Pain and Addiction: More Than a Feeling
Walter Ling, MDIntegrated Substance Abuse Programs (ISAP)
UCLA Dept. of Psychiatry Pacific Southwest ATTC
Tenth Annual Training and Educational Symposium September 18, [email protected]
Pain and Addiction: Role of the Opioids
• Scope of the talk:– Addiction: a brain disease– On becoming and staying addicted– Defining pain: acute and chronic pain– Addiction in pain patients: how to tell– Opioids: the two faces of Janus– Opioids in chronic pain– Overcoming addiction and chronic pain
Addiction: A Brain Disease What, Where, and How
• Our Three Brains• Reptilian brain: Survival--feeding, fighting, fleeing, reproducing • Limbic brain: memory and emotion—love, attachment, consideration for
others, foundation for community and civilization • Cortical brain: CEO and operating system--intelligence, intuition, insight
flexibility, speed, efficiency, creativity, morality, free will, meaningful life, uniquely human, under construction
Addiction: Why Do People Take Drugs?People Take Drugs To: Feel Good (Sensation seeking) Feel Better (Self medication)
One way or the other they like what drugs do to their brain
Dopamine
0100200300400500600700800900
10001100
0 1 2 3 4 5 hrTime After Amphetamine
% o
f Bas
al R
elea
se
AMPHETAMINE
0
100
200
300
400
0 1 2 3 4 5 hrTime After Cocaine
% o
f Bas
al R
elea
se
DADOPACHVA
AccumbensCOCAINE
0
100
150
200
250
0 1 2 3 hrTime After Nicotine
% o
f Bas
al R
elea
se
AccumbensCaudate
NICOTINE
0
100
150
200
250
0 1 2 3 4 5hrTime After Morphine
% o
f Bas
al R
elea
se
Accumbens
0.51.02.510
Dose (mg/k
g)
MORPHINE
Conditioned Response: Reward DrivenLearning, Memory and Behavior
Pavlov’s Dog1849-1936
(
Conditioned learning incorporates the drug use environment into drug use memories and adds weight –salience—to these memories, giving them higher priority in driving drug use behavior
until it takes over everything.
Dopamine Dopamine: the brain’s motivational or “feel good” chemical. It makes us want to do it again—to repeat what activates its releaseDopamine is also involved in reward-driven learning and memory: conditioning
How the Brain Got Its Addiction • You begin with a normal brain and subject it to repeated
exposures to drugs: dopamine spikes • Repeated reward-driven, salient, learning experiences
became encoded as enduring conscious and unconscious memories.
• The reward-driven salient drug use memories gain higher and higher priority in driving drug use behaviors until they take over everything—extreme take over.
• This is how the brain got its disease of addiction.
“First the man takes a drink, then the drink takes a drink, then the drinks takes the man”. Japanese proverb
Disconnection between the limbic and cortical brain, an extreme
take over brain disease
Becoming and Staying Addicted: A Matter of Drugs and Memory
• Becoming addicted is a matter of drugs • Staying addicted is a matter of memory• The problem of addiction is not getting off drugs; it’s
staying off drugs.• Detoxification may be good for a lot of things, but
staying off drugs is not one of them• To stay off drugs—relapse prevention—you have to
deal with drug memories: no memory, no relapse• Relapse prevention means substituting drug
memories with non-drug memories.
Defining 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 through experiences related to injury in early life.—IASP
IASP = International Association for the Study of Pain
Early life -- historical Experience--learned Subjective--private Individual--unique
Acute vs Chronic Pain:
Acute Pain• Physiological; protective• Causes external; obvious• Tissue damage; resolution expected within days/wks• Symptom of illness• Happens TO you• Key issue: what pain?• Meds/big role vs self
Chronic Pain• Pathological; non-protective• Causes internal; obscured• CNS changes; resolution depends
on mastery/control• Disease & way of life • Happens IN you• Key issue: what patient?• Meds/limited role vs self
The Acute pain patient is afflicted; the Chronic patient is transformed. Chronic pain sufferer suffers for nothing
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 provide support• Patient feels neglected when others can’t do all• Patient becomes anxious, angry and depressed• Patient assumes life style of chronic pain
Defining Addiction in Pain Patients
• Addiction….is characterized by behavior that includes one or more of the following: impaired Control over drug use, Compulsive use, Continued use despite harm, and Craving AAPM/APS/ASAM
• Addiction is not taking lots of drugs; it’s taking drugs and acting like an addict.
• Addicts are addicts not for who they are, but for what they do.
Who’s at Risk and How to Tell?
• 4 Ways to identify patients at risk– History—personal history and family history– Screening instruments – Behavioral checklists– Therapeutic maneuver
History• What predicts addiction?– Personal history of drug use– Family history of drug use– Current addiction to alcohol or cigarettes– History of problems with prescriptions– Co-morbid psychiatric disorders– Same predictors as in non-pain patients
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 misuse 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 3Illegal drugs 2 3Prescription drugs 4 4
2. Personal history of substance abuseAlcohol 3 3Illegal drugs 4 4Prescription drugs 5 5
3. Age (mark box if between 16-45 years) 1 14. History of preadolescent sexual abuse 3 05. Psychological disease
ADO, OCD, bipolar, schizophrenia 2 2Depression 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.
Butler S et al, Pain, 2005
SOAPP® V.1 – 24Q
Aberrant Drug-Taking Behaviors•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 clinician
Passik and Portenoy, 1998
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
Patie
nts
Exhi
bitin
g B
ehav
iors
(%
) CancerAIDS
Passik et al. 2003
Probability of positive urine toxicology by number of aberrant behaviors
Katz N et al, Clin J Pain, 2002
05
1015202530354045
%
0 1 2 or more OverallNo. of aberrant behaviors
Higher prevalence of SUD among pts on opioids for chronic pain than general population (8.1% current users)
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 functioningAbsence of toxicity
PseudoaddictionTherapeutic dependence
Unimproved functioningPresence of toxicity
Addictive disease
Opioids in Chronic Pain: The Two Faces of Janus
Opioids:• Relieve pain• Relieve suffering• Relieve misery• Make you feel better • Make you feel good• Make you “high”
Use of Opioids for Chronic Pain
• 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 behavior; “Pees”
The 4 A’s (Passik); the 4 “P’s”
Treating Pain with Opioids: What Can We Expect to Achieve?
Meaningful Pain Reduction• Using a VAS or Numeric scale of 0-10
– (4-6= mod 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%)
M. Soledad Cepeda et al. Proc 10th world Cong on Pain vol 24; pp 601-609 IASP
press 2003
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
• Achievable, enjoyable, and meaningful– Hobbies– Volunteer work
Chronic Pain and Suffering: Some Basics
• Chronic pain hurts, but seldom harms• Chronic pain patients are not bothered by pain; they are plagued by
suffering.• Pain happens to you, suffering happens in you. • Pain is the enemy outside; suffering is the demon within. • Pain is inevitable and universal, suffering is optional and individual• Pain can be likened to how much money you owe; suffering is how
poor you feel.• Suffering cannot be cured, it can only be conquered and mastered.
Chronic Pain and Addiction: Memory Matters
• Characterized by aberrant behaviors that persist despite their being destructive and detrimental to one’s best interest.
• Behaviors are based on a distorted belief system rooted in deeply ingrained learning and memory of past experiences.
• Both involve brain changes that result in the hyperexcitability of a lower brain and loss of control from a higher rational brain
• Neither can be gotten rid of but must be overcome with new and different reward-driven learning life experiences creating a new memory bank and a new belief system and new behaviors.
• We are all created equal, but we don’t sit down at the table with the same hand; hence, different clinical expressions.
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”– Over interpretation– “Catastrophization”
• Addiction– Early trauma– Loss of mastery– Loss of control– Loss of self-efficacy– Cognitive error– “Nirvana”– Denial
Overcoming Chronic Pain• The sufferer of chronic pain is permanently
preoccupied by it and suffers as a result.• Overcoming chronic pain means learning to
overcome suffering, no matter what happens.• Be prepared physically and emotionally• Actually engage in the act and take charge• Reconnect and become engaged with friends and
family and community• Regain a meaningful balanced life
How Not to Succeed • 1. Don’t attend• 2. Try not to learn anything• 3. Don’t do any of the exercises• 4. Don’t try any of the techniques• 5. Keep a closed mind• 6. Resist change• 7. Look and act miserable• 8. Tell yourself “nothing will help me”• 9. Remain very serious and never smile• 10. Don’t share anything (R. N. Jamison)
Relapse: A Three-Character Play • Drug memories: …everything, seems to bring
memories of you…(Eubie Blake)• Cues and triggers: external and internal; craving
and desire for love lost—regression & comfort• Emotional buildup: justification for use—the
internal dialogue making use okay and natural
• Relapse does not happen by accident.
Treating Chronic Pain and Relapse Prevention: Forget It?
• Addiction is memory; so is chronic pain • No memory, no relapse; no memory, no suffering• Both are brains transformed—cannot be gotten rid of, can
only be conquered and controlled • Both require memory substitution• Behavior creates experience, experience creates memory,
memory creates belief systems, belief systems determine new behavior, new behavior determines new outcome.
• Change your memory, change your brain, change your brain, change your life.
• The only way to have your life turn out different is to act differently.
Creating Non-Drug Memories: The Old Fashion Way
• Experience–activities—leads to protein synthesis• Protein synthesis activates new gene expressions• Gene expressions create new brain connections• New brain connections produce new memories • New non-drug memories create non-drug belief
systems that determine behaviors that determine how life turns out.
• The only way to change your life is to do things differently so they will turn out different.
Preventing Relapse:Eight Steps to a Drug-Free Life
• Sound physical health• Sound mental health• Stay off drugs and stay busy• Take care of business: out of jail and on the job• Take personal responsibilities• Live in harmony with family and friends• Be a good member of the community• Search for a meaning in life.
Spirituality, Mindfulness, and a Meaningful Life
In a Nutshell• Mindfulness of motivation: Doing good for
someone else is better than feeling good yourself; it’s the true path to happiness.
• Mindfulness of wisdom: Conventional reality is an illusion; Inherent reality is emptiness. All things follow the laws of impermanence and non-self. Nothing lasts forever, nothing can be possessed, and you can’t take anything with you.
What Are We? Unique or Random?
Thank you Thank you Thank you
Top Related