Published on June 13, 2016
1. Pain and Addiction: Minding the Medicine Cabinet Jennifer Sharpe Potter, PhD, MPH Associate Professor of Psychiatry Associate Dean for Research Division of Alcohol And Drug Abuse Department of Psychiatry School of Medicine University of Texas Health Science Center San Antonio Citation available upon request
3. Opioid analgesics may benefit people when used correctly and under a medical provider’s care. But when abused, they can be just as dangerous as illicit drugs, especially when taken with alcohol or illicit drugs.
4. Pain medicines Addictive! Pain! Safe! Not safe!It depends… Addiction?
5. Start at the beginning: Low back pain (often chronic)
6. Unique characteristics of pain • Pain is a subjective experience Patients experience and “interpret” it differently No test for pain (only for unpleasantness) • Pain tolerance varies from person-to-person Genetic and cultural differences “Significance” of pain plays a role • Requires comprehensive clinical evaluation Health care providers struggle to treat pain effectively Few health care providers are taught adequately how to diagnose and treat Failure to treat/under-treatment common
7. Related Opioid Trends
8. Prescription drug epidemic is unique • Prescription drugs are not inherently bad when use appropriate, under a health providers supervision, and when they provide pain relief • Threat comes from abuse and diversion • Just because prescription drugs are legal and are prescribed by an MD, they are not necessarily safer than illicit substances.
9. Source of Pain Relievers for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2010-2011 National Survey on Drug Use and Health 2011
10. Weiss, Potter et al. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase randomized controlled trial. Archives of General Psychiatry, 68(12), 1238-46.
11. POATS: Study locations WA: Providence Behavioral Health Svc OR: ADAPT, Inc. CA: SF General Hospital CA: UCLA ISAP SC: Behavioral Health Services of Pickens Co IN: East Indiana Treatment Center WV: Chestnut Ridge Hospital NY: Bellevue Hospital Center NY: St. Luke's Roosevelt Hospital Center MA: McLean Hospital
12. POATS: Study schema
13. Successful outcomes at 3 time points Success Phase 1 4-week taper + 8 weeks f/u 7% Phase 2 Week 12 - End of stabilization 49% Week 24 - 8 weeks post-taper 9%
14. Chronic pain location Head/face 16.1% Chest/abdomen 5.5% Upper extremities 29.6% Cervical 27.0% Thoracic 26.3% Lumbar/sacral 65.0% Lower extremities 52.9% Multiple spinal areas 36.1%
15. Primary reason for use: Past and present Major reason for first use among CP patients • pain 83.2% • get high 13.1% Major reason for current use among CP patients whose first reason was pain • pain 22.6% • get high 13.9% • avoid withdrawal 56.5%
16. % of CP Participants with Clinically Meaningful Reductions in Pain Reduction at Ph2 wk 12 from baseline Minimal (>10% Δ) Moderate (>30% Δ) Substantial (>50% Δ) BPI Intensity Scale 69% 51% 35% Worst pain 66% 51% 34% Average pain 67% 55% 43% BPI – (0-10) worst, least, average, and “right now” Results presented for overall sample; no difference between treatment groups n=121 (149 Phase 2 CP participants) (IMMPACT recommendations, Dworkin et al, Pain, 2008)
17. Clinically meaningful reductions in pain interference Reduction at Ph2 wk 12 from baseline Minimal (>1 point Δ) Moderate (>2 point Δ) BPI Interference 59.5% 43.0% Results presented for overall sample; no difference between treatment groups n=121 (149 Phase 2 CP participants)
18. ACT: Acceptance and Commitment Therapy Cognitive-behavioral therapy Mindfulness Physical activity Diet Social support
19. ACT: What we did • Some patients were randomized to health education – learning about pain and health – while other patients were randomized to ACT. Brain imaging was done before and after the 8- week treatment program. • Task - Chronic pain patients who were also addicted to opiates were exposed to experimentally induced pain delivered via a thumb screw. • Resting state - We also look at their brains at rest
20. Pain region connections during resting state (p<0.05 uncorrected) Solid cyan = connectivity ACT pre- > ACT post- treatment Dashed cyan = connectivity ACT post- > ACT pre-treatment Solid red = connectivity HEC post-treatment > ACT post-treatment Correlations of clinical variables in ACT group post-treatment: Green brackets = Pain intensity correlation Magenta brackets = Pain interference correlation Yellow brackets = AAQ-II correlation Values = Fisher’s Z inf PCC sup PCC R Para Rlat Par R ITG R SFG vm PFC am PFCL SFG L ITG Llat Par L Para B 1.94 [-0.99] A Ri PCC Rs PCC Rp Ins Rm Ins Ra Ins R S2 R S1 ACC L S1 Lp Ins R Thal R Amyg C Middle frontal gyrus Inferior parietal lobule Posterior cingulate cortex Insula Anterior cingulate cortex Insula Superior temporal gyrus [0.84] 2.19 3.13 2.94 2.75 2.19[0.89][0.94] 2.67 1.68
21. Take home message •After treatment, the brains of ACT patients were more resilient at rest, and less reactive to pain even when it was deliberately induced. The ACT patients learned how to carry their pain is a less entangling way: chronic pain and induced pain. – Steve Hayes CAVEATS!!!
22. “The nation's defense rests on the comprehensive fitness of its service members ― mind, body, and spirit. Chronic pain and use of opioids carry the risk of functional impairment of America's fighting force.” -Jonas and Schoomaker
23. PDMPs: Prescription Drug Monitoring Programs: By State PDMP Training & Technical Assistance Center
24. Study Aims Examine military trends and trajectories in opioid prescribing Build military-specific tools and strategies to alert clinicians of potential opioid misuse in the military Develop reports and guidelines for addressing opioid misuse in the military context
25. The road ahead…
26. Nonmedical Use of Pain Relievers in the Past Year among Youths Aged 12 to 17, by State: Percentages, Annual Averages Based on 2010 and 2011 NSDUHs Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2010 (Revised March 2012) and 2011
27. What do teens say? Over half of teens (56 percent or 12.8 million) do not see great risk in trying prescription pain relievers without a doctor’s prescription Prescription drugs are easy to get; 70 percent of kids age 12 and older say they get them from friends or relatives, often for free Teens say they abuse prescription painkillers because… they believe they are safer to use than illicit drugs (41%) there is less shame attached to using them (37%) there are fewer side effects than illicit drugs (31%) and parents don’t care as much if you get caught (20%)
28. What can parents do? • Talk with and listen to your kids • Know what your kids are doing – parental awareness/monitoring of their kids’ activities is one of the best predictors of well-being for most behavioral health issues including drug abuse • Teens whose parents express disapproval about drug abuse are less likely to engage in substance use • Universal precautions
29. Specific steps parents can take • Safeguard all drugs at home Monitor quantities Control access • TALK-talking to your children is not dangerous Set clear rules for teens about all drug and alcohol use, INCLUDING not sharing medicine and following the medical provider’s advice and dosages • Be a good role model by following these same rules with your own medicines – don’t share medications • Properly dispose of old or unneeded medicines • Ask friends and family to safeguard their prescription drugs as well
30. Collaborators Erin Finley, PhD Mary Jo Pugh, PhD Don McGeary, PhD Bill Kazanis, MS Kangwon Song, PharmD Don Robin, PhD Kristen Rosen, PhD, MPH Suyen Warzinski, MS Samantha Paniagua Ashley Garcia Lt Col (Ret) Vikhyat Bebarta, MD Maj Josephy Maddry, MD Lt Col David Carnahan, MD COL Robert Gibbons Maj Gen(Ret) Byron Hepburn, MD LTC Brandon Goff, DO Lee Ann Zarzabal, MS Alan Sim, PhD Sandra Valtier, PhD (program officer, 59th MW)
31. Division of Alcohol and Drug Addiction, School of Medicine University of Texas Health Science Center Questions?