Problem Patient or Problem
Prescription?
Ken Roy, MD
Tulane Department of Psychiatry
Addiction Recovery Resources of New Orleans
504-780-2766
www.arrno.org
Scope

Problem patients

Problem prescriptions

Classes of addicting drugs

Recognition of addiction

What to do about problem patients
Potential Problem Patients

Family history of alcoholism

External locus of control

Pain persistent or out of proportion

Litigation

Multiple meds
Problem Prescriptions

Soma, Fiorinal, Valium, Xanax

Ritalin, Adderall

Vicodin, Percodan, Ultram, OxyContin
Classes of Addicting Drugs

Related to the reinforcing pathway

Three main classes

Sedative hypnotics and opioids contain the vast
majority of problem prescriptions
Sedative Hypnotics

Active in the GABA system

Alcohol

Benzodiazepines (Rohypnol)

Barbiturates (Fiorinal)

Anxiolytics & Hypnotics (Ambien, Soma,
Sonata)
Opiates

Active in the endorphin systems

Vicodin, other oxy & hydro codones

Especially ES formulations & OxyContin

Ultram

Methadone
Stimulants

Active in the dopamine system

Amphetamines (Adderall)

Others (Ritalin, Cylert)

*Decongestants
The Case Against
Chronic Sedative Hypnotics

Short term anxiolytic in non-recovering patients

No controversy

Effects on the GABA system

Effects on mood, anxiety and insomnia

Alternatives
The GABA System

Cause tolerance (40,42,43)

Down regulate receptors (36,37,38)

And receptor function (39,40)

Decrease effect of endogenous anxiolytics
(41)

Cause physical dependence (59)
Mood, Anxiety and Insomnia

Paradoxical anxiety with long term use (45)

Cause depression (54,55,56,57)

Not effective long term for sleep (44)

Make opiates less effective (58)

No evidence of long term efficacy for PTSD (60)
Alternatives to Sedative Hypnotics
(Benzo’s)


SSRI’s and TCA’s

Better for GAD (46,47,48,49)

Better for panic (49,50,51,52)

Better for agoraphobia (53)

Better for “stress” (61)
Quetiapine, Trazodone, Doxepin, etc.
The Case Against Chronic Opiates
Chronic Pain

Acute vs. chronic pain

The effects on the endogenous opiate system

The effects on the perception of pain

The effects on activity and behavior

Alternatives to chronic opiate analgesia
in
Acute vs.Chronic Pain

Acute - perioperative, traumatic, infectious


No controversy (except monitoring for relapse)
Chronic

Malignant or progressive


No controversy
Non malignant

Huge controversy (1)
Chronic Non-Malignant Pain

Subjective pain relief


Few studies

Urban - 5 patients (2)

Taub & Tennant - both anecdotal (3,4)

Portnoy - reduced perception of pain in 1/3 (5)
Improvement in function

Not demonstrated (1,6)
It Doesn’t Work


“Overall, the use of opioids in chronic pain of non
malignant origin will achieve analgesic benefit in some
patients, while improved function has not yet been
adequately demonstrated.”(1)
“Until opioid therapy can be shown to yield long term
outcomes that are superior, we cannot endorse it as a
treatment of choice for chronic non cancer pain.” (7)
Even in Non Addicts

“In patients with treatment resistant chronic
regional pain of soft tissue or musculoskeletal
origin, nine weeks of oral morphine in doses of up
to 120 mg daily may confer analgesic benefit with
a low risk of addiction, but is unlikely to yield
psychological or functional benefit.” (6)
The Endogenous Opiate System

Tolerance

B-Endorphin neurons become tolerant after chronic
morphine administration (8)

Release of Pro-opiomelanocortin-derived peptides
decreased in tolerance (9)

Pro-opiomelanocortin synthesis and B-Endorphin
utilization down-regulated in morphine tolerance
(10,11)
The Perception of Pain

Chronic opiates cause sensitization

Hyperalgesia caused by noxious stimulation is
similar to hyperalgesia caused by chronic
opiates (15)

Thermal hyperalgesia develops in morphine
tolerance (16)
Activity and Behavior


Depression

Opiates and opiate system implicated in
model of learned helplessness (17,18)

Opiates cause depression (19,20)
Potential for relapse

Opiate use increases potential for relapse
(21,22,23)
Alternatives

Multidisciplinary chronic pain treatment
programs

Nerve Blocks (24)

Psychotherapy (25,26,27,28,29)

Acupuncture (30)

Exercise (25,31,32)

Spiritual growth and recovery (33)
Substance Abuse




Ubiquitous
Social problem
Legal problem
Economic Problem
Criteria for Substance Abuse




Recurrent use affecting role obligations
Recurrent use where hazardous
Recurrent use causing legal problems
Recurrent use causing social or
interpersonal problems
Prevalence


Almost 50% of persons age 21 abuse
alcohol
 70% drink
22% of persons 18 – 22 years of age use
illicit drugs
 76% are employed
 Rate in college students 21%
Treatment



Harm reduction strategies
 Designated Driver
 Education and conversation
Response to behavior
 Don’t excuse behavior
 Don’t remove consequences
Most people discontinue SUBSTANCE
ABUSE unless they develop SUBSTANCE
DEPENDENCE
Criteria for Substance
Dependence

A maladaptive pattern of use, causing
significant impairment or distress as
manifested by three (or more) of the
following seven criteria, occurring at any
time in the same twelve months

Tolerance, as defined by:


a need for increased amounts to achieve effect
markedly diminished effect from using the same
amount
Substance Dependence
continued

withdrawal, as manifested by:




characteristic withdrawal syndrome
the same substance is used to avoid or relieve
withdrawal symptoms
the substance is taken in larger amounts or over
a longer period than was intended
there is a persistent desire or unsuccessful
efforts to cut down or control use
Substance Dependence
continued


a great deal of time is spent in activities
necessary to obtain or use the substance or
recover from it’s effects
important social, occupational, or recreational
activities are given up or reduced because of
substance use
Substance Dependence
continued

the substance use is continued despite
knowledge of having a persistent or recurring
physical or psychological problem that is likely
to have been caused or exacerbated by the
substance (ulcer, depression, etc.)
Incidence of Substance
Dependence

14.1% National Comorbidity Study 1994


Other drug dependencies in 7.5% of these
5% to 15% is the range in previous studies
Substance Dependence
Shorthand



Compulsion
Loss of Control
Continued use in the face of adverse
consequences
The Disease of Addiction

Criteria for a disease



Recognizable symptoms
Predictable Course
Common Cause
The Course of Addictive Disease




Progressive
Affects all organ systems
Associated with the cause of death
A disease of relationships


Disturbance in the relationship with self and
others
Based on dishonesty in the form of denial
The Cause of Addictive Disease

Genetic




Experience - Family History
Family Studies
Twin Studies
Adoption Studies
Importance of Disease
Orientation

Cause - not Effect of Something Else




Therefore a primary illness
Helps to understand Denial
Providers don’t blame their patients
Patients Have a Healthy Target to Work on
Impact on Treatment

Abstinence is the Only Reasonable Goal


Denial is the Primary and Universal Symptom


Preserves the Right to Drink or Use
Identification With Others Possible


Use Alters Neurotransmitters
OK Not to Have Coping Skills
Treatment Takes Time

Levels of Care can provide time
Contribution of Environment


Similarity to TB
Impact of Using on Emotional Development
Abstinence


Similarity to Diabetes
AA/NA/GA/RR not MM



Common Experiences
Fellowship
Impact on Emotional Development
Getting Help

Public Sector



Overcrowded, under funded, restrictive
32 Detox beds – 900 waiting for treatment
Private Sector



Effective, welcoming, shame reducing
Requires Parity (Non-discrimination) for
maximal effectiveness
Current insurance coverage inadequate and
often inappropriate
So, what do I do?


Call it like you see it
Don’t shame the patient



May point out consequences
Be realistic, don’t try to “scare” the patient
Refer to appropriate addiction specific practices

JPSAC


Public
ARRNO

Private – Insurance, etc