Pain and Chemical
Dependency
Not an “Either – Or” proposition
Douglas Gourlay, MD, FRCPC, FASAM
Wasser Pain Centre, Toronto ON
The Problem
• Pain and Addiction CAN coexist
• Addiction in General Population
– Varies 3 – 16% prevalence
– Varies with the drug, gender, economic status, race,
age…
• Addiction in the Chronic Pain Population
– We really have no idea
– We use the same terms, with different meaning
• Lack of precision in definitions around
abuse/dependency/addiction
DL Gourlay, MD, FRCPC, FASAM
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Definitions
• Addiction: Addiction is a primary,
chronic, neurobiologic disease, with
genetic, psychosocial, and environmental
factors influencing its development and
manifestations. It is characterized by
behaviors that include one or more of the
following: impaired control over drug use,
compulsive use, continued use despite
harm, and craving. (LCPA)
DL Gourlay, MD, FRCPC, FASAM
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Definitions
• Physical Dependence: Physical
dependence is a state of adaptation that
often includes tolerance and is manifested
by a drug class specific withdrawal
syndrome that can be produced by abrupt
cessation, rapid dose reduction,
decreasing blood level of the drug, and/or
administration of an antagonist. (LCPA)
DL Gourlay, MD, FRCPC, FASAM
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Definitions
• Tolerance: Tolerance is a state of
adaptation in which exposure to a drug
induces changes that result in a
diminution of one or more of the drug's
effects over time.
• Tolerance develops at different rates, in
different people, to different effects
DL Gourlay, MD, FRCPC, FASAM
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Definitions
• Pseudoaddiction: Iatrogenic,
maladaptive behavior resulting from
inadequate pain control
• Not to be used “instead of” addiction
• Unwise to diagnose in patient with history
of addictive disorder, even in other
substance
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Addiction *
Environment
Biology
*
Drug
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Diagnosis
• DSM-IV criteria - dependence
– Maladaptive behavior having at least three
of the following in a 12 month period
• Withdrawal
• Tolerance
• Use in larger amounts or over longer period than
intended
• Persistent use, or unsuccessful attempts to cut-down
or control use
• XS time spent using or recovering from use
• Narrowing of focus due to substance use
• Continued use despite harm
DL Gourlay, MD, FRCPC, FASAM
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Pain and Addiction
as Co-morbid Conditions
• Pain often complicate the Dx of Addiction
• Pain and Addiction can coexist
– Pain plus
• Alcoholism
• Cocaine
• Cannabis
– Relatively simple to use current tools to
assess addiction i.e. DSM-IV
DL Gourlay, MD, FRCPC, FASAM
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Pain and Opioid Addiction
• What happens when the ‘drug of choice’ is
both the problem AND the solution,
depending on point of view?
– Addiction Specialist
• Aberrant behavior is due to opioid abuse/addiction
– Pain Specialist
• Aberrant behavior is due to inadequate treatment
of pain (pseudoaddiction)
DL Gourlay, MD, FRCPC, FASAM
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Pain-Addiction
Continuum
Patient
Addiction
Patient
Pain
Patient
DL Gourlay, MD, FRCPC, FASAM
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Boundary Setting
• 90%+ of patients don’t need strict
boundary setting
– Most patients have their own internal set
• For remaining ~10%, strict boundary
setting is essential
• Treatment Agreements, Urine Testing,
interval / contingency dispensing
DL Gourlay, MD, FRCPC, FASAM
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Boundaries – Identification
and Enforcement
Discharge Patient
DL Gourlay, MD, FRCPC, FASAM
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Boundaries – Identification
and Enforcement
Consultation with
Addiction Medicine
DL Gourlay, MD, FRCPC, FASAM
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Aberrant Drug-Related
Behaviors
More Predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or “borrowing” drugs
from another patient
• Injecting oral formulations
• Obtaining prescription drugs
from non-medical sources
• Concurrent abuse of related
illicit drugs
• Multiple unsanctioned dose
escalations
• Repeated episodes of lost
prescriptions
Less Predictive
• Aggressive complaining about
the need for higher doses
• Drug hoarding during periods
of reduced symptoms
• Requesting specific drugs
• Prescriptions from other
physicians
• Unsanctioned dose escalation
• Unapproved use of the drug
• Reporting psychic effects not
intended by the physician
DL Gourlay, MD, FRCPC, FASAM
Jaffee, 1996 15
Assessing Aberrant Behavior
• What does it mean?
– Aberrant behavior is a late and often
unreliable sign of an addictive disorder
– When used to trigger UDT, more often used in
punitive fashion
• Aberrant behavior does NOT equal
inadequate pain management in all
patients
DL Gourlay, MD, FRCPC, FASAM
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Assessment Strategies
• 1st address pain complaints
– Explore AM pain and role of IR opioids
• Carefully document medication use
– Dosing intervals, what worked, what didn’t
– Lost/stolen, early refills, double doctoring,
problems with control, withdrawal symptoms
• Family history of drug/EtOH problems
• Personal psychiatric history
DL Gourlay, MD, FRCPC, FASAM
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Assessment Strategies
• Personal Substance Use History
– Alcohol, tobacco, street drugs
– Time of last use
•
•
•
•
•
Drug Treatment History
Legal Issues
Social
Physical Examination
Lab Tests: Liver, Hepatitis, HIV, CBC, UDS
DL Gourlay, MD, FRCPC, FASAM
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Pain and Chemical Dependency
Program
• Pain and CD Clinic CAMH
– Initially at the AMC
– Problems with stigma (many “no show’s”)
• Pain and CD division at the Wasser
– Easier for patients to comfortably attend
• Very few patients fail to attend appointments
• But difficult to manage dominant SUD pts
– “Easier to teach pain docs about addiction”
DL Gourlay, MD, FRCPC, FASAM
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Pain and Chemical Dependency
Program
• Strong bridge between the Wasser Pain
Centre and CAMH was needed
– Currently fellows and residents from CAMH
spend time at the Wasser Clinic on Thursday
– Queen Street Lab does UDT for Wasser
– Stabilized Pain and CD pts are seen at Wasser
• But we don’t have a place to manage
complex pharmacotherapy problems;
we’re not integrated
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Pain and Chemical Dependency
Program
• 2004, Purdue Canada donated $300,000
over 3 yrs for a Pain and CD division at
the Wasser Pain Management Centre
– We are now discussing possibilities of having
a “Rationalization of Pharmacotherapy Unit”
at the Donwood Site
– Pts will be assessed and medically stabilized
before deciding what services might next be
offered
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Conclusions
• Pain and Addiction can coexist
• Successful treatment of either often
requires assessment and management of
both
• The Pain and CD Division of the Wasser
Pain Centre will do what neither CAMH nor
Wasser could do alone
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