Clinical Track: Diagnosis of Addiction and Impact of Pain

1. Clinical Track:
Diagnosis of Addiction
and Impact of Pain
Presenters:
• Steven Moskowitz, MD, Senior Medical Director,
Paradigm Outcomes
• Robert Hall, MD, Medical Director, Helios
Moderator: CDR Christopher M. Jones, PharmD,
MPH, Senior Advisor, Office of Public Health Strategy
and Analysis, Office of the Commissioner, U.S. Food
and Drug Administration (FDA), and Member, Rx
Summit National Advisory Board

2. Disclosures
• Steven Moskowitz, MD, has disclosed no relevant, real or
apparent personal or professional financial relationships with
proprietary entities that produce health care goods and
services.
• Robert Hall, MD – Employment: Helios
• Christopher M. Jones, PharmD, MPH, has disclosed no
relevant, real or apparent personal or professional financial
relationships with proprietary entities that produce health
care goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Outline the negative consequences of inaccurate
and imprecise diagnoses of pain and substance
use disorders.
2. Express how a precise diagnosis is critical to
devising an effective, individualized treatment
plan.
3. Explain how chronic pain and opioids affect
body systems.
4. Identify strategies to mitigate these adverse
effects.

5. Diagnosis of Addiction
The Impact of Pain

6. Disclosure
Steven Moskowitz, MD, has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.

7. Why Are Opioids a Problem for CNMP?
• They are often not effective
• They frequently lead to physical dependence,
addiction, overdose, crime
• They cause a plethora of short and long-term
medical side-effects in many body systems
• They are often not cost-effective medical
treatment

8. “To get a painkiller approved, companies must prove that it is better at reducing pain than a
sugar pill during short trials often lasting less than 12 weeks…. Do they work for five years, 10
years, 20 years?' …. We're at the level of anecdote.”
“Clearly, if I had an inkling of what I know now then, I wouldn't have spoken in the way that I
spoke. It was clearly the wrong thing to do…”
(Wall Street Journal 12/17/2012)
The Role Of Opioids In Chronic Pain
Second thoughts about opioids, per Dr. Russell Portenoy who originally promoted them

9. Relative Addictiveness of Drugs
9 © Paradigm Outcomes, Proprietary
Active/Lethal Dose Ratio and Dependence Potential of Psychoactive Drugs. Data source is Gable, R. S. (2006). Acute
toxicity of drugs versus regulatory status. In J. M. Fish (Ed.),Drugs and Society: U.S. Public Policy, pp.149-162,
Lanham, MD: Rowman & Littlefield Publishers.

10. Not All Opioid-Dependent Pain Patients
Are Addicts
• Why this matters
– Stigma
– Treatment strategy
– Treatment environment
– Work-relatedness (in Worker’s Compensation)
• But some are “addicts”
– Pre-existing substance use disorders
– Iatrogenic “addiction”
– If it looks like a duck…

11. America’s Fatal Romance With Opioids
• Centuries in the making
• True or False
– Heroin was created by the Bayer Corporation as a
solution to the morphine epidemic
– OxyContin is a safe opioid with little chance of
addiction
– Methadone and buprenorphine are alternatives to
opioids that decrease cravings for opioids
• Failing to learn from the past

12. What Makes This So Complicated?
• Out of control opioid prescribing for pain
• Over-simplification of all pain/opioid issues as
“addiction”
• Evolving substance use terminology (DSM-V)
• New pharmaceutical prescription opioids to treat
pain and to treat addiction
• Heavy marketing of addiction treatments
• Shift in care to non-specialty setting
• Lack of addiction expertise of most pain
physicians and primary care providers

13. The overlap between chronic pain, addiction and psychiatric disorders
is considerable …
What About Injured Workers? Interrelated
Pain Components
Opioids

14. ■ Lack of long term studies--addiction may develop slowly
■ Some studies show lower levels of abuse in pain patients but most exclude “high
risk” patients and did not use Urine Toxicology testing
– Range 3.2 to 18.9%, 6-13% were abusing illicit substances1
■ Develop Abuse/Addiction and/or Aberrant Drug-Related Behaviors? 2
– Five (5) studies (1,965 subjects) that used urine testing reported illicit drugs in
14.5% of patients.
– 20.4% of the CPPs had no prescribed opioid and/or a non-prescribed opioid in
urine.
– (Other studies show “aberrant drug use” in 40%)
How common is substance abuse in patients
on opioids for chronic pain?
1COMORBIDITY BETWEEN PSYCHIATRIC DISORDERS AND CHRONIC PAIN • Fishbain et al Current Review of Pain 1998, 2:1–10
2What Percentage of Chronic Nonmalignant Pain Patients Exposed to Chronic Opioid Analgesic Therapy Develop Abuse/Addiction
and/or Aberrant Drug-Related Behaviors? A Structured Evidence-Based Review(Fishbain Pain Medicine. 2008; 9(4):444-59)

15. Most Important Treatment Strategy is
Getting the Correct Diagnosis
• Correct pain Diagnosis
– CRPS misdiagnosed over 60% of the time
• Correct opioid use diagnosis
– There is no cookbook
– There is no quick fix
– Doctors frequently are unaware of prevalent
substance use problems in their patients

16. Getting to a Correct Diagnosis

17. Nomenclature Confusion
Substance Use Disorder
Addiction
Abuse
Dependence
Misuse
A lot of chiefs: SAMHSA, NIDA, APA, ASAM

18. DSM- IV
■ Substance abuse
■ Substance dependence (e.g. opioid
dependence)
DSM-5
■ Substance use disorders (e.g. opioid use
disorder)
By the Book: DSM-IV and -5
The term “addiction” is used in neither!

19. ■ 11 Criteria (manifestations)
■ Score depends on how many positive criteria
meant
– 2-3 positive = mild substance use disorder
– 4-5 positive = moderate substance use
disorder
– 6-7 positive = severe substance use
disorder
■ It is more of a spectrum of severity, not strict line
■ Types of criteria
– Taken in larger amounts than intended
– Failed attempts to discontinue
– Craving
– Failure of life obligations
– Tolerance
– Withdrawal
Substance use disorder: opioid use disorder
DSM-V Criteria Simplified

20. So, an injured worker who is maintained on oxycodone but:
■ Overused his medication (larger amounts than intended)
■ Presented to the emergency department for a fall related to mixing opioids
with alcohol (dangerous situation)
■ Is only willing to consider opioids as a pain treatment (preoccupied)
■ Is increasing irritability and having marital problems (social consequences)
■ Seems more concerned with getting his prescriptions than returning to
gainful employment (occupational activities given up)
May be diagnosed as having a opioid use disorder, moderate severity (5
symptoms)
DSM-5
Opioid Use Disorder
2002© Paradigm Management
Services, LLC

21. Three “C’s” of Addiction
• Control
– Early social/recreational use
– Eventual loss of control
– Cognitive distortions (“denial”)
• Compulsion
– Craving
– Drug-seeking activities
– Continued use despite adverse
consequences
• Chronicity
– Natural history of multiple relapses
preceding stable recovery
– Possible relapse after years of sobriety
– Continued use despite harm

22. Addiction is a primary, chronic disease of brain reward, motivation, memory
and related circuitry. Dysfunction in these circuits leads to characteristic
biological, psychological, social and spiritual manifestations.
• Reflected in an individual pathologically pursuing reward and/or relief
by substance use and other behaviors
• Often involves cycles of relapse and remission. Without treatment or
engagement in recovery activities, addiction is progressive and can
result in disability or premature death.
American Society of Addiction Medicine
Definition

23. Addiction Reward & well-being
Motivation
Movement
Dopamine

24. Nature Video Cocaine Video
Anterior
Posterior
Amygdala
not lit up
Amygdala
activated
Does the brain change?
How Long Does the Brain Remember?

25. But It Is Vital To Not Overplay The Biology Of A
Biopsychosocial Problem
• Stress
• Early physical or sexual abuse
• Witnessing violence
• Peers who use drugs
• Drug availability
Which Psychosocial Factors Contribute to Addiction co-morbidity?

26. Drugs
Brain
Mechanisms
Behavior
Environment
Historical
Environmental
- Prior experience
- Expectation
- Learning
- Social interactions
- Stress
- Conditioned stimuli
- Genetics
- Circadian rhythms
- Disease states
- Gender
Physiological
Treatment Strategies Can Intervene In Different
Places

27. Treatment: Pills Alone Are Rarely Successful
Pharmacological
Treatments
(Medications)
We Need to Treat the
Whole Person!
In Bio Psycho Social Context
Behavioral Therapies
Social ServicesMedical Services

28. Abstinence Vs. Maintenance
■ Maintenance (substitution)
– Many have long supported replacement
drug (ex: methadone)
– More recently people are advocating for
buprenorphine as a replacement drugs
– Both are opioid agonists
– People still cheat despite getting RX drugs
■ Abstinence advocates say there is too much
emphasis on biologics, not enough on behavior
– “Eighty to ninety percent of people who
use illegal drugs are not addicts," said Carl
Hart, PhD, a drug addiction expert from
Columbia University in New York City.
You need a long-term plan
• Traditional (e.g. 28 day) detox-rehab
• Long-term treatment (often transitions to
sober living or half-way houses)
• Therapeutic communities (a form of long-
term treatment)
• Drug Courts
• 12-Step and other support groups
• Chronic Pain Management Programs
Options for Opioid “Addiction” Treatment

29. Extended Abstinence is Predictive of Sustained
Recovery: Abstinence Takes Time
It takes a year of
abstinence before
less than half
relapse
Dennis et al, Eval Rev, 2007
After 5 years – if you are sober, you
probably will stay that way.

30. • Methadone
• Escalating MED with dose
– Methadone dose
• 20 mg = 80 mg MEDD
• 60 mg = 600 mg MEDD
• Buprenorphine
• This is powerful medication
– Suboxone dose of
• 8 mg/d = 600, MEDD
• 16 mg = 1200 MEDD
– Butrans patch
• 7.5 mcg = 30 mg MED;
• 20 mcg = 80 mg MEDD
Medication Maintenance: These Are
Powerful Opioids Themselves
Methadone:
Highly supervised clinics
Close monitoring
Take-home privileges earned
Risk of overdose
Methadone specific complications
Buprenorphine Purported to be:
Lower OD potential
Less addictive (not)
Suboxone has opioid blocker if injected
More convenient, easy to get from MD

31. • Treatment studies mostly short-term and structured.
• Clinical outcome studied = abstinence during maintenance treatment.
• Little or no information about successful transition from long-term
maintenance to abstinence without medication.
• Types of patients better served with abstinence-based approaches? (Drug
Courts, Professional Assistance Programs?)
Lifelong Treatment?

32. ■ Opioid risk assessment and monitoring
– Opioid risk screening (CAGEAID, ORT)
– Universal guidelines concepts
• Constant reassessment
• End game in mind
• Function, function, function
– Random UDS with consequences
– Above all, now the past medical history
including alcohol and drug abuse and drug
crimes
■ Treatment options
– Recovery from injury/illness should be
guide
– Value and harm of chronic opioids should
be a constant calculation
– We must help treating MD must take
accountability for IW risk
– Treatment strategies
• Wean/detox
• Pain management program
• Drug treatment programs
• Chronic maintenance drugs
Clinical Strategy

33. There Are Major Medical Risks to Long-
term Opioids for Pain or Addiction

34. Diagnosis of Addiction and
Impact of Pain
Dr. Robert Hall
Medical Director
Helios
Robert.Hall@HeliosComp.com

35. Disclosure Statement
• Robert Hall, MD, Employment: Helios

36. THE STORY OF ANNE

37. The Story of Anne
45-year-old delivery driver with 15 years
of service who was moving a package
weighing 50 pounds and felt a pop in
her lower back with immediate pain
radiating into her right leg.

38. The Story of Anne
Initial diagnosis: Radiculitis due to the
displacement of a lumbar intervertebral
disk
Over the course of her claim, which lasted
several years, she underwent
• Lumbar Surgery ‒ which led to post-
laminectomy syndrome
• Treatments ‒ Physical therapy,
injections, spinal cord stimulator trials
• Medications ‒ many for pain and
depression/anxiety

39. Anne’s Medication History
Medication Medication Class Indicated Use
Naproxen NSAID Pain
Tramadol Analgesic Pain
Lyrica Anticonvulsant Neuropathic Pain (Off-label treatment)
Acetaminophen Analgesic Pain
Lidocaine Patch Anesthetic Pain (Off-label treatment)
Diazepam Benzodiazepine Muscle Relaxant
Tizanidine HCl Muscle Relaxant Muscle Relaxant
Nicotine TD Patch Smoking Cessation Smoking Cessation
Milnacipran Serotonin Norepinephrine Reuptake Inhibitor Fibromyalgia
Topical Compound Multiple Medication Classes Pain (Off-label treatment)
OxyContin Opioid, Analgesic Pain
Opana Opioid, Analgesic Pain
Butrans Analgesic, Partial Opioid Agonist Pain
Nucynta Opioid, Analgesic Pain
Meloxicam NSAID Pain
Cymbalta Serotonin Norepinephrine Reuptake Inhibitor Pain
Roxicodone Opioid, Analgesic Pain
Clonazepam Benzodiazepine Anxiety

40. POTENTIAL EFFECTS OF OPIOID USE
ON THE BODY SYSTEMS

41. Respiratory System
• Sleep apnea
• Respiratory depression
• Death

42. Nervous System
• Dependence and Addiction
• Depression
• Social isolation
• Impaired cognition
• Impaired coordination
• Hyperalgesia
• Headaches
• Drowsiness and fatigue
• Seizures

43. Skeletal System
• Falls and fractures
• Osteoporosis

44. Muscular System
• Muscle atrophy
• Worsening debility

45. Cardiovascular System
• Conduction abnormalities
• Myocardial infarction

46. Urinary System
• Urinary retention

47. Digestive System
• Nausea
• Vomiting
• Chronic constipation
• Bowel impaction

48. Integumentary System
• Rash/itching
• Reactions to transdermal

49. Endocrine System
• Osteoporosis
• Hypogonadism
• Androgen deficiency

50. • Women
– Menstrual irregularities
– Birth defects
• Men
– Decreased testosterone
– Decreased libido
• Women and men
– Effects on intimacy
– Sexual dysfunction
Reproductive System

51. • Hypersensitivity reactions
• Immunosuppression
• Pneumonia
Immune and Lymphatic Systems

52. • Reduce and attempt to eliminate
opioids
• Education
‒ Effects of opioids
‒ Potential drug-drug interactions
• Medication agreement
• Increase follow-up frequency
• Prescription medication monitoring
program
• Urine drug testing
• Pill counts
• The 4 As
Checklist for Anne

53. Checklist for Anne
• Cardiac evaluation
• Cautious use of NSAIDs
• Smoking cessation
• Detoxification
• Home safety evaluation
• Medication optimization
• Bowel management
• Monitoring bladder function
• Calcium and Vitamin D
• DME (walker, cane, etc.)
• Psychological intervention
• Continued physical and aerobic activity

54. Thank You

55. • Benyamin MD, R. ,. (2008, March 11). Opioid Complications and Side Effects. Pain Physician 2008: Opioid Special
Issue, pp. S105-S120.
• Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA, United
States, 02421. (2013). Opioid use for non-cancer pain and risk of myocardial infarction among adults. Journal of
Internal Medicine, 273(5).
• CS, B., SA, R., J, R., JM, F., MW, J., T, R.-C., & M, H. (2011). Maternal treatment with opioid analgesics and risk for
birth defects. Am J Obstet Gynecol, 204, 314.
• Daniel, M. H. (2004). Opioid Osteoporosis. Arch Intern. Med., 164, 338.
• Katz, M. M. (2005). The Impact of Opioids on the Endocrine System. Pain Management Rounds (pp. 1-6).
Massachusetts: Massachusetts General Hospital.
• KM, V., MC, S., BH, S., & R, B. (2008). Drug-induced urinary retention: incidence, management and prevention. Drug
Saf, 373-88.
• S, D., RL, W., ML, J., JC, N., N, W., M, V. K., & LA., J. (2011). Use of Opioids or Benzodiazepines and Risk of Pneumonia
in Older Adults: A Population-Based Case–Control Study. Journal of the American Geriatrics Society, 1899–1907.
• Silverman SM, L., Patel VB, H. H., & Manchikanti, L. (2011, March-April 14). A comprehensive review of opioid-
induced hyperalgesia. Pain Physician, pp. 145-161.
• Vallejo, R., de Leon-Casasola, O., & Benyamin, R. (2004). Opioid Therapy and Immunosuppression: A Review.
American Journal of Therapeutics, 354-365.
References

56. Clinical Track:
Diagnosis of Addiction
and Impact of Pain
Presenters:
• Steven Moskowitz, MD, Senior Medical Director,
Paradigm Outcomes
• Robert Hall, MD, Medical Director, Helios