Pain.com: Dr. Passik could you please define and differentiate the terms addiction, physical dependence and tolerance of opioids based on the Consensus Document from AAPM, APS and ASAM ?

Dr. Passik: Addiction is not a technical psychiatric term and means many different things to different people, whether it is used in common parlance or in professional discussions. As defined by the leading societies in pain and addiction medicine, the term addiction is used to characterize a psychological dependence on a substance that is characterized by out of control, compulsive use and use despite harmful physical, psychological and social consequences. This is in stark contrast to the physiologic processes of physical dependence and tolerance. Physical dependence is an expected physiologic consequence of exposure to opioids that is expected to begin days to weeks or more after use. Physical dependence is characterized by the emergence of withdrawal symptoms upon abrupt cessation of a substance or the administration of an antagonist. Interestingly, physical dependence develops during exposure to many other classes of medications including corticosteroids and beta blockers. Tolerance refers to the need to escalate the quantity of a substance to maintain desired effects. In the case of the use of opioids for pain, tolerance also develops to the most of the side effects of opioids (except for constipation) which usually allows for the ability to titrate doses upward to meet the patient’s requirement for pain control over time. Physical dependence and tolerance have little or nothing to do with “addiction” when people are exposed to opioids for pain, where their implications are mainly to make sure people do not run out of their pain medicines abruptly or that they are tapered off if the painful condition ceases (physical dependence) and that dose modifications may be necessary at times to maintain pain control (tolerance).

Pain.com: Could you comment on the differences between a chronic pain patient and an addiction prone patient?

Dr. Passik: There have been many unsuccessful efforts to define an “addiction prone” personality in the substance abuse literature. The best predictors of substance abuse are not generally personality traits but instead are historical and familial risk factors. These predictors include: a personal or family history of substance abuse, psychiatric co-morbidities such as anxiety/mood and personality disorders, social factors that might bring one into increased contact with drugs and the addiction subculture, and a range of spiritual factors such as demoralization and loss of hope.

Interestingly, some chronic pain patients may have many such risk factors in their background. Thus a careful psychiatric interview that touches upon these factors is an important way to help a clinician decide not necessarily whether to give opioids (a medical decision based on the intensity of the pain, the history of failed treatments and to a lesser extent pain type – neuropathic/headache pain syndromes vs. somatic or visceral pain syndromes) but how opioids are to be given. That is to say, a patient deemed to be at lower risk can be treated with a relatively unstructured or minimally monitored approach whereas higher risk patients may need a more structured approach with involvement of mental health resources and a range of other safeguards.

Ultimately, the proof is in the outcome hopefully one characterized by meaningful analgesia, improvement in activity level and function, minimal adverse side effects and little or no aberrant drug-related behaviors – the so-called 4As. Drug abusers will almost always have a deterioration in their function when they use drugs, pain patients are more likely to manifest good outcomes in these areas.

Pain.com: For prevention of abuse, misuse and diversion with opioid treatment for pain, what criteria for patient evaluation and selection should be considered?

Dr. Passik: One of the most important things a clinician (and often this falls to primary care) can do prior to starting opioids is try to come to a determination of risk level for a given pain patient. Then they must decide is this a patient I can safely treat given my resources, time, expertise and setting. Not every pain patient will do well in every treatment setting. Thus, there is no shame in learning who one can treat alone (low risk), who one can treat with help (medium/high risk) and who one might have to refer out (high risk). Once the risk determination is made, if a patient has a significant history of problems with drug abuse, whether or not they can be managed in a particular setting should be considered and this would depend on the ability to provide the necessary structures and safeguards. In addition to psychiatric interviews, there are now multiple screening tools emerging in the literature that can be incorporated into clinical practice.

Many primary care physicians in rural and underserved areas find themselves with limited resources to which to refer higher risk patients. Thus, they may have to try to fashion the more structured approach in their own setting. Some of the reasonable safeguards that can be applied might include:

• limited quantity of drug per prescription
• urine toxicology screening, pill or patch counts
• use of mainly sustained release products with the lowest local street value
• judicious use of rescues
• obtaining an opioid agreement with parameters of acceptable drug-taking defined
• having the patient simultaneously involved in a recovery program, AA or other form of psychotherapy

Pain.com: Could you comment on addiction as it relates to short and long acting opioids?

Dr. Passik: There is, to my knowledge, no convincing empirical evidence that short-acting opioids expose low risk patients to any increased risk of substance abuse. The risk for addiction does not reside in the medications or in the formulation/delivery system, it resides in the interaction between the person and the product. While it is clear that street and recreational abusers prefer fast onset drugs to get high, there is no evidence that this observation translates in a blanket way to the pain population. The same might not be said for higher risk patients, for example those with a previous history of drug abuse who will need to be carefully watched on the shortest acting formulations if they are used at all.

Now one other consideration is whether we are talking about addiction with a “capital A” or addiction with a “small a.” Above we have been dealing mainly with what I call capital A addiction. In the chronic pain patient we sometimes see lower level misuse which has been called “chemical coping” in our literature. This isn’t a well-defined term and it has an unclear relationship to true substance abuse, but it would include self-medication of psychological symptoms and reactions to stressors (among other features). Such patients are often overly drug focused and do not engage readily in non-drug pain treatments, and are often on the fringes of appropriate drug taking but aren’t out of control or compulsive in their use. These patients often fail to reach psychosocial goals or even set them.

Now in my clinical practice, I have seen the short-acting drugs sometimes get caught up in this type of aberrant drug use while long-actings are less likely to. For example, if one gets angry and wants to take a pain pill not so much for pain as to calm down/soothe themselves, a long acting formulation with a delayed onset is unlikely to be appealing in such scenarios. My colleagues and I are working on a tool to identify this chemical coping phenomenon so that patients at high risk for this type of problem might be managed appropriately with the longer acting agents.

Pain.com: What is the importance of urine testing in safely managing the pain patient on opioids?

Dr. Passik: Many pain specialists these days are looking for ways to obtain some form of outside corroboration of patient-reported outcomes in pain management. Urine toxicology screening -- along with pill or patch counts, accessing of electronic prescription monitoring systems (where applicable), and obtaining input from the pharmacy – are different methods by which we can get additional data to this end. Urine screening can be rapid, inexpensive and effective if used in the right way as an adjunct to clinical exams and self-report. Indeed, in a recent study by Katz and Fanciullo, 20% of patients with no outward signs of aberrant behaviors had a positive toxicology screens. It is important to patient safety that they have only one prescriber and do not use illicit drugs during opioid therapy. Urine screens are a way to assure this safety and also for the clinician to be able to document that they are treating pain and not contributing to drug abuse and diversion.

Pain.com: Please advise our Pain.com visitors on prescribing considerations, including psychological, interval and contingency?

Dr. Passik: I think which opioids are used and how much latitude a given patient has for ad lib use of medicines for breakthrough should be the result of a careful consideration of the nature of the patient’s pain and their level of risk for abuse. Clearly a patient with incident pain or cancer pain with breakthroughs and no history of drug abuse should be given more latitude say than a patient with a history significant substance abuse who might need tighter external controls to help them avoid relapse.

Pain.com: What is your view on Opioid Agreements with pain patients?

Dr. Passik: Opioid agreements are important in my view. We can not expect patients to comply with the parameters of what is considered appropriate drug-taking if they have not been spelled out. Opioid agreements can be teaching documents that inform the patient of the risks and benefits of opioid therapy (though they may not substitute for a separate informed consent document in some states) and why certain behaviors (such as self-escalation) are not allowed – namely, because they can be harmful to the patient. Language that allows for clinical flexibility and judgment is important so that the clinician is not in violation of their own agreement. That is to say, that absolute language should be avoided, i.e., “There will be NO early renewals” should be replaced with, “The need for early renewals might be a sign to the treatment team that a patient is not in full control of their medications. Therefore, early renewals are not automatic and may be provided at the discretion of the medical team.”

All too often, opioid agreements are signed and put on the chart and then inappropriately referenced as a way to justify a patient’s discharge from a practice or clinic when they have had a behavioral slip. These agreements should be viewed as ongoing, subject to ongoing discussion and use. The following of the parameters of drug-taking is part of the examination of the patient and the 4As. Appropriate drug taking is to be reinforced and minor misuse corrected before discharge is seen as the only recourse for the patient who is at risk for having minor misuse possibly get out of their control.

Pain.com: What is the role of teamwork for example with pharmacists in a treatment plan for the patient at risk of addiction?

Dr. Passik: I think teamwork is crucial. Many patients will need input from other professionals to help in their rehabilitation and return to function. This may also pertain to the pharmacist, who can provide outside corroboration of drug-taking behaviors and who should be enfranchised as a team member. This should be done after a patient is asked to designate a single pharmacy that they will utilize to fill their prescriptions.

Pain.com: How important is record keeping for patients that are at risk of addiction?

Dr. Passik: Thorough documentation is mandated in most, if not all, guidelines for opioid prescribing regardless of the patient’s risk level. The use of opioids carries with it some professional obligations which are (at minimum) to see your patient at the appropriate intervals, examine them and document findings and outcomes. If a patient is deemed at high risk for addiction or diversion, the clinician should recognize that this is a controversial subgroup of patients for chronic opioid therapy (for non-malignant pain) and documentation might have to be just that much more frequent and detailed. I can recommend visiting the website for the National Pain Education Council (www.npecweb.org) and downloading an assessment tool that I developed as a chart note with colleagues in pain and addiction to be used to improve one’s ability to thoroughly document outcomes and do it a bit more rapidly than might otherwise be possible.
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