger, male patients (cross sectional studies)

• Higher pain interference higher doses of opioids higher risk (prospective)

• Concurrent physical illnesses, substance use, degree of pain-related limitation

• Concurrent anxiety and depression (cross-sectional, prospective studies)

• High levels of pain catastrophizing

• SU Hx: prior SUD, recent use of illicit drugs, prior legal problems related to drug or alcohol use, prior treatment for SUD

• Reduced sleep (every extra 1 hour in avg hours of sleep reduced odds of opioid misuse by 20%)

Hah JM et al. J Pain Res. 2017 May 3;10:979-987. doi: 10.2147/JPR.S131979. eCollection 2017.

Hah JM et al. J Pain Res. 2017 May 3;10:979-987. doi: 10.2147/JPR.S131979. eCollection 2017.

Opioid misuse = 1) taking an opioid prescription in a manner or dose other than prescribed or 2) taking someone else’s opioid prescription

Predictors of Opioid Misuse in Patients with Chronic Pain: A Prospective Cohort Study. Ives, et al., BMC Health Serv Res. 2006 Apr 4;6(1):46

• Prospective, cohort study to examine one year prevalence of “opioid misuse” in chronic non-cancer pain pts (n=196)

• Opioid Misuse defined as: • Negative urine toxicological screen for prescribed opioids;

• UTS positive for opioids or controlled substances not prescribed by our practice;

• Evidence of procurement of opioids from multiple providers;

• Diversion of opioids;

• Prescription forgery; or

• Stimulants (cocaine or amphetamines) on UTS

Predictors of Opioid Misuse in Patients with Chronic Pain: A Prospective Cohort Study.

• Mean patient age was 52 years, 55% were male, and 75% were white.

• Sixty-two of 196 (32%) patients committed opioid misuse.

• Detection of cocaine or amphetamines on UTS most common (40.3% of misusers).

• Misusers more likely than non-misusers • Younger

• Male

• Past alcohol abuse

• Past cocaine abuse

• Previous drug or DUI conviction

• Race, income, education, depression score, disability score, pain score, and literacy not associated with misuse

• No relationship between pain scores and misuse

Ives, et al., BMC Health Serv Res. 2006 Apr 4;6(1):46

Predicting Aberrant Use • In one prospective study, 32 % of patients in an academic chronic

pain practice were identified as using opioids aberrantly

Opioid Misuse 62 (31.6%) of N=196

Stimulants (cocaine or amphetamines) 25 (40.3%)

Negative urines 15 (21.2%)

Doctor collecting 10 (16.1%)

Inconsistent urines (other opioids) 9 (14.5%)

Prescription forgery 2 (3.2%)

Diversion 1 (1.6%)

TOTAL 62 (100%)

BMC Health Serv Res. 2006 Apr 4;6:46.

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Unexpected UDT Results

Michna E, Jamison RN, Pham LD, et al. Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings. Clin J Pain 2007; 23: 173-179.

55%

10.2%

14.5%

17.6%

2.6%

Normal

Missing opioid

Additional drug

Illicit substance

Adulterated

Aberrant Behaviors (n = 388)

0

10

20

30

40

50

60

0 2 to 3 3 to 4 5 to 7 8+

55.4

25.3

8.5 6.7 4.1

% of Patientsexhibiting behs.

Number of Behaviors Reported

(Passik, Kirsh et al, 2005)

Chronic Pain and Substance Use Disorders

• Prevalence of Opioid addiction in CNCP patients receiving opioids? • Opioid addiction 3.3% in CNCP patients

• Aberrant drug related behaviors 11.5%

• Urine drug screen (UDS) with illicit drugs present 14.5%

• UDS with non-prescribed opioids present 20.4%

• Based on review of 67 studies (Fishbain 2008) – many limitations • No breakdown of the clinics studied or dates of study (opioid dependence increasing)

• Dx of addiction depends on clinician’s judgement

• ADRBs and positive UDSs are only proxy measures of addiction

Fishbain DA et al. Pain Medicine 2008 May;9(4):444-59.

Pillar 1 : Risk Assessment

• “Universal Precautions” history (Gourlay et al, 2005) • Current and previous pain treatment • Aberrant drug-related behaviours • Previous drug and alcohol use • Family history of drug or alcohol use • History of other addictions • History of physical, sexual or emotional trauma • Depression, anxiety, and other mental health issues • Urinary drug screen and identification

• Identify the individuals with the greatest risk of aberrant behaviour NOT to stigmatize, but to improve care

The Ten Steps of Universal Precautions in Pain Medicine

1. Diagnosis with appropriate differential

2. Psychological assessment including risk of addictive disorders – PREDICTING RISK

3. Informed consent (verbal vs written/signed) - MANAGING RISK

4. Treatment agreement (verbal vs written/signed) STRUCTURED TREATMENT

5. Pre/post intervention assessment of pain level and function

D Gourlay, HA Heit, A Almahrezi Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain Pain Medicine. 2005;6(2):107-12

How do Different Risk Measures Compare?

• A recent study at a pain practice in Tennessee

• A retrospective study of discharged patients N=48

• Risk rating of each patient with all four measures: • Clinical semi-structured interview by a psychologist

• DIRE (Belgrade et al, 2006)

• ORT (Webster & Webster, 2005)

• SOAPP (Butler et al, 2004)

• “Medium” or “High” risk rating = Accurate prediction

• This measure assesses sensitivity (not specificity)

Moore TM, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Medicine. 2009; 10(8): 1426-1433.

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Accuracy in Predicting ADRBs

Measure % Accuracy Rate

Interview 77%

SOAPP 73%

ORT 45%

DIRE 17%

Moore TM, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Medicine. 2009; 10(8): 1426-1433.

Risk Assessment: Screening Tools

• ORT demonstrated high sensitivity and specificity for detecting individuals presenting to a pain clinic at risk for developing aberrant behaviors around use of opioids (Webster, 2005)

• BUT, none of the screening tools can be recommended with confidence, because samples were small and unrepresentative (Turk, 2008)

• A personal history of abuse of illicit drugs or alcohol remains the strongest predictor of opioid misuse and abuse

Turk DC, et al. Clinical Journal of Pain 2008 Jul;24(6):497-508. Webster LR, Webster RM. Pain Med. 2005;6:432-442.

Structured Treatment • Based on assessment, categorize patient into low or high perceived risk • Structure the therapy to match the perceived risk

• Improves the ability to monitor

• May help the vulnerable patient maintain control

• Stigma can be reduced • Overall risk contained

• Patient care improved

Structured Treatment • May initiate therapy with:

• Requirement of all prior records and permission to contact other health care professionals

• Requirement of consultation with addiction medicine specialist or other mental health professional

• Written agreement, perhaps a formal “contract”

• Prescription of long-acting drug only

• Frequent visits

• Small prescription (one-week or two-week supply)

Structured Treatment

• May initiate therapy with: • Urine drug screen

• Requirement that only one pharmacy be used

• Requirement that pill bottle be returned for count

• Instruction that there will be no early refills or replacement of loss drug without police report

• Requirement of concurrent nonpharmacologic therapy

• Requirement that others (e.g., spouse) be allowed to comment periodically on progress

Structured Treatment • Opioid “contract”: common elements

• Avoid improper use

• Terms of disciplinary termination

• Limitations for replacing or changing prescriptions

• Inform physician (e.g., side effects, other meds)

• Random drug screens

• Terms regarding appointments

• Requirement for consultation

• Limits on drug refills (e.g., phone allowances or in person)

• Side effects education (including withdrawal)

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Monitoring Outcomes

Monitoring drug-related behaviors:

• Step 1: Are there aberrant drug-related behaviors

• Step 2: If yes, REASSESS (consider consultations)

• Step 3: How should they be interpreted?

What are the diagnoses?

What factors are driving the behaviors?

ADRBs: DDx

• Addiction (out of control, compulsive drug use)

• Pseudo-addiction (inadequate analgesia) – CAUTION

• Other psychiatric diagnosis • Organic Mental Syndrome (confused, stereotyped drug-taking)

• Personality Disorder (impulsive, entitled, chemical-coping behavior)

• Chemical Coping (drug overly central)

• Depression/Anxiety/Situational stressors (self-medication)

• Criminal Intent (diversion) • Jung and Reidenberg: MDs cannot detect actors

(Passik & Portenoy 1996)

Addiction vs. Pseudoaddiction in Pain Management

Addiction – Prospectively Patient’s behavior and complying with the treatment agreement becomes aberrant despite “Rational Pharmacotherapy.”

Pseudoaddiction - Retrospectively Patient’s behavior and complying with the treatment agreement normalizes with “Rational Pharmacotherapy.”

Gourlay D, Heit HA et al. Pain Med. 2005;6(2):107-112.

AIDS Patients and Aberrant Behaviors

Adequate

Analgesia

(n=49)

Inadequate

Analgesia

(n=24)

Total # of aberrant behaviors 305

(6.2)

152

(6.3)

Aberrant behaviors “probably

less predictive of addiction

239

(78%)

116

(74%)

Aberrant behaviors “probably

more predictive of addiction

66

(22%)

40

(26%)

Passik SD, et al. Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse. Clinical Journal of Pain. 2006; 22(2): 173-181.

Responding to ADRBs: ENFORCEMENT

29

Discharge Patient

Responding to ADRBs: Engagement

DL Gourlay, MD, FRCPC, FASAM 30

Consultation with Addiction Medicine

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ADRB Response: Adjusting Structure

• Depends on diagnoses REASSESS

• Are opioids indicated? Safe?

• Tighten the structure and support

• More frequent visits

• More frequent dispensing / observed dosing

• Prescription of long-acting drug only

• Referral to Addiction Medicine Specialist

• Ongoing coordination with sponsor or program, if addiction therapy is ongoing

ADRB Response: Adjusting Structure

•Written agreement, perhaps a formal “contract”

• Referral to psychiatry for concurrent disorder specialist

• Other specialty consult to clarify underlying diagnosis

• More frequent UDS

• Pill counts

• Treating co-morbidities

• Non-pharmacological approaches

ADRB Response: Adjusting Structure

• Patients whose behavior is out of control, or cannot be brought quickly under control, should not be treated

• Patients who cannot accept structure should not be treated

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