Joining us at Outlook on Outcomes for the second consecutive week is Dr. Steven Moskowitz, a physical medicine and rehabilitation specialist. See his previous entry for more on this very important topic. – Dr. Holt
Last week we looked at the unique chronic pain patient profile and concluded that clinicians must recognize pain as a biopsychosocial condition. When the treating physician fails to address each of the biopsychosocial components and applies only medical remedies, results are often sub-optimal. Today we’ll explore the appropriate corresponding care plan and resources.
Maladaptive coping combined with the use of medication that is addictive and induces euphoria, is a recipe for addiction. Most chronic pain patients have long medical histories, have become functionally debilitated, and have developed fixed beliefs about their illness. If you simply detoxify a chronic pain patient of their addictive medication, you have the dilemma of a debilitated, poorly functioning person who can easily find a new practitioner willing to treat his pain complaint with opiates. Recidivism is a huge problem in addiction treatment; imagine what happens when a patient shows up at an unsuspecting physician’s office with an MRI showing two back surgeries. When physicians do not take all the biological, psychological and social components into account at every visit, the patients most in need fall through the cracks.
Treating chronic pain addiction based on needs
Successful treatment is in part due to appreciating that addiction is best seen in the context of pain rehabilitation. Physicians can often wean patients who demonstrate adaptive coping and a desire to discontinue opiates. However, less adaptive patients or those on very high doses require more formal detoxification. Treatment can be provided via a specialized office practice, but in many areas these reliable services do not exist. At times, we can piece together a detoxification program followed by a rehabilitation program. For the more complicated case, carefully selected multidisciplinary rehabilitation programs offer detoxification in the context of a highly intensive and multidisciplinary functional restoration program. As an example, I refer you to the Rosomoff Comprehensive Pain Center’s excellent detoxification and rehabilitation results.
A major key to success for Paradigm is the company’s treating physician intervention and concurrent onsite case management intervention with the injured person, healthcare providers and significant others. This course of action promotes entry into a rehabilitation program and ushers the injured person back into the community with a more appropriate care configuration. The Paradigm team recognizes the resources for each individual are dependent on the intensity of their needs, what is or can be made available in their community, and the cooperation of the injured person, his treating physician and, at times, his attorney.
Outcome goal setting
Paradigm recommends the following general outcome goals be a part of any chronic pain program:
1. Medications management: the injured person should be off opiates, decrease intake of other medications, and have decreased side effects.
2. Greater functional capacity: for example, the injured person should become comfortable sitting, walking and lifting through intensive graded exercise.
3. More adaptive coping strategies through cognitive-behavioral techniques
4. Establish MMI status and functional capacity.
5. Family intervention: support the patient’s family so they can assist with greater patient independence and less sick role behaviors.
6. Independent self management and decreased reliance on the health care system.
7. Discharge the injured person to a provider that is competent in conservative care without opiate reinstitution.
Preventing iatrogenic addiction recurrence
Preventing recurrence depends upon avoiding the type of care that initially caused the problem. Once gains are achieved it is important that the patient’s future care be conservative and focused on continuing the interventions that work: therapeutic exercise, independent modalities and avoidance of addictive or habit forming medications. The Paradigm team works to identify such resources and facilitates the transition which can be a bumpy road.
Joining us at Outlook on Outcomes this week and next is Dr. Steven Moskowitz, a physical medicine and rehabilitation specialist. As our first guest blogger, Dr. Moskowitz will cover a very important topic in our healthcare system and particularly in workers’ compensation. Thanks for sharing your expertise! – Dr. Holt
Dr. Holt asked me to comment on why treating prescription medication addiction is not as simple as a forced referral to a drug and alcohol detoxification or rehabilitation program. I believe chronic pain patients present a greater challenge for several reasons, including maladaptive coping with ongoing pain complaints, fear of activity and debilitation, high incidence of untreated concurrent psychological problems, and, lastly, the availability of community clinicians willing to repeatedly treat subjective pain complaints with opiates without addressing the accompanying psychosocial issues. Such physicians increasingly treat chronic pain patients with escalating or high doses of opiates despite dependence, addiction, the development of complications, and limited overall clinical and functional improvement. To break this pattern, we must consider the unique profile of a chronic pain patient and identify appropriate resources for the management of addiction.
This week, I’ll illustrate the main features of iatrogenic addiction in patients with chronic pain and argue that this particular profile requires a comprehensive response. Next week, part two will answer the question of what that methodology for treating iatrogenic addiction looks like.
Defining addiction and dependence
Two major problems with treating chronic pain with opiates are addiction/dependence and side effects. The actual definitions of drug addiction and dependence are very controversial and have been the subject of much debate in the development of the updated criteria for the Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-5), due out in 2013. The American Society of Addiction Medicine defines addiction as “a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.” It is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm, and cravings. The term dependence is often used to denote a physiological dependence composed of tolerance and/or withdrawal symptoms, but sometimes is used to describe psychological dependence on a drug. For our discussion, I’ll use these terms interchangeably since the real concept is problem drug use.
What is iatrogenic addiction?
Iatrogenic addiction refers to addiction that is caused by healthcare professionals. The National Institute of Health’s MedLine Plus online dictionary defines iatrogenic as “induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.” Unlike addiction to non-prescription drugs (e.g. alcohol, cocaine, heroin), addiction to prescription opiates requires a clinician who prescribes the medication. It is tempting to classify those with prescription medication problems as “addicts” and to believe all can be fixed by “detox.” This may be true for a small portion of these patients; professionals in the fields of addiction and law enforcement are well aware of illicit drug addicts who find their way into the medical system specifically to acquire prescription drugs. But it is difficult to know exactly what percentage of chronic pain patients is primarily driven by the desire to acquire drugs versus a secondary addiction or psychological dependence as a result of treatment.
Research regarding the chronic pain population suggests that for the majority of cases, addiction or dependence is the result of prescription medication use, not the cause of it. Consider the following:
- “The prevalence of lifetime substance use disorders ranged from 36% to 56%, and the estimates of the prevalence of current substance use disorders were as high as 43%. Aberrant medication-taking behaviors ranged from 5% to 24%.” (The “Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction (Annals of Internal Medicine, January 16, 2007 vol. 146 no. 2 116-127)
- Fishbain, et. al, in their article, “Comorbidity Between Psychiatric Disorders and Chronic Pain,” estimated that perhaps up to 18.9% of chronic pain patients have issues with abuse, addiction or dependence, but stated that recent studies showed current problems with dependence in up to 34% of chronic pain patients. Up to 12.5 percent were found to use illicit drugs.
- In my informal discussion with colleagues who run comprehensive pain programs, it was felt that of the patients presenting to their program with problematic prescription drug use, perhaps 20-30% had a primary addiction problem, separate of pain issues.
The chronic pain population includes a wide variety of people who can be vulnerable to addiction to prescription medications. Some have addictive habits, such as smoking, over-eating and alcohol, while others have a past history of addictions. Conversely, others had no prior vulnerability to addiction. One of the most common traits in pain patients with problematic opiate use is maladaptive coping abilities. The Fishbain article noted that 71% of chronic pain patients have adjustment disorders.
It is vital that clinicians recognize pain as a biopsychosocial condition. That means most patients not only have biological factors causing pain, but also significant psychosocial aspects prolonging disability and delaying recovery. This makes treatment a more complicated endeavor than standard drug and alcohol detoxification or rehabilitation.
Return next week to learn how to identify the appropriate resources for treating iatrogenic addiction.
Recently, Alex Swedlow and his colleagues at the California Workers Compensation Institute (CWCI) published a study that will be presented at their annual meeting in San Francisco next week. In this study, they report on the prescribing patterns of California workers’ compensation medical providers who write Schedule II prescriptions. CWCI has previously reported on the large increase in narcotic prescription filled as part of workers’ compensation claims, growing from 1% to 6% of prescriptions filled. That six-fold increase in prescriptions has resulted in a more than six fold increase in prescription drug payment, increasing from 3.8% to 23.6% of total prescription drug payment in the California workers’ compensation system. All of this is occurring despite warnings from the US Department of Health and Human Services Office of the Inspector General that these drugs cause “severe psychological or physical dependence if abused.”
There were 9,174 Schedule II opiate prescribing physicians in the study. The top 1% (93 physicians) accounted for nearly one third of the prescriptions, as well as 41% of the morphine equivalents and the associated payments. Translated into dollars, that is $36.5 million in payments for Schedule II narcotics. The top 3% accounted for more than half (54.9%) of the prescriptions. The top 10% of injured workers who were accounting for the opiates obtained their prescriptions from an average of 3.3 physicians.
How big is the problem of opiates in chronic pain?
■ More than one-quarter of Americans (26%) age 20 years and over—or, an estimated 76.5 million Americans—suffer from chronic pain
■ Admission rates for abuse of opiates other than heroin—including prescription painkillers—rose by 345% from 1998-2008
■ 20% of workers’ compensation medical costs of fully developed claims are spent on prescription drugs; narcotics account for 34% of this spend
■ 120,000 Americans a year go to the emergency room after overdosing on opioid painkillers, according to Laxmaiah Manchikanti, chief executive officer and board chairman for the American Society of Interventional Pain Physicians
Pain management has become an industry for some, as evidenced by the high opiate prescribing patterns of some physicians in the CWCI study. In addition, the pharmaceutical industry has profited from the “off-label” use of both narcotic drugs and non-narcotics. Take Actiq (Fentanyl “lollipops”) as an example. Actiq had a very specific indication from the FDA—for breakthrough cancer pain. At $65 per lollipop, it is the most expensive oral narcotic prescription. In 2006, oncologists (cancer physicians who would be prescribing them for the indicated use) were writing only 1% of the prescriptions for Actiq. Instead, 80% of the prescriptions were being written for back pain and migraines in 2006. The number one cost category for Schedule II opiates in Swedlow’s study was for the diagnosis of back pain.
According to the Model Policy for the Use of Controlled Substances for the Treatment of Pain by the Federation of State Medical Boards of the United States, “physicians (should) incorporate safeguards into their medical practices to minimize the potential for abuse and diversion of controlled substances.”
Ethical experts who treat chronic pain patients, like Fernando Branco, MD, at the Rosomoff Comprehensive Pain Center in Miami, Florida, recognize the dangers of opiate addiction and provide treatment programs with the following goals:
- Improve quality of life
- Restore optimum levels of function
- Reduce or eliminate pain
- Reduce or eliminate addictive pain medications
- Enable independence from the healthcare system (related to pain)
The following is the progression of pain as a chronic problem and the downward spiral that can result:
Unraveling the biologic, psychological and social components of chronic pain in injured workers has been the Paradigm approach. This proven methodology has resulted in better pain management, high return to function and work rates, the reduction and elimination of opiate use, and a substantial reduction in costs. We need to be careful as we look at pain therapies for the evidence that there is a long-term benefit and not some quick fix (which is usually tied to a substantial revenue generation for the provider). From a clinical and financial standpoint, we need to use the tools that provide comprehensive assessment and management of chronic pain patients in order to achieve long-term opiate free pain control.
Next week, one of our pain physician specialists will discuss addiction and pain in more detail.