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Prescription Medication Abuse

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Introduction

Pain and addiction can co-exist. Addictions have a prevalence of 3-15%, with varying rates of drug, gender, etc.

Predisposition does not mean predestination.

Abuse of prescription medications has skyrocketed. The most common medications include:

opioids (oxycontin, percocet)
stimulants (ridalin)
benzodiazepines

There is a continuum of pain and addiction. Some patients sit in both camps.

When the drug is both the problem and solution, care can be made quite challenging.

Most patients don't need strict boundary setting, as they have their own internal set.

It is important to have a high index of suspicion for drug-seeking behaviour.

A single question -- "How many times in the past year have you used an illegal drug or used a prescripton medication for nonmedical reasons?" -- can effectively rule out drug abuse in a high prevalence population (Smith et al, 2010).

Universal Precautions in Pain Medicine

It is prudent to consider addiction in all patients.

Thoroughly inquire into drug and alcohol history in all patients.

ORT, CAGE, etc
set boundaries around medication use
identify aberrant behaviour

triage for risk

chronic pain patient

Dependence and Addiction

We need to use precise definitions around abuse, dependency, and addiction.

Addiction is a primary disorder, with continued use despite harm. An addicted enviroment's environment contracts with addiction.

Physical dependence is a state of adaptation...

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a decreased effect over time. Toleran

Pseudoaddiction: iatrogenic, maladaptive behavious resulting from inadequate pain control.

Boundaries:

treatment agreements
urine testing
interval/contingency dispensing: provide fewer pills and frequent check-ins with pharmacist
pill counting when the bottle should be half full.

Warning Signs

Be aware of the alarms and be forthright with addressing these.

"I don't like this other medication"

"I'm travelling. Can I have extra?"

Unilateral escalation of dosage is a very bad thing.

When people come in early.

When you increase the long-acting, and they continue with the same amount of PRN dosing.

Other considerations.

Comorbid psychopathology

Underlying primary addiction

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Prescribing Strategies

Contract with patient that they do not change the dose on their own.

** get an example of this contract

Get patients to bring in their medications when they come in for an appointment.

Ask the patients "What are you doing for your pain?", as looking to medications only is not ideal. Ensure they are trying to exercise appropriately, not damaging themselves further, caring for themselves, etc.

You need to provide a stable anchor for these patients.

If you people are running out; give them a higher dose but many less meds. If this does not work, bring in addictions medicine, but keep them as your patient.

Do not discharge patient if at all possible; they will now be free to wreak havoc in walk-in clinics/emergency departments.

If you set the box too tight, everyone will step out of bounds.