NYSAM 2011 Case Presentation Edwin A Salsitz M

NYSAM 2011 Case Presentation Edwin A. Salsitz, M. D. FASAM Beth Israel Medical Center New York City

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ADDICTION/PAIN TREATMENT “All Treatments Work For Some People/Patients” “No One Treatment Works for All People/Patients” Alan I. Leshner, Ph. D Former Director NIDA

CT 2010 Case Presentation 54 y. o. ♀ evaluated on 6/19/09 n Headaches major medical problem n ? Paternal uncle—Et. OH n Lives with husband, has 2 adult stepchildren n Upper level executive in marketing, 250 K n Through H. S. no drugs or Et. OH n

CT 2010 Case Boyfriend 1 st year of college introduced to heroin IN n 1 st use may have led to gang rape? Uncontrollable crying over story n 1 st “migraine” around this time, frequent & severe n “nervous breakdown” after boyfriend ends relationship in 2 nd year college n Heroin IN IV x 2 yrs illicit methadone TC Abstinent age 25 n

CT 2010 Case Migraines lessened in 30’s and 40’s n frequency and severity post-menopause n Opioids X 4 years—oxy. CR & oxy. IR n Nationally known HA clinic—weaned off opioids 2 yrs ago—severe HAs opioids(1 mo. ) n Neuro and Pain Specialist—ran out of meds 1 week early ? Inpatient “detox”--? work n Current meds. Oxy CR 30 mg tid Oxy. IR 5 mg qid(NSAID, ondansetron, prednisone, venlafaxine, topiramate) n

CT 2010 Case Age 17—appendectomy— 1 st opioid— “felt good, ” “took away my insecurities” n Subsequent heroin--- “energized” n Sobbing and Crying at mention of mother who died 9 mos ago at age 93 n Felt she was a terrible disappointment to mother n Saw therapist on and off for many years— currently not in psychotherapy n

Diagnosis and Plan After Initial Consultation Opioid Physical Dependence n Pain Paradigm n Husband to Dispense Opioids n Attempt to taper opioids n Rx Oxy CR 30 mg—attempt bid n One week later 1. Oxy CR bid 2. D/C venlafaxine, start duloxetine 3. Oxy IR 5 q 6 h prn n

3 Weeks later Headaches have markedly increased while on vacation—husband not in agreement on chronic opioid paradigm n Neurologist adds gabapentin 300 mg tid and topiramate(now 100 mg. qd) n Continued attempts to taper opioids not successful n

4 Weeks Later Husband no longer coming in with patient n Headaches daily—making work and home difficult n After long discussion, OXY CR d/c’d and methadone low dose started and titrated upwards n

After 7 months Stable methadone dose 30 mg tid n Infrequent short acting opioids n Significant improvement in headache frequency, severity, n Improved function at work n Stopped therapy, and refuses new therapy n Marital issues difficult to discuss n All urines, pill counts, appts. , etc reveal no problematic behavior n Overall patient rating 9 3(as of 4/13/10) n

April 2010 Present June 2010— 2 Rxs given for methadone n October 2010 ---Short Acting Opioids D/C’d n October 2010 ---Methadone 30 mg bid n Headaches present, but intensity/frequency n Stigma issue around methadone continues n Marital issue, no psychosocial n Random urines negative n

NEUROLOGY 2004; 62: 1687 -1694 160 enrolled 70 remained on daily scheduled opioids X 4 yrs 74% LA, 26% SA 41(59%) Responders by 50% in SHI—freq x duration severe headache/week

Figure 1. Medical record versus visual analog scale: mean percentage improvement in year 3 or 4 of daily scheduled opioids (year 4 for patients in program for 4 years or more) Saper, J. R. et al. Neurology 2004; 62: 1687 -1694

Figure 2. Problem drug-related behavior: patients with any incident of problem opioid behavior over 4 years of daily scheduled opioids Saper, J. R. et al. Neurology 2004; 62: 1687 -1694 Dose Violation most common Most problems not “severe”

Chronic Pain S U B S E T Addiction ê Hedonic Tone Somatic Sxs OPIOIDS ? Endorphin Deficiency Pain Medicine Prescriptions Pharmacies Legitimate Anti-Depressants Anti-Convulsants Mood Stabilizers Addiction Treatment Methadone Clinics Regulations

** * *Anterior Cingulate Gyrus

Acc VTA FCX GLU HIPP AMYG CRF GLU GABA 5 HT OPIOID GABA DYN 5 HT ENK VP OFT BNST Opiates Amphetamine Cocaine Opiates Cannabinoids Phencyclidine Ketamine DA GABA NE LC ABN HYPOTHAL ICSS Meso. Limbic Dopaminergic Circuit Pleasure/Reward Center H 2 O, Food, Sex, Parenting, Socializing NE LAT-TEG Opiates Ethanol Barbiturates Benzodiazepines Nicotine Cannabinoids PAG END 5 HT Raphé To dorsal horn RETIC

HCC=Healthcare for Communities 1998, 2001

Association of common mental disorders in 1998 with regular prescription opioid use in 2001: unadjusted odds ratios with 95% confidence intervals Sullivan, M. D. et al. Arch Intern Med 2006; 166: 2087 -2093. Non-Cancer Pain Copyright restrictions may apply.

Journal of Addictive Diseases, Vol. 27(3) 2008

Journal of Addictive Diseases, Vol. 27(3) 2008

Problematic (Aberrant) Behaviors • Probably more predictive – – – – Selling prescription drugs Prescription forgery Stealing or borrowing another patient’s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Recurrent prescription losses Passik and Portenoy, 1998 • Probably less predictive – Aggressive complaining about need for higher doses – Drug hoarding during periods of reduced symptoms – Requesting specific drugs – Acquisition of similar drugs from other medical sources – Unsanctioned dose escalation 1 -2 times – Unapproved use of the drug to treat another symptom – Reporting psychic effects not intended by the clinician

The ORT Form-Opioid Risk Tool Mark each box that applies 1. Family history of substance abuse Female Male Illegal drugs [ ] 1 [ ] 2 [ ] 3 Prescription drugs [ ] 4 Alcohol [ ] 3 Illegal drugs [ ] 4 Prescription drugs [ ] 5 3. Age (mark box if 16 -45) [ ] 1 4. History of preadolescent sexual abuse [ ] 3 [ ] 0 compulsive disorder, bipolar, schizophrenia [ ] 2 Depression [ ] 1 Alcohol 2. Personal history of substance abuse 5. Psychological disease Attention deficit disorder, obsessive- Courtesy of Lynn Webster, M. D.

Total score risk category Low risk: 0– 3 Moderate risk: 4– 7 High risk: ≥ 8 Aberrant Behavior Displayed (%) Validation Study Results 100 ORT Total Score Risk Category 90. 9 80 60 40 28 20 5. 6 0 Low Moderate High Webster LR and Webster RM. Predicting aberrant behaviors in opioid-treated patients: validation of the Opioid Risk Tool. Pain Med. 2005; 6: 432 -442. Non-Cancer Pain

Russell Portenoy, M. D.

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ADDICTION/PAIN TREATMENT “All Treatments Work For Some People/Patients” “No One Treatment Works for All People/Patients” Alan I. Leshner, Ph. D Former Director NIDA

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