Managing Drug Abuse, Addiction, and Diversion in Chronic Pain

Kenneth L. Kirsh, PhD; Steven D. Passik, PhD

Posted: 9/2/2005

Introduction

What is the goal of chronic pain management? Is it to feel better? Is it to function better? Do doctors and patients agree on these points?

There is a dearth of literature on how patients set goals for pain management and whether they and their pain providers see eye to eye on them. It is well known that, at least in the case of cancer patients, those with pain are often satisfied with low levels of pain relief.^[1,2] We are just beginning to understand what the "denominator" is in this satisfaction equation -- a complex combination of expectations, relationship issues (ie, not wanting to distract the physician from treating the disease), previous experiences with relief of pain, and goals of care.

Little is known about these issues in chronic noncancer pain. Some patients will realize functional gains (such as returning to jobs that they love) with low levels of pain relief. Others will maintain that they cannot function (such as returning to jobs that they loathe) until they get nearly 100% pain relief. There is also the specter and fear of addiction and abuse among patients. Overall, there is little doubt that it will be hard for patients to understand the need for compliance, avoidance of potentially aberrant drug-taking behaviors, psychotherapy, pacing, and smoking cessation as parts of pain treatment if they understand their pain management goals and we are able to work to bring them on board.

The goal of pain management is not simply pain relief measured on a 0-10 scale, just as the goal of diabetes therapy is not simply lowered blood sugar levels. The goal of chronic pain management is to enable people with pain to live full and rewarding lives in the face of chronic illness. As stated above, however, this is complicated by the problems of drug abuse, addiction, and diversion.

Identifying Addiction

How do we identify problem patients? Traditional definitions of addiction that include phenomena related to physical dependence or tolerance cannot be the model terminology for medically ill populations that receive potentially abusable drugs for legitimate medical purposes. A more appropriate definition of addiction is the following: Addiction is a chronic disorder that is characterized by "the compulsive use of a substance resulting in physical, psychological or social harm to the user and continued use despite that harm.^[3]" Any appropriate definition of addiction must include the concepts of loss of control over drug use, compulsive drug use, and continued use despite harm. The concept of "aberrant drug-related behavior" is a useful first step in operationalizing the definitions of abuse and addiction, and recognizes the broad range of behaviors that may be considered problematic by prescribers. If drug-taking behavior in a medical patient can be characterized as aberrant, a "differential diagnosis" for this behavior can be explored. The differential diagnosis of aberrant drug-taking attitudes and behavior includes:

• Addiction;
• Pseudoaddiction (inadequate analgesic);
• Other psychiatric diagnoses: encephalopathy, borderline personality disorder, depression, and anxiety; and
• Criminal intent.

Differentiating Aberrant Drug-taking Behaviors

When assessing the degree of aberrancy of a given behavior, it is necessary to be cognizant that these behaviors exist along a continuum with certain behaviors being less aberrant (such as aggressively requesting medication), whereas other behaviors are more aberrant (such as frequent, unsanctioned dose escalation). The ability to classify these questionable behaviors as outside the social or cultural norm presupposes that there is certainty regarding the parameters of normative behavior. However, in the area of prescription drug utilization there are no empirical data defining these parameters. If a large proportion of patients were discovered to engage in a specific behavior, it may be normative and judgments concerning aberrancy should be influenced accordingly.^[4,5]

Prescreening Patients

To use opioids safely and effectively, candidates for therapy should be appropriately selected; drug administration should be optimized; and ongoing monitoring should provide detailed information in multiple domains. Also, suboptimal physician monitoring and documentation during opioid therapy are a significant problem,^[6] and may have adverse clinical, medicolegal, and regulatory implications.^[7] To this end, it is important to carefully preselect patients for opioid therapy and then follow them with long-term assessments.

In an attempt to improve the selection of candidates for therapy, Butler and colleagues^[8] tested a screening measure for patients suffering from chronic pain. A consensus from 26 pain and addiction experts was obtained on the salient characteristics of chronic pain patients that predict future medication misuse. The 24-item self-administered Screener and Opioid Assessment for Patients with Pain (SOAPP) questionnaire was developed based on this consensus and tested in their validation study. They administered the SOAPP questionnaire to 175 chronic pain patients and were later able to reassess 95 of them after 6 months. From their results, a 14-item short form was derived that had adequate psychometrics and shows much promise to screen patients who may be at risk for substance abuse and addiction.

The 4 A's for Ongoing Monitoring

Based on extensive clinical experience, 4 domains have been proposed as most relevant for ongoing monitoring of chronic pain patients on opioids: pain relief, side effects, physical and psychosocial functioning, and the occurrence of any potentially aberrant (or nonadherent) drug-related behaviors.^[9,10] These domains have been summarized as the "4 A's" (analgesia, activities of daily living, adverse side effects, and aberrant drug-taking behaviors).^[9] The monitoring of these outcomes over time should affect therapeutic decisions and provide a framework for documentation of the clinical use of these controlled drugs.

To test this notion, Passik and colleagues^[10] conducted a study to examine the relationship between aberrant drug-taking behaviors and pain outcomes during long-term treatment with opioids for nonmalignant pain. In particular, the focus of the study was on providing the nature, frequency, and predictive value of drug-taking behaviors in pain management. This effort could ultimately assist physicians in the assessment and management of these behaviors, whether they resulted from the undertreatment of pain or a substance use disorder.

The main objective of the study was to develop a user-friendly checklist that physicians could employ to examine the 4 A's. In addition, it was hoped that this checklist could also be used to monitor pain and treatment outcomes for patients receiving long-term opioid therapy for chronic pain. The checklist was developed by a group of experts in pain and addiction medicine and distributed to participating physicians throughout the United States who treat pain patients. These physicians evaluated patients who had been receiving opioid therapy for at least a period of 3 months with a structured interview approach and clinical observations.

The results of the study were enlightening. Cross-sectional results suggested that the majority of patients with chronic pain achieve relatively positive outcomes in the eyes of their prescribing physicians in all 4 relevant domains with opioid therapy. Analgesia was modest but meaningful, functionality generally stabilized or improved, and side effects were tolerable. Potentially aberrant behaviors were common (44.6% of the sample engaged in at least 1 aberrant behavior), but only viewed as an indicator of a problem (ie, addiction or diversion) in approximately 10% of cases. Thus, there is a clear need to document and assess the intricacies of aberrant drug-taking behavior in chronic pain patients.

Clinical Management

Out-of-control, aberrant drug-taking behavior among chronic pain patients represents a serious and complex clinical problem. The principles outlined herein will help clinicians establish structure, control, and monitoring so that they can prescribe freely and without prejudice.

First, a multidisciplinary team approach is recommended for the management of substance abuse in chronic pain patients. Mental health professionals with specialization in addiction can be instrumental in helping palliative care team members develop strategies for management and treatment compliance. Second, the first member of the medical team (frequently a nurse) to suspect problematic drug taking or a history of drug abuse should alert the patient's care team, thus beginning the assessment and management process,^[11] which includes use of empathic and truthful communication.

The following list outlines sample questions and suggestions for approaching patients about potentially aberrant drug-taking behaviors:

1. Take a nonjudgmental stance: You are on a fact-finding mission and not beginning an inquisition of your patient. If you can do this, patients will likely be much more forthcoming because they believe that they are not being judged.
   
   
2. Start with sweeping questions: Jumping right in to tough questions about possible abuse of medications is difficult and will undoubtedly put the patient in a defensive posture from the very beginning. Sweeping questions allow you to find out general attitudes toward medications and what they mean to your patient. Examples:
   
   
   • What do your medications mean to you?
   • How helpful have they been for you?
   • Have you ever had any bad outcomes with your medications (either from side effects, in your social life, or legally)?
3. Avoid "yes/no" style questions: Again, the goal is to help the patient to open up and share his/her perspective. Yes/no questions create the sense of a cross-examination and do not allow an opportunity for exposition. These can be used later in the conversation when necessary.
   
   
4. Remember: The patient is the expert in these matters: You should take a curious and interested stance in what your patient has to say. You may find that your patients reveal a great deal about how they use their medications and what they mean to them in their daily lives (ie, if they are used to cope with stress instead of as a routine medicine solely for pain).
   
   
5. Hone in with detailed questions about warning signs: When appropriate avenues open, question the patient looking for signs of self-medication and chemical coping. Examples:
   
   
   • Have you ever taken your pain medications for other reasons?
   • Have you ever taken them to help you sleep? When under stress? After a fight with a partner or loved one?
6. Examine the patient for signs of flexibility: Building on the last step, you need to determine how central the medications are to the patient's life. It is important to determine how open they are to alternate forms of pain therapy (ie, relaxation training, interventional procedures, adjuvants, etc). A patient who lives life "by the bottle" and cannot see other possibilities is likely having issues with chemical coping.
   
   
7. Use existing questionnaires: Use measures, such as the SOAPP questionnaire and Cut down, Annoyed, Guilty, Eye-opener (CAGE), to augment your discussion. Many measures can be found at sites, such as PainEDU.org or National Pain Education Council.

This approach entails starting the assessment interview with broad questions about the role of drugs (eg, nicotine and caffeine) in the patient's life and gradually becoming more specific to include illicit drugs.

Third, the development of clear treatment goals is essential for the management of drug abuse, although the distress of coping with a chronic pain concern can make complete abstinence an unrealistic goal.^[4] Rather, a harm reduction approach should be employed. A written agreement between the team and patient helps to provide structure to the treatment plan, establishes clear expectations, and outlines the consequences of aberrant drug taking. The inclusion of spot urine toxicology screens and pill counts in the agreement can help maximize compliance.

Fourth, the team should consider using longer acting drugs (eg, the fentanyl patch and sustained-release opioids). The longer duration and slow onset of these therapies may help reduce aberrant drug-taking behaviors when compared with the rapid onset and increased dose frequency of short-acting drugs. Fifth, as described previously, the team should plan to frequently reassess and document the adequacy of pain and symptom control. Finally, the team should involve family members and friends to help bolster social support and functioning. Becoming familiar with the family may help the team identify family members who are themselves drug abusers and who may potentially divert the patient's medications and contribute to the patient's noncompliance. Although this level of teamwork creates challenges for physicians and medical staff, ultimately, it can be successful and rewarding for these difficult patients.

Conclusion

Managing addiction in chronic pain patients is labor-intensive and time-consuming. Clinicians must recognize that virtually any centrally acting drug, and any route of administration, can potentially be abused. The problem does not lie in the drugs themselves. Effective management of patients with pain who engage in aberrant drug-taking behavior necessitates a comprehensive approach that provides a practical means to manage risk, treat pain effectively, and ensure patient safety.