Co-occurring Disorders: Pain, Depression and Substance Abuse

Walter Ling MD

Integrated Substance Abuse Programs

UCLA

lwalter@ucla.edu

www.uclaisap

Fifth Annual Statewide Conference on Co-Occurring Disorders

October 3, 2006

Long Beach Convention Center

Long Beach, California

Scope of the Talk

• “What’s the big deal”? “Why bother with it”?

• How big a problem is it?

• How do we go about it?

• What can we do?

• A few specific tricks?

What’s the Big Deal?

• Common clinical problems

• Overlaps in neurobiology

• Confusing diagnosis

• Complicates treatment , presence of one predicts poor

treatment outcome of the other

• Strain on treatment systems and resources

What’s the Problem?

• Estimates of psychiatric co-morbidity among clinical populations in substance abuse treatment settings range from 20-80%

• Estimates of substance use co-morbidity among clinical populations in mental health treatment settings range from 10-35%

Differences in incidence due to: nature of population served (eg: homeless vs. middle class), sophistication of psychiatric diagnostic methods used (psychiatrist or DSM checklist) and severity of diagnoses included (major depression vs. dysthymia).

ECA DSM-III Diagnoses (rates per 100 people)

1 Month Lifetime

Any Alcohol, Drug or Mental Health

Disorder

15.7 32.7

Any Mental Disorder 13.0 22.5

Alcohol Dependence 1.7 7.9

Drug Dependence 0.8 3.5

Regier, et al. (1990)

Lifetime Prevalence and Odds Ratios ECA Study

Alcohol OROtherDrug OR

Any mental 36.6% 2.3 53.1% 4.5

Schizophrenia 3.8% 3.3 6.8% 6.2

Any affective 13.4% 1.9 26.4% 4.7

Anti-social 14.3% 21.0 17.8% 13.4

Alcohol 47.3% 7.1

Regier, 1990

Chronic pain, Depression and Anxiety

• National Co-morbidity Study (8098 15-54 y.o. chronic pain arthritic patients vs general population control)

Mood disorder: 27% patients vs 10% controls

Anxiety disorder: 35% vs 9%

Depression: 20% vs 9%

Generalized anxiety disorder: 7% vs3%

Panic disorder: 7% vs 2%

PTSD: 11% vs 3%

Odds of disability from chronic pain increase: anxiety (2.86); depression (2.8);panic disorder ( 4.27)

The “ideal, but infrequent” patients for the separated service delivery systems

The mental health service system

• The uncomplicated schizophrenic

• The “simple” affective disordered individual

• The “pure” bi-polar patient

The substance abuse service system

• The “plain” alcoholic

• The addict who uses only heroin

• The stimulant dependent individual w/o other psych diagnoses

Drug Induced Psychopathology

Drug States

• Withdrawal

- Acute

- Protracted

• Intoxication

• Chronic Use

Symptom Groups

• Depression

• Anxiety

• Psychosis

• Mania

Rounsaville ‘90

Likelihood of a Suicide Attempt

• Risk Factor

• Cocaine use

• Major Depression

• Alcohol use

• Separation or Divorce

NIMH/NIDA

Increased Odds Of Attempting

Suicide

62 times more likely

41 times more likely

8 times more likely

11 times more likely

ECA EVALUATION

Facts about Suicide:

• 500,000 ER visits for attempts in 1997

• Four times as many US citizens died by suicide during the Viet Nam War period than died as soldiers.

• Rates increase with age ( as do other causes of death) CDC web site

• Suicide rate among addicts is 5-10 times that of non-addicts Preuss/Schuckit Am J Psych 03

Less than than half of the women with interpersonal

trauma and co-morbidity will receive treatment that

addresses their trauma history and co-occurring

conditions

(Timko & Moos, 2002).

49% of social anxiety disorder patients have panic disorder**

50% to 65% of panic disorder patients have depression†

11% of social anxiety disorder patients have OCD**

67% of OCD patients have depression*

70% of social anxiety disorder patients have depression

Comorbidity of Depression and Anxiety Disorders

Depression

OCD

Social Anxiety Disorder

Panic Disorder

HIGHLY COMMON…

HIGHLY COMORBID

The Four Quadrant Framework for Co-Occurring Disorders

A four-quadrant conceptual framework to guide systems integration and resource allocation in treating individuals with co-occurring disorders (NASMHPD,NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002)

Not intended to be used to classify individuals (SAMHSA, 2002), but  . . . 

Less severemental disorder/

less severe substance

abuse disorder

More severemental disorder/

less severe substance

abuse disorder

More severemental disorder/

more severe substance

abuse disorder

Less severemental disorder/

more severe substance

abuse disorder

High severity

High severity

Lowseverity

DSM and ICD: The “Bibles”

Assessing for addiction in pain patients

Substance Abuse

• One or more within a 12 month

period

- Failure to fulfill major role

obligation

- Recurrent use in hazardous

situations

- Recurrent legal problems

- Recurrent social or

interpersonal problems

Substance Dependence

• Three or more within a 12 month period

- Abuse criteria, plus:

- Tolerance

- Withdrawal

- Larger amount/longer time than intended

- Persistent desire to control use

- Great deal of time spent in activities related to use

Diagnostic and Statistical Manual of Mental Disorders*

*4th ed, APA, 1994

Pain and Depression

• What comes first?

- The antecedent hypothesis

- The consequence hypothesis

- The “scar” hypothesis

- “Pain-prone personality”

- Life experience and personal mastery

• Does it really matter?

Pain and depression make each other worse

Pain and Depression

• Between 30% and 60% of depressed patients have chronic pain

• Chronic pain patients who are depressed are 9 times more likely to

be disabled

- This depression is responsive to treatment

- Treatment lowers pain intensity and improves function and quality of

life

• Treatment needs to be adequate and sustained; combined

pharmacotherapy with behavioral therapy, aim to improve self

management, beware of increased suicide risks

Depression IS Pain

• Pain is second most common somatic symptom in

depression, second only to insomnia.

• Pain occurs in over 50% of depressed patients

• Common pain in depressed patients: headaches, facial

pain, neck and back pain, chest and abdominal pain and

extremity pain

• Pain often dominate clinical picture overshadowing other

depressive symptoms

Pain and Depression

• Pain is depressive equivalent

• Chronic pain leads to depression

• Circular relationship, vicious circle

• Common association and overlapping

• Common neurobiological substrate

• Psychological determinants critical

• Responsive to antidepressants

• Non-pharmacological strategies critical

Pain and Depression

• Two thirds of new neurological patients have pain.

• One third are depressed; 75% of them have pain.

• One quarter have both pain and depression.

• Neuropathy, neuromuscular disease, headaches.

• Sx persist at 3 & 12 mo. follow up

• Pain predicts depression at f/u and vice versa

• Odds of pain increase: female, depressed, NMD

• Odds of depression increase: CVD, Cognitive disWilliams LS et al J Neuro Neurosurg Psych. 2003

Pain IS Depression

• Somatic cyclothymia

• Periodic melancholy

• Vegetative depression

• Masked depression

• Affective equivalents

• Depressive equivalents

• Variant of depressive disease

Pain and Depression

•Co-occurrence makes diagnosis difficult

• Pain patients tend to show more irritability,

anhedonia, loss of interest, reduced capacity to

experience pleasure.

• Depressed patients tend to exhibit more

dysphoria, early morning awakening,

indecisiveness, despair and suicidal ideations

Treating Co-morbid Pain and Depression

• Tricylclic antidepressants

- Efficacy in neuropathic pain

• SSRI’s

- Safety profile

• Dual-acting agents

- Effective for depression and pain

- Detke MJ 2002

Treating Co-morbid Pain and Depression

• Non-pharmacological treatment

- Cognitive behavioral treatment

- Operant behavioral treatment

- Biofeedback training

- Motivational interviewing

- Private emotional disclosure

• Integrating pharmacotherapy and behavioral

treatment

What happen when pain becomes chronic

• The one certain thing: treatment didn’t work

• Patient frustrated and lost faith in doctors

• Patient blamed for not getting better

• Lost “role”; becomes dependent on others

• Others must pick up slack and must provide support

• Patient feels neglected when others can’t do all

• Patient becomes anxious, angry and depressed

• Patient assumes life style of chronic pain

Chronic pain: identifying early risk factors

• Attitude and belief of pain

• Whose fault?

• Behavior and compensation issues

• Dx and Tx issues

• Emotions

• Family

• Work

Early signs of chronic pain

• Not healing as expected

• Perceived neglect or ill treatment

• Perceived management abandonment

• Not adequately treated

• Accident was some one’s fault

• Expanding Sx

• Sleep disturbance, anger fear

Opioid, Pain and Addiction: Confluence of Events

• Under treatment of pain:

• Increasing availability of opioids:

• Rise in abuse of prescription opioids

New Demand:

Core competency in pain and in addiction

From Pain Relief to Addiction: Opioids and the Faces of Janus

• Relieve pain

• Relieve pain and suffering

• Relieve suffering and misery

• Make you feel better

• Make you feel good

• Make you “high”

The Clinician’s Dilemma

• What God hath joined together, can man put

asunder?

• What to do in the meantime to maximize pain

relief while minimizing abuse ?

Definitions: Addiction

• Addiction- primary, chronic, neurobiologic disease

characterized by behaviors that include one or

more of the following: impaired control over drug

use, compulsive use, continued use despite harm,

and/or craving

American Pain Society. Available at:

http://www.ampainsoc.org/advocacy/opioids2.htm

“Addiction is not taking a lot of drugs; it’s taking drugs and

acting like an addict.”—Alan Leshner

Characterizing Pain

• Pain: An unpleasant sensory and emotional experience

arising from actual or potential tissue damage or

described in terms of such damage

• It is always subjective; each individual learns the

application of the word (pain) through experiences

related to injury in early life—IASP

IASP = International Association for the Study of Pain.

Acute Versus Chronic Pain

Acute pain:

• Related to a particular event (eg

fall)

• Resolution expected within

days/weeks

Chronic pain:

• Cause not often easily

identified

• CNS changes

• Not repeated acute pain

episodes

Acute pain: a sensation; what pain does the patient have?Chronic pain: a life style: what patient does the pain have?

Pain in Addiction: “More Than a Feeling”

• Feeling (sensory experience): pain

• Meaning (emotional and cognitive): suffering

- Historical—early life

- Learned—experience

- Private—subjective

- Unique—individual

• Action—expression of the “word”: behavior

• Chronic pain is not having lots of pain; it is having pain and

behaving like a chronic pain patient

The Martyrdom of St. Sebastian by Hans Holbein (1516)

Chronic Pain and Addiction:Common Overlapping Features

• Chronic pain

- Early trauma

- Loss of mastery

- Loss of control

- Loss of sense of self

- Cognitive error

- “Personalization”

- Overinterpretation

- “Catastrophizing”

• Addiction

- Early trauma

- Loss of mastery

- Loss of control

- Loss of self-efficacy

- Cognitive error

- “Nirvana”

- Denial

Chronic Pain Common in Methadone Clinics

• Over 60% of methadone clinics patients experience chronic pain

Less employed; more disabilities

More medically and psychiatrically ill

Take more prescribed and non-prescribed drugs

Most feel under treated

Most believe prescribed opiates led to addiction

• Most believe methadone is very helpful

• Most have “problems most of their lives”

• Most believe “always need something to feel good”

Ref: Jamison et al. (2000)

With respect to chronic opioid therapy and the patient with chronic non-malignant pain,

• How does one identify addiction in the patient on

chronic opioid therapy?

• How does one identify the patient at risk for

becoming addicted to chronic opioid therapy?

Published rates of abuse and/or addiction in chronic pain populations are ~ 10% (3-18%)*

• Suggests that known risk factors for abuse or addiction in the

general population would be good predictors for problematic

prescription opioid use

- History of early substance use

- Personal/family history of substance abuse

- Co-morbid psychiatric disorders

*Adams et al., 2001; Brown, 1996; Fishbain, 1986, 1992; Kouyanou et al., 1997

Who’s at Risk for Addiction and How to Tell?

•4 Ways to identify patients at risk

- History—personal history and family history

- Screening instruments

- Behavioral checklists

- Therapeutic maneuver

Screening Instruments

• Several clinical tools are available that estimate risk of noncompliant opioid use1,2,3

• The results determine how closely a patient should be monitored during the course of opioid therapy3

- Scores implying a high risk of abuse are not reasons to deny pain relief3

1 Webster, et alr. Pain Med. 2005;6:432.2 Coambs, et al. Pain Res Manage. 1996;1:155.3 Butler, et al. Pain. 2004;112:65.

Opioid Risk Tool (ORT)

Mark each box that applies: Female Male

1. Family history of substance abuse

Alcohol 1 3

Illegal drugs 2 3

Prescription drugs 4 4

2. Personal history of substance abuse

Alcohol 3 3

Illegal drugs 4 4

Prescription drugs 5 5

3. Age (mark box if between 16-45 years) 1 1

4. History of preadolescent sexual abuse 3 0

5. Psychological disease

ADO, OCD, bipolar, schizophrenia 2 2

Depression 1 1

Scoring totals:

Scoring

• 0-3: low risk (6%)

• 4-7: moderate risk (28%)

• > 8: high risk (> 90%)

Administration

• On initial visit

• Prior to opioid therapy

Webster, et al. Pain Med. 2005;6:432.

Screener and Opioid Assessment for Patients in Pain (SOAPP)

• 14-item, self-administered form, capturing the primary

determinants of aberrant drug-related behavior- Validated over a 6-month period in 175 chronic pain patients

- Adequate sensitivity and selectivity

- May not be representative of all patient groups

• A score of ≥ 7 identifies 91% of patients who are high risk

Butler, et al. Pain. 2004;112:65.

Aberrant Drug-Taking Behaviors: The Model

•Probably more predictive

- Selling prescription drugs

- Prescription forgery

- Stealing or borrowing another patient’s

drugs

- Injecting oral formulation

- Obtaining prescription drugs from non-

medical sources

- Concurrent abuse of related illicit drugs

- Multiple unsanctioned dose escalations

- Recurrent prescription losses

•Probably less predictive

- Aggressive complaining about need for

higher dose

- Drug hoarding during periods of reduced

symptoms

- Requesting specific drugs

- Acquisition of similar drugs from other

medical sources

- Unsanctioned dose escalation 1 – 2 times

- Unapproved use of the drug to treat another

symptom

- Reporting psychic effects not intended by

the clinicianPassik and Portenoy, 1998

Aberrant Behaviors

0

10

20

30

40

50

60

0 1 to 2 3 to 4 5 to 7 8 or more

Number of Behaviors Reported

Pati

en

ts E

xh

ibit

ing

Beh

avio

rs

(%)

N=388

Passik et al. 2003

Aberrant Behaviors in Cancer and AIDS

0

10

20

30

40

50

60

70

0 1 to 2 3 to 4 5 or more

Number of Behaviors Reported

Pati

en

ts E

xh

ibit

ing

Beh

avio

rs

(%) Cancer

AIDS

Passik et al. 2003

Therapeutic Maneuver: Is the Pain Patient Addicted?

Drug-seeking or increased requests for pain medication

Detailed pain work-up Pathology/pain of new source

No new pain pathology

Opioid dose

Improved functioning

Absence of toxicity

PseudoaddictionTherapeutic dependence

Unimproved functioning

Presence of toxicity

Addictive disease

Treating Pain with Opioids: What Can We Expect to Achieve?

• Reduction in pain and suffering

- Meaningful pain reduction (Analgesia; Pain)

- Acceptable side effects (Adverse effects; Price)

• Improved functionality

- Meaningful functional improvement (Activities; Performance)

- No unacceptable aberrant behavior (Aberrant bahavior; “Pees”

The 4 A’s (Passik); the 4 “P’s”

Meaningful Pain Reduction: How Much?

• Using a VAS or numeric scale of 0–10

(4–6 = moderate pain; 7–10 = severe pain)

• For moderate pain (mean = 6)

- Meaningful reduction = 2.4 (40%)

- Very much better = 3.5 (45%)

• For severe pain (mean = 8)

- Meaningful reduction = 4.0 (50%)

- Very much better = 5.2 (56%)

VAS = visual analogue scale.Cepeda MS. Pain. 2003;105:151–157. [Evidence Level B]

Analogue Pain Scale

Evaluation of Functional Restoration

• physical capabilities

• psychological intactness

• family and social interactions

• Relationships with healthcare professionals and

therapeutic outcomes

• degree of health care utilization

• drug use for symptom control

Remission of Addictive Disease Improves Pain and

Functionality

• Increased ability to comply with regimes

• Enhanced cognitive skills

• Able to use behavior modification techniques

• Improved social support

• Better management of neuropsychiatric problems

• Improved stress control

Meaningful Functional Improvement: My Favorites

• Patient perspective of “improvement”

- Used to do, can’t do now, would like to do again

- Could be physical, social, recreational

- With friends, family, church, neighborhood

• Achievable, enjoyable, and meaningful

- Hobbies

- Volunteer work

Pain Behavior

• Pt behavior is total out put of

- Belief

- Emotional reaction to perceived “pain”

- Modulation by internal neural mechanism

- Modulation by external social mechanism (family)

Belief, Expectation, & Outcome

• What you believe and expect and do as a result are far more

important than what situation you’re in.

• Prayers and hope are useless if you don’t recognize the

answers.

• Behavior are largely self-fulfilling prophesies; if the sky falls,

it will fall on those who believe the sky is falling

• Pain is part of life, so is uncertainty

Dr. to Patients

• What are your concerns, worries, and goals for this visit?

• What condition you have, what will happen, what we can expect, and why we recommend what we recommend

• Here are some specific strategies for Sx relief and for high risk situations

• Let’s develop a plan for your future

Treating Neuropathic Pain

• Five first-line drugs:

- Gabapentin

- 5 % lidocaine patch

- Opioid analgesics

- Tramadol

- Tricyclic antidepressants

- NIH consensus panel Arch Neurology 2003; 60:1537-1540

Opioids for Neuropathic Pain

• Postherpetic neuralgia

- Neurology 1998; 50: 1837-41(60 mg/d )

- Neurology 2002; 59:1015-21 (controlled release ms 240 mg/d

• Diabetic neuropathy

- Neurology 2003; 60:927-34 (120 mg Oxycontin)

• Phantom limb pain

- Pain 2001; 90:47-55 (300mg/d)

• Peripheral and central neuropathic pain

- NEJM 2003; 348: 1223-1232

Documentation

• Why opioids are prescribed in this case

• What reduction in pain has been achieved

• What functional improvement has occurred

• Document acceptable side effects

• Document responsible medication use and absence of aberrant

behaviour

Remember: 1.What is not written down didn't happen. 2.Your record will testify in public not what patients you have but what doctor they have

Summary

• Pain and addiction: public health problems

• Opioids critical in both

• Demarcation is not always clear

• Pathophysiological and clinical overlaps

• Identifying risks: challenging, not hopeless

• Core competency in both pain and addiction

Treatment of Co-occurring Disorders

•Treatment System Paradigms

- Independent, disconnected

- Sequential, disconnected

- Parallel, connected

- Integrated

Treatment of Co-occurring Disorders

• Independent, disconnected “model”

Result of very different and somewhat antagonistic

systems

- Contributed to by different funding streams

- Fragmented, inappropriate and ineffective care

Treatment of Co-occurring Disorders

• Sequential Model

- Treat SA Disorder, then MH disorder

- Treat MH Disorder, then SA disorder

- Urgency of needs often makes this approach inadequate

- Disorders are not completely independent

- Diagnoses are often unclear and complex

Treatment of Co-occurring Disorders

• Parallel Model

- Treat SA disorder in SA system, while concurrently treating MH disorder in MH system. Connect treatments with ongoing communication

- Easier said than done

- Languages, cultures, training differences between systems

- Compliance problems with patients

Treatment of Co-occurring Disorders

• Integrated Model

- Model with best conceptual rationale

- Treatment coordinated best

- Challenges

- Funding streams

- Staff integration

- Threatens existing system

- Short term cost increases (better long term cost outcomes).

Thank you, thank you, and thank you…