Tag Archives: addiction

NY – Beth Israel Medical Center

Russell Portenoy, MD
Pain Medicine Specialist
Chairman, Department of Pain Medicine and Palliative Care, Beth Israel

Depression and Chronic Pain Is Extremely Common

In some patients, depression follows the pain, and if you can effectively treat the pain, the depression would get better. And in some patients the depression seems to drive the pain, says Dr. Portenoy. He explains that when these two conditions coexist, patients need carefully coordinated treatment.

Dr. Portenoy is among New York Magazine’s “Best Doctors” for 2008, as listed in the June 16, 2008 edition of the magazine. The New York Magazine list is excerpted from Castle Connolly’s annual guidebook, “Top Doctors: New York Metro Area.”

Address

First Avenue at 16th Street
New York NY 10003
Telephone:(212) 844-1505

Questions About Using Opioids for Chronic Pain

Q: Would you say that opioids are a last resort?

A: No. Opioids should be considered for every patient with chronic, moderate to severe pain, but in every case, you would only prescribe the opioid after carefully considering the responses to several questions.

Q: What are those questions?

A: First, what is typical treatment with respect to this pain? Second, is there some other therapy that has as good or better efficacy and safety? Third, is this person at relatively high risk of opioid side effects for whatever reason? And fourth, is this patient likely to be a responsible drug taker, or is there a history of substance use problems?

So in some cases, for example a patient with severe pain who has not done well with several steroid or other drug injections and physical therapy, and who presents to the doctor with back pain so severe that he can’t walk—that patient might be considered a candidate right then for a trial.

Q: What is an example of that review process with a typical patient who has arthritis of the knees and hips.

A: Everybody would agree that the first-line therapies typically would include acetaminophen, physical therapy, or a TENS unit, or maybe—if there’s a single joint that has some swelling—an injection.

The next-line therapy would be an NSAID. But if that person has a history of an ulcer or a history of bad heart disease, the NSAID risk gets to be relatively high. So that patient might be considered for a trial of an opioid at that point.

Q: If I’m that patient and I’m put on a trial, how will I use the drugs?

A: Almost everyone with chronic pain appears to benefit more from regular, fixed, scheduled use as opposed to PRN [when needed] use. There is a general perception, two decades old, that patients do better if they have pain medicine in their blood 24/7. It’s done in a sustained way, so that the blood levels don’t fluctuate much.

Q: In the whole range of treatments for chronic pain, where do opioids fit in?

A: The chronic use of opioid therapy to treat noncancer pain syndromes, such as headache and low-back pain, and arthritis, continues to be controversial. Most pain specialists nowadays would say that opioids might be considered in any patient who has chronic, moderate to severe pain, but generally should only be implemented if there are no other treatment options that have a favorable and safe effect. The shortest way of saying this is that most pain specialists would not consider opioids first-line treatment for chronic noncancer pain except in highly selected patients.

But we have accumulated clinical experience that suggests the following: There is a sub-population of patients with chronic pain, who can be given access to long-term opioid therapy, and they will experience sustained and meaningful control of pain in the absence of intolerable side effects and without the development of tolerance or the need for dose escalation. And they will not develop any aberrant drug-related behaviors consistent with abuse, diversion, or addiction.

Q: What about the use of opioids for breakthrough pain?

A: It looks like about 60% of patients with chronic pain have flairs that can be called breakthrough pain, and in the cancer population, the use of a short-acting opioid co-administered with a long-acting drug is the standard of care.

With noncancer pain, it’s a moving target. People are trying to figure out if it should be the standard of care or not. I think it should not. I think it should be a case-by-case decision.

Q: What are some of the risk factors when opioids are being considered? Do they all relate to addiction?

A: No. Suppose you have a patient with very bad lung disease who might be at risk for the respiratory effects. (Opioids can suppress breathing.) Or you have a patient who has severe gastrointestinal problems—where the constipation induced by the opioid might become very problematic. Or you have an elderly person with arthritis who has a mild dementia: In that case, the bias would be to try an NSAID because the opioid has a higher likelihood of causing cognitive impairment.

Q: Is the ultimate concern, though, addiction?

A: No, it’s broader than that. It’s responsible drug use, a term I use purposely because for clinicians, addiction is an uncommon problem—a very, very serious problem, but it’s an uncommon problem.

Q: So there are irresponsible uses that do not involve addiction?

A: What’s much more common for clinicians than addiction is what has been called aberrant drug-related behavior. Behaviors like doctor shopping or frequent visits to the ED [emergency department], or increasing the dose during pain flare-ups without permission. Or taking an opioid to help you get to sleep at night, or taking it when you’re feeling anxious. Or in some cases using an illicit drug, like smoking marijuana on the weekend, without telling you.

A clinician who is trying to prescribe these drugs safely ought to be monitoring all of those behaviors and trying to work with the patient so that the behavior regarding these drugs is responsible—meaning take the drugs as prescribed.

Q: It’s not as simple as saying that opioids deliver a “high,” is it? What “benefits” do abusers get from the drugs?

A: There are studies that have been done that show that in the usual person—with no history, and no family history of addiction—the typical mood response produced by opioids is dysphoria, not euphoria. But in some cases, they might be driven by co-morbid psychiatric disease—they may have anxiety disorder and realize that these drugs produce some reduction in anxiety. Or they have a depressive disorder—these drugs were used in the 1950s as antidepressants before we had any real antidepressants.

Or the patient may have a co-morbid psychiatric disorder associated with impulsive drug use—they would take any centrally-acting drug, any drug that alters their consciousness, impulsively.

There are also people who have an addiction biology, and it’s profound. I talked to a physician who became addicted to opioids, and he told me that the first time he took an opioid, it was like he had discovered something very magical about life. He said, “I knew this was my substance, this was something that I needed.” With a single dose.

Q: What is the risk of actual addiction?

A: Most scientists who work in this area think that about 10% of the population in developed countries have the biological predisposition, the genetic predisposition, to potentially become addicted. Truly addicted. Which is a huge number, 10%.

Q: If a chronic pain patient passes your various tests and is a good candidate for an opioid, what happens then?

A: At the present time the professional community is telling doctors that they have two obligations whenever they prescribe a controlled prescription drug.
Number 1: To know the pharmacology so that the patient’s outcomes—meaning the pain relief they get, and the side effects they experience—those outcomes are optimal.
Number 2: They need to do risk assessment and management to ensure that the patient takes the drugs in a responsible way, and there is minimal risk of abuse, diversion, and addiction.

Q: What does that mean for the patient’s experience?

A: Every patient should undergo a comprehensive assessment and risk stratification. The doctor takes a history and then makes a decision: Is this person at high risk or at low risk of developing problematic drug-related behaviors?

The most accepted factors that put a person into a high-risk category is a personal history of substance abuse now or in the past, a family history of substance abuse now or in the past, or a history of major psychiatric disorder. And there are many, many other factors: Current smoking, history of physical or sexual abuse.

Q: Give an example of a high-risk patient.

A: A young man who injures his back at work and has pain for six months, sees a doctor, and the history reveals that the patient binge drinks on the weekend, uses marijuana three nights a week, and has a brother who has been through detox. If an opioid is being considered for that patient, then the structure of the therapy should be very defined and very rigid, it might include any or all of the following.
An opioid agreement that is used to educate the patient about responsibilities and consequences of bad behavior
A small number of pills prescribed
The requirement that the patient returns with the pill bottle so that a pill count can be done
The requirement that the patient gets urine drug screens periodically
A requirement that the patient gets a consultation with an addiction-medicine specialist
The requirement that the patient uses only one pharmacy, so that you can track what has been dispensed

Q: What about a low-risk example?

A: A patient 70 years old develops bad knee and hip pain from arthritis, and the history reveals no personal history of substance abuse, including no use of alcohol, no family history, and no known psychiatric disease—that patient has very, very low risk of developing problematic behaviors. For that patient, a structure might be to come back in a month and provide a phone call in the middle.

Q: Sounds complicated. Should chronic pain patients seek out a specialist?

A: Only about 5% of people with chronic pain ever see a specialist. This is a type of therapy that, for 20 years, people like myself had been promoting as needing to be done by primary care doctors.

Q: What advice do you give patients who are looking for possible opioid treatment?

A: I would like patients to think, “Opioids may or may not be appropriate. But I need to see a physician who’s comfortable with prescribing opioids and also knows how to do it in a way that’s safe and effective for me. When I go into that physician, I know that I’m going to have to be honest and let that person do a good assessment. And I’m going to have to provide my records to that person. If that means that I have to have urine drug screens, so be it. If I have to sign an opioid agreement, if it’s reasonable and educational, I’ll sign it. If I have to go and get treated by a psychologist at the same time and I can afford it, I’ll do it.”

There has to be a recognition that this is a controversial therapy that takes a lot of effort on the part of the clinician, and the patient has to not only adhere to the therapy, but also has to communicate and be willing to be monitored.

Q: Given all that, do you believe that opioids are underused in the treatment of chronic pain?

A: Absolutely. I’ve seen this controversy in the U.S. going back and forth for about 25 years. This is a pendulum that swings back and forth depending on how frightened people are of addiction and abuse, and depending on how much the advocacy community gets the word out about undertreatment.

There’s a whole political and social context here that is not based on any known science. And in the 2000s we seem to have the pendulum shifting toward more denial that the therapy can be useful, more reluctance to prescribe, more concern about regulation.

Q: That’s an unfortunate swing for those people who would benefit from these drugs.

A: No question. But I want to acknowledge what my colleagues would say, many of them—that 25 years of research has yet to show the evidence that long-term opioid use is effective for chronic pain.

There have been a large number of good clinical trials, but they’ve all been either short-term or in very selected populations, or didn’t measure all the issues.

But the bottom line is that we have about 9,000 years of clinical experience showing that they can work. And you also have a consensus in the professional community of pain specialists—not just in the U.S., but also in Canada and England and other countries in Europe. You have a consensus that has evolved based on the data that do exist and the observations that exist.

The real issue is, let’s stop arguing about should patients ever get opioids and start arguing about who should get them and how you prescribe in a way to optimize the outcomes.

Q: Of course, even when drugs work, patients don’t always take them.

A: In the past 20 years, there’s been all of these new modified-release formulations, so now there are once-a-day drugs, twice-a-day drugs, patches that last three days, all for the treatment of chronic pain.

So you would think that compliance would be easier because it’s more convenient, and in some respects that’s true. But we just did a little study here, which we haven’t fully analyzed yet or published, and what we discovered in our group was this: In almost 100 patients, about 50% were non-adherent, and the vast majority of that group was undertreating.

It raises questions: Why are they undertreating? Are they afraid? Or do they have side effects? Is it money?

The bottom line is, most patients are not out there acting like [drug addicts], most patients are pushing you to give less, or not taking everything you prescribe. They’re not interested in abuse, they’re interested in getting off this stuff!

Studies Find Opioids Ineffective

“Opioids are often ineffective for some types of pain at any dose. Pain intensity scores were unchanged postoperatively in patients receiving titrated opioid analgesia in accordance with Agency for Health Care Policy and Research guidelines when compared with a matched control group before guideline implementation. None of our patients with chronic nonmalignant pain receiving opioids according to protocol had complete relief of pain.

Although opioids themselves may not cause addiction, the high prevalence of addiction in the general population and the even higher comorbidity of addictive disorders with psychiatric illness mean that a substantial minority of patients with chronic pain treated with opioids display problem behavior that makes opioid management arduous, if not impossible. The proportion of problem cases appears to be 10% to 15% of patients with chronic pain selected for opioid maintenance analgesia.

It is true that many patients do tolerate remarkably high daily doses of opioids and are able to function as well as before using the drugs. However, it is equally true that at least as many patients seem to be unable to tolerate any opioid at even the lowest dose. We must be respectful of the serious array of side effects of these agents. Tachyphylaxis and gradual adjustment of opioids may avoid respiratory arrest, but constipation, nausea, sedation, and confusion often become limiting adverse effects. ”

Links to articles and studies:

Opioids for chronic nonmalignant pain
Choosing suitable candidates for long-term therapy.

Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction
Opioids are commonly prescribed for chronic back pain and may be efficacious for short-term pain relief. Long-term efficacy (≥16 weeks) is unclear. Substance use disorders are common in patients taking opioids for back pain, and aberrant medication-taking behaviors occur in up to 24% of cases.

No More secrets

Banker hopes to help others get off drugs

Kristi Metzger had it all: a job she loved as a bank vice president, loving family and friends, community activities, a house to shelter her at the end of a productive day.

And a secret.

Metzger was addicted to the prescription pain reliever Vicodin.

After 10 surgeries in 15 years in a fruitless effort to relieve chronic pain caused by endometriosis, Metzger had almost quadrupled the maximum number of Vicodin she was allowed. And to keep her secret, she had turned into a liar.

Now, after two stays in chemical dependency treatment centers, Metzger, 31, has decided to keep that secret no longer. She has begun talking to civic groups about her addiction to painkillers and the resources available.

“My point is, addiction knows no boundaries,” Metzger said. “It doesn’t matter what you do or where you come from or how smart you are. It’s a very real problem, people are struggling with it, and I want to help.”

An estimated 4.7 million Americans used prescription drugs nonmedically for the first time in 2002, according to the 2003 National Survey on Drug Use and Health. The number who used pain relievers was estimated at 2.5 million.

Studies also suggest that women are more likely than men to be prescribed an abusable prescription drug, particularly narcotics and anti-anxiety drugs.

“More women come to me for prescription drug use than men do, but I think the drug of choice has changed,” said Janell Christenson, a registered nurse and a certified chemical dependency counselor with Avera McKennan Hospital.

“I can remember when it was Demerol that was most abused, then Percodan and Percocet. I don’t know the top one now, probably oxycodone or Vicodin.”

First there’s pain

Most addictions start out innocently, Christenson said. Generally people have an accident, injury, surgery or medical problem that causes pain and requires prescribed medication.

Three things are required for someone to become an addict, said Dr. John Hansen, supervisor of Sioux Valley Hospital’s Pain Clinic. First is a psychological or biologic predisposition; second is a substance that can produce addiction or chemical dependency, such as the painkillers known as opiates, and third is an unrestricted access to the drug.

That is why his clinic provides a highly structured environment in which the patient has no discretion in deciding to increase the dosage of their drug, Hansen said. In addition, the clinic offers a multidisciplinary approach providing physical therapy, psychology and associated physician services.

Professionals can easily recognize the difference between a person with chronic pain who is properly using opiates and one who is abusing them, Hansen said.

“People who have chronic pain who get opiates look better, their mood improves, they function more, and they look better when their pain is controlled. People who are chemically dependent, when they have unrestricted access to the meds they’re dependent on, they look worse, their behavior deteriorates, their mood can deteriorate.”

That happened to Metzger, who cut herself off from family and friends as her dependency worsened.

“My life was just constantly filled with, ‘When am I going to take my next pill?’ It got so incredibly bad (but) I thought I was hiding it well,” she said.

At a high cost

No local physician would have prescribed the number of pills she needed, but Metzger recalled something she had heard the first time she entered a substance-abuse center: Pills could be purchased online, after a quick chat with a physician.

She was amazed at how easy it was to get her Vicodin that way.

How costly was Metzger’s addiction? She has never totaled it up, but it easily cost her thousands of dollars to buy the pills online, she said.

For example, the Web site my247md.com offers 120 tablets of Vicodin for $145. For Metzger, that was a four-day supply. That’s $1,015 for a four-week supply.

When she was taking eight painkillers a day, she ended up at Keystone Treatment Center. On 30 pills a day, she frantically tried to hide her problem.

But her family, particularly her uncle Ken Ness, president of the bank that employed her, knew something was wrong. He contacted Metzger’s parents and three brothers, and they staged an intervention after Thanksgiving 2005.

“They had planned for me to go to Hazelden in Center City, Minn., and I just started crying as soon as I saw them all sitting at this table, and I knew that everybody knew and I had lied to them,” she said.

After a sleepless night, Metzger’s parents drove their daughter to Hazelden.

Metzger knew what was awaiting her, since she had been through withdrawal once before. This time, with her body’s greater reliance on drugs, it was much worse.

“It was pure torture, the physical agony I went through,” Metzger said. “I was so sick, with flu-like symptoms. I was dry heaving; eventually I threw up the pills I’d taken that hadn’t gone into my system. The anxiety was worse than anything, and they couldn’t give anything until the pills were out of my system.”

Metzger lay in a bed at the clinic, her body convulsed with tremors. Staff changed her sweat-soaked sheets several times. Doctors and nurses closely monitored her that first week.

“I looked like ‘dead girl walking,’ ” Metzger says. “I was pasty white. I didn’t look like I was alive.”

Slowly, helped by a drug that reduced withdrawal symptoms, Metzger began to feel better.

Just before Christmas, she returned home. But the battle wasn’t over.

All in the attitude

Metzger’s pain had started years earlier. As a 15-year-old student at Hills-Beaver Creek High School, she was in a car accident. About the same time, she learned she had endometriosis, a painful condition in which the uterus’ lining invades the abdominal cavity.

The condition worsened during college. Eventually, an ovary and part of her fallopian tubes were removed. As the pain persisted, and it became less likely Metzger would ever be able to become pregnant, depression surfaced.

But she persisted in maintaining a positive front. She became a trust officer and vice president at First National Dakota Bank. She played piano, tennis and golf. She volunteered with Sioux Empire United Way, the Sioux Falls Community Foundation’s investment board and Kiwanis Club.

And she kept swallowing painkillers.

“I took these pills to get up, I took them during the day at work, and I took them to go to sleep, so now my life revolved around these drugs,” Metzger says.

She realized she was addicted in July 2004, after undergoing surgery. She entered the chemical dependency program at Keystone Treatment Center in Canton in October 2004.

But her attitude was wrong.

“I went there very naïve, not knowing anything about addiction, thinking that this is really a fluke that happened to me, I’m not really the addict type, I shouldn’t be here, and when I was with other alcoholics and drug addicts, there was really arrogance on my part,” she said.

That arrogance is gone. Metzger attends two Alcoholics Anonymous meetings a week, and she volunteers at a halfway house.

Jane Pugh of Yankton serves as Metzger’s AA sponsor.

“She has her ups and downs,” said Pugh, who agreed to let her name be used. “It’s a new lifestyle she’s learning. She’s also discovering who Kristi is.”

To help in that discovery, Metzger has left the bank. She lives with her parents, who now reside in Brandon. She can return to a career when she knows she is healthy, Metzger says. It may be in law or chemical dependency counseling.

Whatever it is, it won’t involve secrets.

“I just don’t want people to worry and be scared that this could be the end for them,” Metzger said. “There are treatment centers, there’s doctors willing to help you, there’s pastors at your church. There’s resources.”

BY JILL CALLISON
PUBLISHED: October 6, 2006

Principles of opioid maintenance analgesia for chronic pain

  1. Successful management of chronic pain usually does not require the use of opioids; however, some patients with chronic pain can benefit from long-term opioid maintenance analgesia (OMA). These patients function better, maintain improved pain control with acceptable side effects, and continue to use their medications in a responsible, reliable manner.
  2. In some patients, pain cannot be managed with long-term use of opioids. Pain control is marginal, function does not improve, side effects may prohibit ongoing therapy, or the patient’s abilityto keep medication use under control is poor or erratic.
  3. Opioids are rarely adequate as the sole treatment for complex chronic pain, which usually requires a multimodal and often a multidisciplinary approach.
  4. OMA for chronic pain is neither a patient’s right nor a privilege. It is one treatment approach that may be chosen by mutual agreement between patient and physician.
  5. Candidates for OMA should:
    • Have an established diagnosis that is concordant with moderate to severe pain
    • Be reliable patients who are known to the physician and are expected to be compliant with the treatment protocol
    • Have exhausted reasonable alternative treatments and be open to new ments in the future
    • Not be using illegal drugs
    • Not be pregnant or likely to become pregnant during the course of treatment
  6. Patients with a history of addiction or poor impulse control are at increased risk for failing to comply with an OMA regimen.
  7. For daily pain, long-acting opioids taken on a fixed schedule are generally preferred for OMA. Limited quantities of nonopioids or shorter-acting opioids are acceptable for breakthrough pain in some cases.
  8. For episodic pain, limited quantities of opioid analgesics may be prescribed as needed.
  9. Meperidine hydrochloride is a poor choice for OMA because of metabolite toxicity with repeated dosing.
  10. For patients initiating OMA, a signed agreement outlining expectations and responsibilities is recommended (see box below). Failure to comply with the agreement should result in discontinuation of OMA or actions to ensure compliance in the future.
  11. Continuation of OMA depends on the following five factors:
    • The medication is safe with acceptable side effects.
    • The medication is effective; that is, pain is reduced and function and quality of life are improved.
    • The patient is a reliable and responsible participant in the treatment program.
    • The condition causing pain persists.
    • No specific or better alternative treatments are available.
  12. The physician’s responsibilities for OMA include:
    • Initial assessment of the pain problem, including relevant medical, psychological, and social factors
    • Scheduling regular office visits for reassessing pain and related conditions; monitoring safety, efficacy, and compliance; and managing side effects
    • Being prepared to continue OMA when it is working
    • Being prepared to taper and discontinue OMAwhen it is not working
    • Thorough documentation of the responsibilities listed
  13. Techniques for monitoring compliance include:
    • Conducting patient interviews
    • Checking patient’s compliance with appoint-ments
    • Obtaining collateral information from family members, other physicians, nurses, and pharmacists
    • Obtaining pharmacy profiles
    • Scheduling drug screens
  14. When discontinuing OMA, the weaning schedule depends on daily dosage and duration of treatment. No weaning is needed when opioids havebeen used occasionally; daily opioid use may re-quire weaning that ranges from 10 days to a few months.
  15. Referral to a pain specialist for consideration of OMA is warranted when:
    • The cause of pain is unclear
    • Behavioral, psychological, and social factors complicate the pain problem
    • The physician is unsure what additional treatment may be effective, or how to administer such treatment

Adapted, with permission, from Fairview Pain Management Center, Minneapolis.

MD – Pain clinics in Maryland

AGS Foundation For Health in Aging
http://www.healthinaging.org/

Non-profit organization established by
the American Geriatrics Society to build a bridge between the
research and practice of Geriatrics and the Public, and to
advocate on behalf of older adults and their special health
care needs.

American Alliance of Cancer Pain Initiatives
http://www.aacpi.wisc.edu

National organization dedicated to promoting cancer
pain relief nationwide by supporting the efforts of state and
regional pain initiatives.

American Cancer Society
http://www.cancer.org/docroot/home/index.asp

Nationwide, community-based voluntary health
organization that is committed to fighting cancer through
research, education, patient service, advocacy, and
rehabilitation. It provides health information and support for
patients, families, friends and professionals.

American Chronic Pain Association
http://www.theacpa.org

Organization offers support and information for people
with chronic pain, with over 400 chapters and support groups
throughout the U.S., Canada, Mexico, Australia and Europe.

American Pain Foundation
http://www.painfoundation.org

Independent nonprofit organization serving people
with pain through information, advocacy and support. Its
mission is to improve the quality of life for people with pain
by raising public awareness, providing practical information,
promoting research, and advocating to remove barriers and
increase access to effective pain management.

American Society For Pain Management Nursing
http://www.aspmn.org/

An organization of professional nurses dedicated to
promoting and providing optimal care of individuals with pain
through education, standards, advocacy and research.

Beth Israel Medical Center Dept. of Pain Medicine & Palliative Care
http://www.stoppain.org

Resource and information center with support
and information for patients, caregivers and professionals.

JCAHO Standards For Pain Management Revisions 2001
http://www.jcrinc.com/subscribers/perspectives.asp?durki=3243&site=10&return=2897

Develops professionally based standards and evaluates
and accredits general and rehabilitation hospitals, long term
care and assisted living facilities, clinics, home care
agencies and other health care organizations and programs in
the United States.

Johns Hopkins Chronic Pain Treatment Program
http://www.hopkinsmedicine.org/jhhpsychiatry/pain.htm

Comprehensive, multidisciplinary pain center for
the reduction of intractable chronic pain and its accompanying
emotional and medical complications.

Maryland Cancer Plan
http://www.marylandcancerplan.org

A new comprehensive cancer control planning
initiative to update the Maryland State Cancer Plan. It is
housed under the office of the Maryland State Council on
Cancer Control and includes subcommittees on pain management
and end of life issues.

Maryland General Assembly
http://mlis.state.md.us/

Provides information about the Maryland State
Legislature, including names and contact information of
Maryland Senators and Delegates, who sponsored a bill, what
the bill is about and what actions were taken.

Maryland Health Care For All!
http://www.healthcareforall.com/

Grassroots coalition working to ensure that all
Marylanders have access to quality and affordable health care.

Maryland Quality Care End-of-Life Council
http://www.oag.state.md.us/Healthpol/SAC/

Created in December 2002, the
Council advises the Office of the Attorney General, the
Department of Aging, and the Department of Health and Mental
Hygiene. It also advises the General Assembly on changes in
laws related to the provision of care at the end of life.

Maryland State Advisory Council on Pain Management
http://www.dhmh.state.md.us/ohcq/council/home.htm

Established in November 2002 to provide advice and
recommendations regarding issues of acute and chronic pain
management by Maryland health care providers, as well as the
pain management needs of adults and children.

Medbank of Maryland
http://www.medbankmd.org/

Non-profit organization whose mission is to provide
access to prescription medications for chronically ill,
low-income, underinsured/uninsured Maryland residents. MEDBANK
assists healthcare providers and patients in completing the
paperwork required to enroll patients in Pharmaceutical
Company Patient Assistance Programs.

National Initiative for Rheumatoid Arthritis
http://www.rheumatologycme.org/

Independent multi-component education program
offering online CME course, case studies, slides and other
resources for healthcare professionals.

Pain and Addiction Medicine Information Site (ASAM)
http://www.asam.org/pain/pain_and_addiction_medicine.htm

Information and resources on addiction
medicine and pain management from the American Society of
Addiction Medicine.

Pain Connection
http://www.pain-connection.org/

Non-profit human service agency in
Maryland that provides monthly pain support groups, information,
referrals and community education.

Pain Law Initiative

Mary Baluss, an attorney from
Washington, DC, is the Director of the Pain Law Initiative and
specializes in pain management cases, hospice care and end of
life care issues. She has developed and litigated legal
concepts intended to improve access to pain relief. She
advocates for both patients and the physicians who prescribe
opioids for chronic pain. She is also the General Counsel for
The National Foundation for the Treatment of Pain
http://www.paincare.org/. Ms. Baluss can be contacted
at the following address, phone numbers and/or email:

Mary Baluss, Esq.
Pain Law Initiative

2850 Arizona Terrace NW
Washington, DC 20016
202/244-0710 (phone)
202/361-2775 (cell-preferred number)
202/318-3027 (fax)
mbaluss@yahoo.com

Sickle Cell Information Center
http://www.scinfo.org

Sponsored by the Georgia Comprehensive
Sickle Cell Center at Grady Health System, the site o patient
and professional education, news, research updates and
worldwide sickle cell resources.

Stronger Bones
http://www.strongerbones.org/osteoporosis.html

Resource devoted to promoting bone
health and preventing osteoporosis, provided by the Maryland
Department of Health & Mental Hygieneís Office of Chronic
Disease Prevention.

University of Maryland Medicine Pain Center
htttp://www.umm.edu/pain/

Comprehensive, multidisciplinary pain center for
the assessment and treatment of chronic pain syndromes.

Addiction

In considering the contemporary role of opioids it must be borne in mind that, although these substances are subject to abuse, the intention for which opioids exist is the treatment of pain. Far too often, the potential for abuse interferes with the appropriate use of pain medications for those in need. Although drug abuse is a compelling public health problem, allowing abuse potential to limit access to opioids for those with medical illnesses is an unjust response. A useful analogy is our system of using checks to pay for purchases which is circumvented when ìbadî checks are ìbounced,î —- but we donít respond by banning checks as legal tender, a policy decision that would punish everyone. If you believe in a higher power, especially one that did not put us here to suffer unnecessarily, then we can reason that God gave us the opioids and their derivatives to better cope with pain and suffering. Unfortunately, as a culture we have been tragically ineffective in distinguishing between drug abuse and the treatment of pain, and thus when it comes to pain medications, it has been a classic case of a few bad apples ruining things for the whole bunch: todayís patients with pain have become the innocent victims of a war on drugs that should have nothing to do with them.

Research consistently demonstrates that exposure to pain medications does not foster addiction. In fact, under-prescribing is more likely to fuel addictive behavior, because pain is never relieved, and patients are left feeling abandoned, left to continually seek help that becomes increasingly elusive. With chronic treatment, patients may become tolerant or accustomed to the effects of opioids (thus requiring higher doses over time), and physical dependence (the onset of withdrawal or an abstinence syndrome when treatment is abruptly stopped) may arise, but addiction, a reversible complication, is extremely rare, occurring in no more than a few per cent of patients exposed to analgesics in the course of treatment. Tolerance and physical dependence are inevitable biologic consequences of chronic opioid use, that are independent of the patientís background, values and circumstances. The onset of tolerance and physical dependence are expected, are unrelated to addiction and are not problematic since they can be overcome by simply adjusting doses pf medications gradually. Addiction, which is the same as psychological dependence, is an infrequent outcome that is highly dependent on the patientís prior history, experiences and values. Addiction involves compulsive, nonmedical use of drugs that persists despite the presence or threat of physiologic or psychological harm, and indeed is a highly disruptive phenomena. Rare in otherwise well-adjusted individuals, exaggerated perceptions of its dangers causes a great many patients with legitimate pain to be mistrusted and undertreated. Unfortunately, when pain is ignored, most other aspects of healing (rest, mood, nutrition, energy and rehabilitation) also falter. Too often, we operate from the mistaken belief that simple exposure to painkillers produces addiction, while in fact addiction appears to be much more person- and style-specific than substance-specific. Predisposition to addiction has much more to do with an individualís style of coping with adversity, stress and illness. Addicts are less functional as a result of their drug use and become more isolated from the mainstream of life, family and work, while patients using drugs appropriately are consequently more functional, less isolated, and more prone to resuming activities they once avoided because of pain.

In the course of twenty years of educating physicians and nurses, patients and their families, administrators and policymakers and other interested parties about pain management, the topic of addiction never fails to elicit great interest. As a means to convey my thinking about this complex issue and especially the thorny distinction between addiction and the treatment of painful medical disorders with drugs. I created and have come to rely on a vignette that, by employing an analogy focuses our attention in a way that may help us think more clearly about issues that appear bewilderingly complex but are perhaps more simple than they appear to be.

So….heaven forbid, your teenage child or grandchild ìborrowsî the key to the family car, say a Ford Taurus, goes on to drink a six pack of beer and then wraps said car around a tree. Fortunate enough to walk away from the event, employing another example of adolescent logic, he/she draws the following conclusion: ìFord Taurusí are bad cars.î

The obvious corollary is that drugs, in and of themselves are neither ìgoodî nor ìbad,î although their use can produce dramatically opposed good or bad outcomes depending on how they are prescribed, dispensed and taken (ìdriven,î if you will). Our culture strives to ascribe pat answers to complex phenomenon, and thus arises the oversimplistic temptation to denounce a substance as being responsible for a behavioral problem, because it is often easier than looking honestly at our own maladaptive behaviors. As we have come to recognize the dangers of alcohol and tobacco, it becomes clear that the problem of addiction transcends the domain of illicit drugs, and viewed from an even broader perspective we have come to recognize the hazards of addictions to activities as diverse as gambling, risk-taking and sex.

The recent media feeding frenzy condemning a newer opioid compound, Oxycontin is a prototypic example of how unless such hysteria can be curbed many of the advances that have been made on the behalf of patients with chronic pain can be summarily annihilated. Oxycontin is simply a preparation of an opioid drug that is slowly released over twelve hours to promote even relief without the roller coaster effects and the clock-watching associated with short-acting painkillers. The recognition by abusers that this when crushed, chewed, sniffed or injected, the safety of this miraculous ìtiny time pillî could be bypassed led major news organs to irresponsibly capitalize on the sensationalist aspects of this criminal misuse of a product that used properly has helped countless sufferers. This irresponsible journalism has not only disseminsated an otherwise obscure strategy of abuse in the minds of susceptible addicts, but has terrified patients who have been benefitting from an otherwise appropriate treatment for years, and has frightened prescribing physicians and pharmacist who are now reluctant to dispense an otherwise very helpful drug. Just like a truly resourceful burglar will find a way to circumvent even the most stringent security system, an addict who is truly intent on abusing drugs will find a mechanism to abuse almost anything. The bottom line message is not to throw out the baby with the bathwater: the answer to curbing addiction to prescription drugs is not to limit their availability, but to teach doctors, patients and pharmacists to communicate more effectively about a problem that is distressing to all of us.

Patients should be aware that while the risk of addiction is exaggerated by even (well meaning) experts, it still exists. Addiction may arise in between 0.1-10% of patients, but it is a treatable disorder, and shouldnít interfere with the consideration of trials of opioids in patients with lower risk profiles. Individuals who have had difficulties with drugs, alcohol and tobacco in the past are at high risk for addiction and are generally considered poor candidates for treatment. Patients in denial who expect a ìquick fixî and wish to eliminate rather than manage pain are also likely to encounter difficulties with treatment.

Medications

ANALGESICS.

i) Non-steroidal anti-inflammatory drugs (NSAIDs) have been used for 150 years in Europe, and probably for a great deal longer in the East, in the form of willow bark extract. Useful when given appropriately, examination of the chronic pain population indicates that a very high number of patients are intolerant to these drugs because of gastrointestinal or other side-effects. There are two possible hypotheses for this. Firstly, chronic pain sufferers tend to be somewhat hypochondriacal and intolerant of body symptoms in general and thus less tolerant of real or perceived side-effects when taking medication. The second is that there may be a sub-group of patients whose pain is not managed well early on. NSAIDs may produce side-effects, limiting their use. With no pain relief, the patient fails to exercise. This hampering of their rehabilitation because of inadequate analgesia may contribute significantly towards the chronicity.

Recently COX2 antagonists have come on the scene, but the first wave of these have been disappointing in the UK, in that the side-effect profile does not appear to be particularly better than the present drugs (Meloxicam, Etodolac). The newer drugs, Vioxx and Celebrex, are now available in the USA and will soon become available in Europe. Their arrival is awaited with eager anticipation, but the results may prove to be disappointing. The products may not be as side-effect free as they first seem.

ii) The use of opioid drugs for the management of chronic non-malignant pain is fraught with difficulties, some real and some perceived. Morphine itself has tended not to be prescribed for chronic pain, because of a fear or stigma concerning Morphine. Physicians may fear dependence, tolerance and side-effects. There is a wide difference of opinion, which is still to be resolved; however, some patients can have their pain adequately controlled with opioids, without an unacceptable level of addiction problems. The potential risk of addiction remains a very real problem for a minority. Also, a significant number of patients with chronic pain complain of bothersome side-effects from medication. Mobility and distress must be monitored and benefits must accrue in both these parameters, as well as in reduction of pain.

iii) In the UK and in the USA, traditionally most patients with chronic pain receive an opioid derivative such as Codeine, Dihydrocodeine or Dextropropoxyphene. In the past Pentazocine and Buprenorphine enjoyed a passing vogue but are now little used. Pentazocine proved to have unacceptable side-effects, and Buprenorphine, originally thought to be non-addictive, was shown to have addictive potential and since being classified as a controlled drug has enjoyed little popularity. Nefopam has limited efficacy and popularity, and Meptazinol is short-acting, and often associated with an unacceptable level of side-effects.

Recent work suggests that Codeine and Dihydrocodeine are merely pro drugs for Morphine, and exert their action through metabolism to this compound. Given that a significant number of the population do not have the metabolic pathway to facilitate this, it is not surprising that there is a significant failure rate to produce any analgesia at all and that patients getting analgesia seem to get limited relief-hence possibly the popularity of these preparations being compounded with Paracetamol. There is good evidence that in some patients, much of the analgesic effect in these combined preparations lies with the Paracetamol itself, whilst many of the side-effects lie with the opioid.

v) Tramadol hydrochloride is an orally active, clinically effective, centrally-acting analgesic. It can produce analgesia that has been compared to Codeine or Dextropropoxyphene. It has been used in post-surgical pain, obstetric pain, cancer pain and chronic pain of mechanical and neurogenic origin. Analgesic tolerance is not a significant problem, and psychological dependence and euphoric effects are minimal. There are a significant number of patients in the chronic group who develop side-effects, but many of those who tolerate the drug get useful benefit in pain reduction. This slow-release formulation is an appropriate vehicle for chronic pain management.

Tramadol has an affinity, albeit relatively weak, for mu opioid receptors. It is also a neuronal uptake inhibitor. The monoamine neurotransmitters 5HT (Serotonin) and Noradrenaline (NA) are involved in the inhibition of spinal cord dorsal horn neurone responses to painful stimulation (i.e. closing the gate). Analgesia can result from activating the pain inhibitory pathways originating from higher CNS levels, and containing these neurotransmitters. Tramadol inhibits the uptake of 5HT and Noradrenaline but not Adenosine, Cyclic AMP, Dopamine, or Gaba.

Metanalysis by Moore and McQuay indicates an appropriate dose response curve for Tramadol, and suggests a reduced number needed to treat to show therapeutic efficacy as compared with Codeine, in doses of 75 to 150 mg. Nausea, vomiting and dizziness are greater than with Codeine, somnolence about the same and constipation much less. In the chronic pain situation nausea and vomiting are attenuated with usage, as is somnolence for both drugs, but constipation remains a particular problem with Codeine and Dihydrocodeine, and less of a problem with Tramadol.

Side-effects from Tramadol can be minimised by starting with a low dose and increasing gradually. There is evidence that this reduces the side-effects and improves tolerance. According to need, it can be started in a low dose of 50 mg daily or twice a day, and gradually titrated to reach 50 mg three times a day by day 3. Once a patient is established on a therapeutic dose, they can be put on the slow-release formulation to provide round-the-clock analgesia.

B. PSYCHOACTIVE DRUGS.

i) Anticonvulsants are well acknowledged as being effective in the management of shooting pain, for example: trigeminal neuralgia and the shooting element of neurogenic pain, such as post-herpetic neuralgia, diabetic neuropathy and similar conditions. Carbamazepine appears to be the most effective drug although there is a higher incidence of side-effects than with Sodium Valproate. Recently Gabapentin and Lamotrigine are enjoying popularity, either as “add on” drugs, or as sole agents. Further drug development of these types of agents might produce useful efficacy in the future.

ii) Tricyclic antidepressants are one of the most commonly used analgesics in pain clinics. This is not for the specific antidepressant action, but is more associated with the activation of pain inhibitory pathways. This appears to be less of a feature with the tetracyclic agents, and has meant that their usage in chronic pain has as yet remained unproven. This is of course is disappointing as the side-effect profile is significantly better. The sedative effect of Amitriptyline can be harnessed to good usage by giving the tablet one or two hours before retiring, and it should not be used during the day.

ANALGESIC PAIN MANAGEMENT

In general, patients with pain can be given a trial of Paracetamol. An appropriate non-steroidal can be used if there is an inflammatory process, and continued if these are effective and if side-effects are minimal. The next optimal step in the analgesic ladder will be the use of agents like Tramadol, Dextropropoxyphene, or Dihydrocodeine, with long-acting preparations being ideal for chronic pain. At present, slow-release Tramadol would appear to be the most effective drug in chronic pain for this group of patients. If side-effects preclude its usage, one of the other agents can be considered.

Finally a small group of patients might be suitable for the use of opioids themselves.

In conjunction with this ladder, anticonvulsants and tricyclic antidepressants can be considered, for their specific and appropriate actions on shooting and burning pain, usually of neurogenic origin.