ADDICTION Michael Baron, MD, MPH, FASAM Medical Director Tennessee - PDF document

4/10/2018 ADDICTION Michael Baron, MD, MPH, FASAM Medical Director Tennessee Medical Foundation - Physician’s Health Program DISCLOSURE I have no financial relationships to disclose. I will not discuss off label or investigational medication use in my presentation. Board Certified - Anesthesiology, Psychiatry and Addiction Medicine 2010 – 1/2017 Board of Medical Examiners 2014 – 1/2017 Chair - CSMD Committee 2/2017 – present Medical Director – TMF- Physician’s Health Program Steering Committee: Chronic Pain Guidelines, DOH OBJECTIVES Attendees will • Learn the definitions of Addiction. • Understand the etiologies of Addiction. • Grasp the concepts and potencies of non ‐ opioid analgesics. • Recognize Misprescribing and Drug Seeking Behavior. 1

4/10/2018 USA’s Appetite for Opioids 2017 - % of World’s… 99% 100% 90% 61% 80% 53% 49% 70% 60% 37% 50% 40% 5% 30% 20% 10% 0% International Narcotic Control Board WHAT IS ADDICTION? ORIGINAL RESEARCH “ Significant Pain Reduction in Chronic Pain Patients after Detoxification from High Dose Opiates ” Journal of Opioid Management 2:5 September/ October 2006 Michael Baron, MD 2

4/10/2018 Figure 1. Individual Pain reports 10 9 8 Pain Self Report 7 6 5 4 3 2 1 0 Pre Post Detox State Journal of Opioid Management , S ept ember/ Oct ober, 2006. Figure 2. Change in Patient pain after detox * 9 8 rt 7 o p 6 e lf R 5 e 4 S in 3 a P 2 1 0 Pre post Journal of Opioid Management , S ept ember/ Oct ober, 2006. Figure 3. * * 9 8 rts 7 o p 6 e lf R 5 4 e S 3 in a 2 P 1 0 Pre Post Pre bup Post bup Ibuprofen alone with buprenorphine Journal of Opioid Management , S ept ember/ Oct ober, 2006. 3

4/10/2018 Number Needed for 50% Pain Relief 4.6 2.7 2.7 1.6 CATEGORY 1 Oxy 15mg Oxy 10 + APAP 650 Naproxen 500 Ibu 200 + APAP 500mg Derry, C., Derry, S., & Moore, R. (2013). Efficacy of Pain Medication 70 60 50 40 30 20 10 0 Ibuprofen 200 Acetaminophen Ibuprofen 400 Oxycodone 15 Oxy 10 + acet Ibu 200 + acet mg 500 mg mg mg 1000 500 Bandolier. (2007). The Oxford League Table of Analgesic Efficacy Efficacy of Pain Medication JAMA. CHANG, 2017;318(17):1661-1667. 4

4/10/2018 Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. 240 randomized patients – 12 months Pain was significantly better in the nonopioid group. Adverse medication-related symptoms were significantly more common in the opioid group. Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain. JAMA. 2018:319(9):872-882 What is Addiction Addiction is a brain disease 5

4/10/2018 ADDICTION A primary, chronic disease of brain reward, motivation, memory and related circuitry WHAT IS ADDICTION? Addiction is a Disease! Addiction is the single most preventable cause of Disability and Death in the US. 6

4/10/2018 Addiction = Substance Use Disorder NIDA ASAM 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. 4 C s ‐ Substance Use Disorder = Addiction DSM ‐ IV DSM ‐ 5 Abuse and Substance Use Disorder Recurrent use of alcohol or other Dependence drugs that causes clinically and functionally significant impairment, such as health problems, disability, Abuse = Willful misuse and failure to meet major responsibilities at work, school, or home. Dependence = Addiction Depending on the level of severity, this disorder is classified as mild, moderate, or severe. ADDICTION ADDICTION Environment Biology/Genes DRUG Brain Mechanisms ADDICTION Nora D. Volkow, M.D. National Institute on Drug Abuse 7

4/10/2018 ETIOLOGY - GENETICS Children of Alcoholics: • Four times more likely to develop alcohol problems then the general population. • Studies of Adopted ‐ away children of persons with alcohol dependence • Higher risk for many other behavioral and emotional problems. ETIOLOGY - GENETICS • Genetic and environmental influences may be correlated to substance initiation and use. • Progression to Addiction (Substance Use Disorder) is more related to genetic factors. ETIOLOGY - TRAITS • High novelty and sensation seeking • Impulsivity • Low harm avoidance • High reward dependence • Temperament – anxiety, aggression or irritability • Intelligence – cognitive abilities 8

4/10/2018 ETIOLOGY - ACE Adverse Childhood Experiences The quantity of traumatic events experienced in childhood correlates with the development of addiction. The greater the number the more likely. HIGH NUMBER OF ACE’s Increasing Adverse Childhood Experiences strongly correlates with the risk for: • Substance use disorder/addiction • Anxiety disorders • Depression • Diabetes • Heart disease • Obesity • Suicide attempts • Increased risk for intimate partner violence 9

4/10/2018 Etiology - Exposure Length of postoperative opioid exposure associated with large increase in misuse. • Duration of opioid use was strongest predictor of misuse. • 568,612 patients received postoperative opioids • Each refill and additional week of opioid use associated with an adjusted increase in rate of misuse of 44% BMJ 2018;360:j5790 WHICH BRAIN IS ON DRUGS? Which is the Cocaine Brain? NIDA A BRAIN ON DRUGS NORMAL COCAINE NIDA 10

4/10/2018 Brain Healing Takes Time OPIOID DEATHS BY FENTANYL ANALOGS 3 ‐ methylfentanyl, acrylfentanyl, butyrylfentanyl, para ‐ fluorofentanyl, para ‐ fluorobutyrylfentanyl, and para ‐ fluoroisobutyrylfentanyl MMWR Vol 66, October 27, 2017 11

4/10/2018 MISPRESCRIBING Prescribing in quantities or frequency inappropriate for the complaint or illness. Examples: • Large quantities/frequent intervals/crescendo pattern • Progression to multiple drugs • For trivial complaints • Family members • Known alcoholic or drug addict Categories of Misprescribing Dated : Fails to keep current Disabled : Impaired judgment Duped : Doesn’t detect Disempowered : Skewed perception deception of power Dysfunctional : Can’t say no Disorganized : No systems in place Dismayed : Prescription is to Disregard for Scope : Practicing out make up for lack of time of specialty Dishonest : Prescribing for Dodging : Using refills to avoid financial gain patient visits. Suspect Drug ‐ Seeking Behavior in the Patient who . . . 12

4/10/2018 Possible Drug-Seeking Behavior • A dramatic, compelling but vague complaint • Pressures for an increases in dose • Drug screens are negative for Rx’ed medicine • Symptoms contradict clinical observation • Patient asks for a specific drug • Patient has no interest in the diagnosis • Rejects all treatment that is not opioids Possible Drug-Seeking Behavior • Reports an NSAID Allergy • Has abundant pharmacologic knowledge • Patient makes veiled threats • Patient is very flattering • Primary doctor is out of town • Travels long distances to get to you • Primary doctor just retired THANK YOU 13