Randall Henthorn, MD
Anesthesiology/Pain Management
U of Oklahoma Health Sciences Center
5 Oct 2012

In the United States:
~ 8% of population has used an illicit drug in past
month
~ 6-15% of the U.S. population have a substance
abuse disorder
~ 2.8% of people have used a prescription drug for
nonmedical reasons
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Substance Abuse and Mental Health Services Administration. (2007). Results from the 2006
National Survey on Drug Use and Health: National Findings. Retrieved April 24, 2008, from
http://www.oas.samhsa.gov/nsduhLatest.htm
SAMHSA
Survey
2010
SAMHSA
Survey
2010
SAMHSA
Survey 2010
SAMHSA Survey 2010
SAMHSA Survey 2010
SAMHSA
Survey
2010
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Answer: Generally no, excepting those with:
• Personal history of substance abuse
• Young age- especially 18-23
• Family history with chemical abuse
• Preadolescent sexual abuse
• ARCH GEN PSYCHIATRY 2000 57;10: 953-9
15.0
Million
Substance Use
Disorder
(SUD) Only
19.3
Million
5.6
Million
Serious
Psychological
Distress (SPD)
Only
2006
(SAMHSA
survey)
11
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Interventional pain management study
500 Patients taking supplemental
opioids
UDT with rapid drug screen
Overall 16% positive for either THC (11%),
cocaine (5%), Meth/amp(2%)
Age <45 (26%) 45-64(13%) >64 (0%) of
the 500.
Medicaid> 3rd>Medicare +Medicaid>
Medicare w/o 3rd
◦ Pain Physician 2006 9:2 123-129
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ALCOHOL ABUSE slightly greater than general
population (10-18%) Webster RL and Dove B
Avoiding Opioid Abuse While Managing Pain.
Sunrise River Press 2007 page 19
GENERAL ADDICTION TO OPIOIDS-1%. Addiction in
chronic pain patients in opioid dependent pain
patients 2-5%
◦ Pain Med:2005,6(6):432-42
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Substance abuse
Substance dependence-Addiction
Substance specific withdrawal syndrome
Tolerance
Pseudoaddiction
Pseudotolerance
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Maladaptive pattern of abuse producing
significant impairment or distress in a 12
month period with one or more
◦ Recurrent substance use leading to failure to fulfill
major role obligations at work, school, or home
◦ Recurrent use in situations in which it is physically
hazardous (e.g., driving while being impaired)
◦ Recurrent substance –related legal problems (e.g.,
arrests for disorderly conduct)
◦ Continue use despite recurrent social and
interpersonal problems caused by the effects of the
substance (e.g., intoxication-induced arguments,
fights)
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Intentional overuse of the substance during periods of
celebration, anxiety, despair, or result of self-medication or
ignorance.
A maladaptive pattern of substance use that leads to
clinically significant impairment or distress. Abusers may or
not be addicted, Can often stop use. Frequently stop when
harm occurs.
According to US Substance Abuse and Mental Health
Services Administration Drug abuse is “any non-medical use
of a substance.” Any use of medication in defiance of
medical direction.
◦ Webster L and Dove Beth: Avoiding Opioid Abuse While
Managing Pain. Sunrise River Press 2007 pages 24-27
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Opioid addiction is a primary, chronic,
neurobiological 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.
◦ American Academy of Pain Medicine, American Pain Society,
American Society of Addiction Medicine, 2001.
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Associated with the limbic region of the brain
designated as the “reward center”
◦ Opioid as well as other receptors related to
potentially other addictive substances are located
here and can cause excessive release of dopamine.
◦ Dopamine excess can causes sensitization
pathways in the limbic system and reinforce the
acquisition of use of substances of abuse.
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Physical dependence is a state of adaptation
that 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.
◦ It is physiological response prolonged drug exposure.
◦ Many non-abused medications have withdrawal symptoms
e.g., clonidine, beta-blockers, and baclofen to name a few.
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Systems are Dysphoric mood, nausea
vomiting, muscle aches, lacrimation or
rhinorrhea, pupillary dilation, lacrimation,
piloerection, diarrhea, yawning, fever, and
insomnia
◦ DSM-TV-TR
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To avoid, taper the opioid by 10-15% over
48-72 hours over a 2-3 weeks
◦ Wilsey BL and Fishman S: Long-term Opioid Therapy, Drug
Abuse and Addiction The Massachusetts Handbook of Pain
Management 3rd Ad,2006, Lippincott Williams and Wilkins
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“Tolerance is a state of adaptation in which exposure
to a drug induces changes that result in diminution of
one or more of the drug’s effects over time.”
Generally periodic opioid dose escalation is needed to
sustain analgesia.
Many of the non-analgesic side effects disappear as a
result e.g, sedation, cognitive impairment, and
others. Unfortunately constipation usually stays.
Opioid-Induced Hyperalgesia is a rare phenomenon
whereby the tolerance mechanisms are excessive and
making the pain worse. In this case restoration of
analgesia requires either the opioid be reduced or
anther opioid given. Process is thought to largely
involve facilitated NMDA activity and hopefully specific
antagonist will be developed against it.
Pharmacologic
Tolerance
OIH
1
5
Large dosage
increase is
frequently needed
to restore
analgesia
10
Analgesi
a
5
0
0
2
3
Dose
4
5
Kinetics of chronic drug action
Cox B: Mechanisms of tolerance. Opioids In Pain Control
Christopher Stein, ed., Cambridge University Press, 1999.
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Associated with the under treatment of pain
Manifested by behaviors similar to addiction
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Clock watching
Focus on obtaining drug
Aberrant behaviors
Behaviors resolve with increase opioid dosage other
intervention that relieves the pain
◦ American Academy of Pain Medicine, American Pain Society, & American
Society of Addiction Medicine. (2001). Public policy statement on
definitions related to the use of opioids in pain treatment. Retrieved
October 5, 2007, from http://www.ampainsoc.org/advocacy/opioids2.htm
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Need to increase the dose for reasons other
than pharmacologic tolerance
Reasons may include:
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Disease progression
New disease
Anxiety
Increased activity
Adherence issues
Addiction
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Jimmy is 36 year-old male mechanic drove his
truck off the road and hit utility pole. He barely
missed a pedestrian in the crosswalk at 2100.
ESMA transported him to trauma center. He
sustained multiple rib fractures on left chest,
pelvic fracture, and spleen laceration. Chest tube
was placed for small hemopneumothorax. Apart
from sinus tachycardia vitals were normal and
SPO2 95 on mask at 40 % oxygen. Glasgow
Coma Score is 14 and CT neck free of fractures.
Hg is 10.2 Blood alcohol is 0.17 and urine
positive for opioids and cannabinoids.
No allergies
Medical history: Hypertension, BMI-38, sleep
apnea, lumbar laminectomies and fusion at L4-5
and L5-S1.
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Medications: Oxycontin 40-mg tid, oxcodone 10-mg/APAP 325mg qid along with Neurontin 300-mg tid has been prescribed
for 1 year for back and leg pain. Reports running out of pain
meds 2 days ago. Takes 10 x 200 mg OTC Ibuprofen daily. Takes
Linsinopril 10 mg daily and Zoloft 50 mg daily two months ago
for depression.
3 months ago he underwent divorce has 2 teenage middle school
children in spouse’s custody. Jimmy has been temporarily living
with mother who is an alcoholic in recovery. Mother states he
has been upset but states he drinks only 2 beers nightly. Jimmy
never knew father. Older sister states Jimmy has been addicted
to pain killers for years, consequently avoids interaction. Jimmy
smokes and chews tobacco.
Surgeons elect to observe in ICU. He was given a total 10-mg of
IV morphine during the first hour in ER. Reports pain > 10/10,
mainly in left chest at chest tube site. He reports it hurts to
breath and cries out frequently “Can’t you see I ‘m hurt”.
Morphine is prescribed 2- 4 mg IV P.R.N. pain every 30 min.
Surgeons “don’t want to mask the exam or slow the respirations”
with too much morphine. They do allow fentanyl-mcg 50-100 IV
bolus every 2-hours if he is alert. Lidoderm patches are placed
over the rib fracture sites. IV acetaminophen 1000 mg is given q
8 hours.
When the nurse gives IV medication, Jimmy insists that she hurry
it up and five fast.
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2 hours after admission the pain score is still
greater than 10/10 on numerical scale. Screams
frequently vulgarities with small bodily
movements. He is diaphoretic, hurts all over, and
nauseated, despite Zofran 4-mg every 6 hours.
RR is 26/min and breathing pattern is shallow.
He has to be restrained for trying to get out of
bed. Mother is furious about inadequate
treatment of pain. She has been worried for
weeks about his low mood and energy, wishing
at times death. Pain consult requested by
surgeons.
6-hours after admission serum creatinine is 2.5
mg and BUN is 30. K+ is 5.6 and Hg is 9.5
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Answer: Start IV PCA with 2-3 mg of
morphine loading doses up to 10-mg within
30 minutes. In this case convert the prehospital Oxycodone to IV morphine equal and
give it as basal infusion.
An estimate of daily pre-hospital Oxycontin
plus Perocet conversion is:
◦ PO Oxycodone 20-mg = 30 mg PO morphine
◦ Then the total 160 mg Oxycodone x 1.5 = 240
mg PO morphine
◦ P0 divided by 3 (3:1 rule) divided by 24
hours/day = 3.3 mg per IV per hour
Oral
(mg)
Parental
(mg)
Morphine
30
10
Dilaudid
7.5
1.5 (2)
20
-------
hydromorphone
Oxycodone
Comment
Duration (hr)
MSIR, 3-6
MS-ER, 8-12
Exalgo 24 hour
Oxycodone SR
slow-release
Fentanyl
Patch
0.1 mg
8-12
25 mcg/hr =
45 mg/24
American Pain Society Equianalgesic
Conversion 6th Edition -2008
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PCA Morphine with 1.5 mg every 10 mg with
hourly limit of 12 mg. Set basal at 3 mg to cover
the oxycodone to morphine conversion.
Hydromorphone could work as well but 5x more
potent.
Continue Fentanyl 50 mcg q 5 min to 100 mcg
every 2 hour p.r.n. for movements bed
significant bodily moves.
Fentanyl is great for quick short but short
duration analgesia, but not so good IV for IV PCA
because its higher fat solubility which allows for
rapid redistribution from the CNS effect site of
action.
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Does he have pseudoaddiction?
He wants the IV meds given fast. Is trying to get high?
Did he show signs of opioid withdrawal syndrome.
Does he have alcohol abuse disorder?
What about the cannabinoids screen? What is the
detection window for marijuana? Does positive test
indicate he has addiction to it?
What opioids or other addictive drugs can a routine
hospital urine toxicology?
Is he at risk for suicide and need psychiatric consult?
Oklahoma Narcotics Prescription Monitoring check
shows multiple doctor prescriptions for hydrocodone
besides that of the family physician in the last 2
months and one prescribed alprazolam at 1.0 mg
every hours p.r.n. anxiety x 60 tablets
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The family doctor office nurse was contacted
the next morning and reports that
◦ last month came up 5-days short on the Percocet.
◦ last year lost half of his medication being stolen
from glove compartment
◦ the doctor has not used the prescription monitoring
system.
◦ the doctor did get a standard urine drug screen 3
months ago, it showed opiates and no illicit drugs.
◦ consent for continued opioid therapy is not in the
chart.
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Pain controlled better with PCA regimen to 7/10.
James escapes needing spleenectomy but the pelvis required
ORIF on Post MVA day 3. Anesthesia does bupivacaine intercostal
nerve blocks for 4 fractured ribs and gave Fentanyl 350 mcg
intraoperative for pelvic surgery. Endotracheal tube extubation
is OR. Report pain score 5/10 in PACU. Home CPAP used in the
PACU and back in ICU.
Post Operative IV PCA morphine was 1.5 mg q 10 min and basal
at 2.0 mg/hour to total maximum hourly dose of 11. Chest tube
removed 5 days after MVA and PO was started. Off his CPAP
device and on nasal oxygen support. Hg 9.0 after 2 PRBC
transfusion, and Cr decreased to 0.9. PCA morphine decreased
to 1.0 mg q 12 and basal decreased to 1.0 mg. Analysis of last 8
hour shift showed 36 mg used. Pain worse in area of old back
pain more than major injury sites. Reported score of 5/10 and
taking deep breaths.
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James was started on MSContin rather than Oxycontin
because potential cost savings as future outpatient. IV PCA
removed.
Estimated IV dose 90 mg/24 hours. Therefore according
3:1 rule would require about 270 mg daily PO. Speaker at
this point would use MS Contin 75 mg tid with MSIR 15 q 8
hours for breakthrough. Pain score manageable at 5/10.
Infrequently, requested breakthrough fentanyl injection.
Patient progressively walked the halls progressively and
lost 20 lbs during 2 weeks of hospitalization.
Does not feel as depressed but worried about costs. Needs
to get back to work.
He was readied for discharge after urine catheter removed
8 days after MVA.
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Confront him that he has exhibited a series of aberrant
drug seeking behaviors before the accident and explore
what motivated that behavior suggest treatment.
Suggest to PCP to refer to pain management specialist
after discharge unless more is done to monitor the opioid
abuse and diversion.
Social services consult for financial aid while recovering
from surgeries and get back to work in 2-3 months.
Suggest exploring adequacy of depression treatment.
Spiritual counseling?
AA meetings?
Chemical dependency consult? Perhaps ultimate
detoxification from opioids in 3-4 months.
Multidisciplinary
Team
Physician
Addictionologist
Nurse
Patient
Psych
Sponsor
Social
Worker
Counselor
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Monitor behaviors that seem “manipulative”
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Favoring one nurse over another
Complimenting staff to obtain needs
Exhibiting anger when needs are unmet
Requesting IV medications be given “fast”
Suspicious behaviors
◦ That arise after friends or families visit where the
patient becomes unusually euphoric or cognitively
impaired.
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Network with persons who can help these
uniquely ill persons.
Educate the family to supportive as substance
abuse is notoriously difficult problem to treat.
Educate that improvement in function is the best
goal and not just reduction in the numerical pain
score.
Reassure that everything will be done to
minimize distress or pain or combination thereof.
Encourage the patient while in the hospital to
stay focused on goals to improve function and
self worth.
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Inadequate knowledge and fear of addiction
hinder pain management in all patient
populations
Diagnosis requires ongoing assessment of
aberrant behaviors along a continuum
Goals of pain management include improving
analgesia and activities of daily living, and
controlling adverse events and aberrant
behaviors
Pain management requires effective
communication and a multimodal approach
including drug and nondrug strategies
Patients with an addictive disease present unique
challenges but deserve appropriate pain
management