Aberrant Drug-taking Behaviors Aberrant Drug-taking Behaviors in Medically Ill Pain Patientsin Medically Ill Pain Patients

Steven D. Passik, PhDSteven D. Passik, PhDDirector, Symptom Management and Palliative Care Program - Director, Symptom Management and Palliative Care Program -

Markey Cancer CenterMarkey Cancer CenterAssociate Professor of Medicine and Behavioral SciencesAssociate Professor of Medicine and Behavioral Sciences

University of KentuckyUniversity of KentuckyLexington, KY Lexington, KY

APA, NYC, 05/03/04APA, NYC, 05/03/04

Indiana/UK Studies on Aberrant Drug-Indiana/UK Studies on Aberrant Drug-taking in Pain Managementtaking in Pain Management

Attitudes and behaviors in cancer patients and women Attitudes and behaviors in cancer patients and women with AIDS, Passik, et al., JPSM,1998with AIDS, Passik, et al., JPSM,1998UTS in pain management, Passik et al, JPSM, 1998UTS in pain management, Passik et al, JPSM, 1998Survey of clinicians’ perceptions of ADTB, Passik et al, Survey of clinicians’ perceptions of ADTB, Passik et al, JPSMPC, 2002JPSMPC, 2002Development of a tool to assess pain outcomes in Development of a tool to assess pain outcomes in chronic opioid therapy, Passik et al submittedchronic opioid therapy, Passik et al submittedAberrant drug taking in cancer and AIDS patients, Aberrant drug taking in cancer and AIDS patients, Passik et al, in prepPassik et al, in prepRetrospective Characterization of abusers of Retrospective Characterization of abusers of OxyContin seeking drug treatment in Kentucky, Hays, OxyContin seeking drug treatment in Kentucky, Hays, et al., JNCCN, 2003; Preliminary prospective data et al., JNCCN, 2003; Preliminary prospective data

Aberrant Drug-taking Behaviors: Aberrant Drug-taking Behaviors: The ModelThe Model

Probably more predictiveProbably more predictive– Selling prescription drugsSelling prescription drugs– Prescription forgeryPrescription forgery– Stealing or borrowing another Stealing or borrowing another

patient’s drugspatient’s drugs– Injecting oral formulationInjecting oral formulation– Obtaining prescription drugs Obtaining prescription drugs

from non-medical sourcesfrom non-medical sources– Concurrent abuse of related Concurrent abuse of related

illicit drugsillicit drugs– Multiple unsanctioned dose Multiple unsanctioned dose

escalationsescalations– Recurrent prescription lossesRecurrent prescription losses

Probably less predictiveProbably less predictive– Aggressive complaining about Aggressive complaining about

need for higher dosesneed for higher doses– Drug hoarding during periods of Drug hoarding during periods of

reduced symptomsreduced symptoms– Requesting specific drugsRequesting specific drugs– Acquisition of similar drugs from Acquisition of similar drugs from

other medical sourcesother medical sources– Unsanctioned dose escalation 1 Unsanctioned dose escalation 1

– 2 times– 2 times– Unapproved use of the drug to Unapproved use of the drug to

treat another symptomtreat another symptom– Reporting psychic effects not Reporting psychic effects not

intended by the clinicianintended by the clinician

Passik and Portenoy, 1998

Differential Diagnosis of Aberrant Drug-Differential Diagnosis of Aberrant Drug-Taking Attitudes and BehaviorTaking Attitudes and Behavior

AddictionAddiction

Pseudo-addiction (inadequate analgesia)Pseudo-addiction (inadequate analgesia)

Other psychiatric diagnosisOther psychiatric diagnosis– EncephalopathyEncephalopathy– Borderline personality disorderBorderline personality disorder– Depression Depression – AnxietyAnxiety

Criminal IntentCriminal Intent(Passik & Portenoy 1996)

Physician-Ranking of Ab. Behs.Physician-Ranking of Ab. Behs.(Passik, Kirsh, et al, J Pain Pall Care Pharm, 2002)(Passik, Kirsh, et al, J Pain Pall Care Pharm, 2002)

Rank Aberrant Behavior: Mean (SD)

1 Selling prescription drugs 4.0 (3.5)

2 Forging Prescriptions 4.4 (3.6)

3 Altering route or drug delivery system (i.e., crushing sustained release tablets for snorting or injecting)

4.7 (3.6)

4 Concurrent abuse of related illicit drugs 5.1 (2.9)

5 Stealing or borrowing medications from others 5.2 (2.9)

6 Obtaining drug from non-medical source 5.8 (3.0)

7 Frequent Prescription losses 6.2 (2.7)

8 Multiple unsanctioned dosing 7.4 (2.9)

9 Aggressive demand for more drug 7.6 (3.4)

10 Unapproved use of drug to treat non-pain symptoms 7.7 (3.1)

11 Drug hoarding 8.6 (3.3)

12 Unsanctioned dose escalation once or twice 9.8 (3.6)

13 Unkempt appearance 11.0 (3.2)

Aberrant drug-taking in cancer and Aberrant drug-taking in cancer and AIDSAIDS

73 patients with AIDS - 100% with reported past or current 73 patients with AIDS - 100% with reported past or current history of substance abuse (42% of total sample)history of substance abuse (42% of total sample)

100 patients with cancer -18% reported past or current 100 patients with cancer -18% reported past or current history of substance abuse (58% of total sample)history of substance abuse (58% of total sample)

101 men (58% ), 72 women (42%)101 men (58% ), 72 women (42%)

118 Caucasian (68%), 50 African-American (29%) 5 118 Caucasian (68%), 50 African-American (29%) 5 “Other” (3%); Mean age = 51.6 (SD = 15.2)“Other” (3%); Mean age = 51.6 (SD = 15.2)

MeasuresMeasures

SCID – substance abuse module SCID – substance abuse module

Brief Pain InventoryBrief Pain Inventory

Pain Management IndexPain Management Index

Brief Symptom InventoryBrief Symptom Inventory

Memorial Symptom InventoryMemorial Symptom Inventory

Marlowe Crowne Social DesirabilityMarlowe Crowne Social Desirability

Aberrant Behavior Interview Aberrant Behavior Interview

ResultsResults

Compared to cancer patients , patients with AIDS Compared to cancer patients , patients with AIDS were significantly more likely towere significantly more likely to : :

-Be single-Be single

-Be male-Be male

-Be of a minority ethnic group-Be of a minority ethnic group

-Be younger -Be younger

-Report past or present psychiatric problems-Report past or present psychiatric problems

-Report being inadequately medicated for pain-Report being inadequately medicated for pain

Aberrant Behaviors ReportedAberrant Behaviors Reported

Total SampleTotal Sample Cancer patientsCancer patients AIDS AIDS patientspatients

(n = 173)(n = 173) (n= 100)(n= 100) (n = 73)(n = 73)Total # aberrant behaviorsTotal # aberrant behaviors 590590 142 142 448 448

(100%)(100%) (24%)(24%) (76%) (76%)

Average # of aberrant behaviorAverage # of aberrant behavior 3.413.41 1.421.42 6.146.14

Total # of “aberrant behaviors Total # of “aberrant behaviors 423 423 122122 301301““probably less predictive of probably less predictive of (72%)(72%) (86%)(86%) (67%)(67%)addiction” addiction”

Total # aberrant behaviors Total # aberrant behaviors 167167 2020 147147““probably more predictive probably more predictive (23%)(23%) (14%)(14%) (33%)(33%)of addiction”of addiction”

Numbers of Aberrant BehaviorsNumbers of Aberrant Behaviors

0

10

20

30

40

50

60

% OF SAMPLE

0 1 TO 2 3 TO 4 5 ORMORE

# OF ABERRANT BEHAVIORS

CANCER

AIDS

MostMost Frequently Reported Aberrant Behaviors Frequently Reported Aberrant Behaviors

Aberrant BehaviorAberrant Behavior Cancer patientsCancer patients AIDS patientsAIDS patients (n= 100)(n= 100) (n = 73)(n = 73) Freq. %Freq. % Freq. Freq. %%

Expressed anxiety orExpressed anxiety or 27 27 27 27 37 5137 51desperation overdesperation overrecurrent symptomsrecurrent symptoms

Hoarded medicationsHoarded medications 22 22 22 22 28 3928 39

Taken someone else’sTaken someone else’s 11 11 11 11 36 5036 50pain medicinepain medicine

Aggressively complained Aggressively complained 13 13 13 13 29 4029 40to doctor for more drugsto doctor for more drugs

Requested a specific drugRequested a specific drug 18 18 18 18 24 33.324 33.3

LeastLeast Frequently Reported Aberrant Behaviors Frequently Reported Aberrant Behaviors

Aberrant BehaviorAberrant Behavior Cancer patientsCancer patients AIDS patientsAIDS patients (n= 100)(n= 100) (n = 73) (n = 73)

Freq. %Freq. % Freq. %Freq. %

Prescription forgeryPrescription forgery 0 0 0 0 11 <1<1

Prostituted others for drugsProstituted others for drugs 0 0 0 0 44 66

Sold prescription drugs Sold prescription drugs 0 0 0 0 66 88

Stolen drugs from others Stolen drugs from others 0 0 0 0 77 1010

Performed sex forPerformed sex for 0 0 0 0 77 1010money to obtain drugsmoney to obtain drugs

Reported Pain ReliefReported Pain Relief

CancerCancer AIDS AIDSpatientspatients patientspatients(n =100)(n =100) (n =73)(n =73)

Percent of pain relief Percent of pain relief 76%76% 37%37%

Adequate pain reliefAdequate pain relief (PMI)(PMI) 9292 4949 (92%)(92%) (67%) (67%)

Inadequate pain reliefInadequate pain relief (PMI)(PMI) 88 24 24(8%)(8%) (33%) (33%)

AIDS Patients and Aberrant BehaviorsAIDS Patients and Aberrant Behaviors

AdequateAdequate InadequateInadequateAnalgesiaAnalgesia AnalgesiaAnalgesia (n = 49)(n = 49) (n = 24)(n = 24)

Total # aberrant behaviorsTotal # aberrant behaviors 305305 152152(6.2)(6.2) (6.3)(6.3)

Aberrant behaviors “probablyAberrant behaviors “probably 239239 116116less predictive of addictionless predictive of addiction ““ (78%)(78%) (74%)(74%)

Aberrant behaviors “probablyAberrant behaviors “probably 6666 4040more predictive of addiction”more predictive of addiction” (22%)(22%) (26%) (26%)

The Four “A’s” of Pain The Four “A’s” of Pain Treatment OutcomesTreatment Outcomes

Analgesia – modest but meaningfulAnalgesia – modest but meaningful

Activities of Daily Living (psychosocial Activities of Daily Living (psychosocial functioning) – 80% rated as improved overallfunctioning) – 80% rated as improved overall

Adverse effects (side effects) – common but Adverse effects (side effects) – common but tolerable tolerable

Aberrant drug taking (addiction-related Aberrant drug taking (addiction-related outcomes)outcomes)

Passik & Weinreb, 1998

Aberrant BehaviorsAberrant Behaviors (Passik, Kirsh et al, in prep, 2004)(Passik, Kirsh et al, in prep, 2004)

55.4

25.3

8.5 6.7

4.1

0

10

20

30

40

50

60

0 2 to 3 3 to 4 5 to 7 8+

% of Patientsexhibiting behs.

(n = 215)

(n = 98)

(n = 33) (n = 26) (n = 16)

Number of Behaviors Reported

Characterization of OxyContin abusers Characterization of OxyContin abusers seeking drug abuse treatment in KYseeking drug abuse treatment in KY

Chart review survey of admissions to drug Chart review survey of admissions to drug treatment center in Lexington at height of media treatment center in Lexington at height of media coverage of the epidemiccoverage of the epidemic

195 admissions for OxyContin abuse195 admissions for OxyContin abuse

SCID diagnoses and other SCID diagnoses and other medical/demographic data recordedmedical/demographic data recorded

Characterization of OxyContin abusers Characterization of OxyContin abusers seeking drug abuse treatment in KYseeking drug abuse treatment in KY

OxyContin abusers were:OxyContin abusers were:– Using on average, 180mgs per dayUsing on average, 180mgs per day– History of other DSM IV, nonsubstance abuse Dx History of other DSM IV, nonsubstance abuse Dx – History of poly-substance abuseHistory of poly-substance abuse– History of other prescription drug abuseHistory of other prescription drug abuse

OxyContin abusers compared to other opioid abusers:OxyContin abusers compared to other opioid abusers:– YoungerYounger– MaleMale– RuralRural

Characterization of OxyContin abusers Characterization of OxyContin abusers seeking drug abuse treatment in KYseeking drug abuse treatment in KY

The 60 patients who ostensibly began using in The 60 patients who ostensibly began using in pain treatmentpain treatment– Treated mainly by primary care and other non pain Treated mainly by primary care and other non pain

expertsexperts– Similar med/demos to other OxyContin abusersSimilar med/demos to other OxyContin abusers– Equally likely to alter route of administration, with Equally likely to alter route of administration, with

13% reporting crushing and injecting13% reporting crushing and injecting

Characterization of OxyContin abusers Characterization of OxyContin abusers seeking drug abuse treatment in KYseeking drug abuse treatment in KY

The 60 patients who ostensibly began using in The 60 patients who ostensibly began using in pain treatmentpain treatment– Treated mainly by primary care and other non pain Treated mainly by primary care and other non pain

expertsexperts– Similar med/demos to other OxyContin abusersSimilar med/demos to other OxyContin abusers– Equally likely to alter route of administration, with Equally likely to alter route of administration, with

13% reporting crushing and injecting13% reporting crushing and injecting

Rx Drug Abusers Entering TreatmentRx Drug Abusers Entering Treatment(Passik, Kirsh, et al, in process)(Passik, Kirsh, et al, in process)

DrugDrug # of instances# of instances (of n = 89)(of n = 89)

Got from Got from Street Dealer?Street Dealer?

**

Amount of $ per Amount of $ per mg/mcgmg/mcg

OxyContinOxyContin 57 (64%)57 (64%) 46 (81%)46 (81%) $0.50-1.25/mg$0.50-1.25/mg

LortabLortab 31 (35%)31 (35%) 18 (58%)18 (58%) $0.40-1.20/mg$0.40-1.20/mg

PercocetPercocet 13 (15%)13 (15%) 6 (46%)6 (46%) $0.20-1.60/mg$0.20-1.60/mg

MorphineMorphine 4 (4%)4 (4%) 1 (25%)1 (25%) $0.25-0.40/mg$0.25-0.40/mg

MethadoneMethadone 3 (3%)3 (3%) 1 (33%)1 (33%) $1.00/mg$1.00/mg

DilaudidDilaudid 2 (2%)2 (2%) 2 (100%)2 (100%) $7.50-12.50/mg$7.50-12.50/mg

DuragesicDuragesic 2 (2%)2 (2%) 0 (0%)0 (0%) $1.00/mcg$1.00/mcg

* At least once

Rx Drug Abusers Entering TreatmentRx Drug Abusers Entering Treatment(Passik, Kirsh, et al, in process)(Passik, Kirsh, et al, in process)

DrugDrug Altered Altered deliverydelivery

Snort*Snort* Crush*Crush* I.V.*I.V.*

OxyContinOxyContin 55/5755/57 5353 2727 1414

LortabLortab 17/3117/31 1515 99 44

PercocetPercocet 11/1311/13 1010 44 33

MorphineMorphine 4/44/4 22 11 33

MethadoneMethadone 1/31/3 11 00 00

DilaudidDilaudid 2/22/2 11 11 22

DuragesicDuragesic 0/20/2 00 00 00

* Not mutually exclusive

ConclusionsConclusions

Patients of all types engage in some ambiguous Patients of all types engage in some ambiguous drug-taking behaviordrug-taking behavior

Substance abuse history is associated with Substance abuse history is associated with increased number of aberrant behaviors and increased number of aberrant behaviors and types of aberrant behaviorstypes of aberrant behaviors

Provision of adequate analgesia may not be Provision of adequate analgesia may not be enough to limit aberrant behaviors in complex enough to limit aberrant behaviors in complex patients who have a history of drug abusepatients who have a history of drug abuse

Assessment should be multimodal – 4A’sAssessment should be multimodal – 4A’s