When Should Opioids Be Discontinued? Assessing Aberrant Medication-Use Behaviors in Patients with Chronic Pain

When Should Opioids Be Discontinued?

Assessing Aberrant Medication-Use Behaviors in Patients with Chronic Pain

Penelope P. Ziegler, MD, FASAM

Program Overview

In many cases, opioids are an effective therapy for the management of moderate-to-severe chronic pain. Although popular belief often exaggerates the relationship between opioids and addiction, the risk does exist. It is necessary, therefore, for the practitioner to be aware of the aberrant behaviors that may be indicative of the disease of addiction or which may play a part in the process of drug diversion. Additionally, the practitioner must recognize that not all aberrant behaviors are caused by addiction, abuse or misuse. In particular, pseudoaddiction may lead to symptoms similar to those of addiction, but these behaviors easily resolve upon obtaining adequate pain management. All patients deserve adequate pain management; the pain practitioner is better able to fulfill this patient right when aberrant behaviors are appropriately addressed.

This activity highlights some of the behaviors that the practitioner may encounter in a pain management practice and describes how they may be effectively managed.  The reader will learn the criteria necessary for a diagnosis of addiction, the conditions that should be included in the differential diagnosis, and the responsibilities of the practitioner when opioid therapy is discontinued. Case studies are used to highlight the diagnostic process, as well as both pharmacological and nonpharmacological treatment approaches for addiction and the related disorders.

Target Audience

This activity is designed for physicians, pharmacists, physician assistants, and nurses who have an interest in enhancing their knowledge and understanding of pain management.

Learning Objectives

Persons reading this monograph should be able to:

1. Give four criteria for the diagnosis of addiction in a patient being treated for chronic pain with opioid medications;
2. Describe three nonpharmacologic therapies which can be added to a medication regimen to improve outcomes for patients with chronic pain;
3. Define pseudoaddiction, and give three examples of aberrant behaviors that may contribute to a finding of pseudoaddiction in a patient with chronic pain;
4. List the ethical obligations of a practitioner who has determined that a patient being treated for chronic pain should discontinue opioid therapy.

General Information

This activity is eligible for credit through April 1, 2009. After this date, this activity will expire and no further credit will be awarded.

Expected time to complete this activity as designed: 60 minutes

There are no fees for participating in this activity. All participants must complete the Activity Evaluation Form. Participants must receive a minimum score of 70% on the self-assessment portion of the form to qualify for CE credit. Certificates may be printed immediately after successfully completing the online self-assessment and evaluation.

Faculty Biography

Dr. Penelope Ziegler received her medical degree from The George Washington University in Washington, DC and completed a psychiatry residency at The Sheppard and Enoch Pratt Hospital in Baltimore, Maryland. She is medical director emeritus of Williamsburg Place and the William J. Farley Center in Williamsburg, Virginia. She is also an associate clinical professor of psychiatry at Virginia Commonwealth University in Richmond, Virginia.

A board certified addiction psychiatrist and certified fellow of the American Society of Addiction Medicine, Dr. Ziegler has been working in the field of addiction medicine for more than 20 years. She currently serves on the Board of Directors for both the American Society of Addiction Medicine and American Academy of Addiction Psychiatry. Her special interests include addictive disease in health care professionals and women, the relationship of addiction in sexual trauma, and the challenging relationship of pain and addiction.

Accredidation

CME CREDIT

Accreditation Statement: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of MediCom Worldwide, Inc. and Medical Learning Solutions. MediCom Worldwide, Inc. is accredited by the ACCME to provide continuing medical education for physicians.
Designation Statement: MediCom Worldwide, Inc. designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

CPE CREDIT

MediCom Worldwide, Inc. is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. Its CE programs are developed in accordance with the “Criteria for Quality and Interpretive Guidelines” of the ACPE. This program is acceptable for 1.0 contact hour of Continuing Education Credit. Universal Program Number: 827-999-08-105-H01-P

NURSING CREDIT

Accreditation Statement: This activity has been planned and implemented through the joint sponsorship of MediCom Worldwide, Inc. and Medical Learning Solutions. MediCom Worldwide, Inc., 101 Washington Street, Morrisville, PA 19067 is approved by the California Board of Registered Nursing, Provider Number CEP11380. MediCom designates this CNE activity for 1.0 contact hour. Program Number: 08-205-201

Disclosure

It is the policy of MediCom Worldwide, Inc. to plan and implement educational activities in accordance with the ACCME, ACPE and California Board of Nursing. As a provider, it is the policy of MediCom Worldwide, Inc. to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities.

All program planners, faculty, and providers are required to disclose any relevant financial relationships they may have or have had within the last 12 months with the commercial supporter or the manufacturer(s) of any commercial device(s) discussed in this educational activity.

Faculty Financial Disclosure

The presenting faculty reported the following: Dr. Penelope Ziegler has disclosed that she has no significant relationships with the grantor Cephalon, Inc. or any other commercial company whose products and services may be related to her presentation.

Planner and Provider Financial Disclosure

The individuals listed below from MediCom Worldwide, Inc. reported the following for this activity: Joan Meyer, executive director and Alan Vogenberg, RPh, FASCP, clinical advisor have nothing to disclose.

Jeffrey Gudin, MD, was the clinical reviewer for this activity and has nothing to disclose. Ruth Widmer, medical editor of Corona Productions has nothing to disclose. 

Conflict of Interest Resolution

To identify and resolve conflicts of interest, the educational content was fully peer reviewed by a member of the MediCom Worldwide, Inc. Clinical Content Review Committee. The resulting activity was found to provide educational content that is current, evidence based, and commercially balanced.

Off-Label/Investigational Disclosures

In accordance with MediCom Worldwide, Inc. policy, the audience is advised of the following disclosures regarding unlabeled or unapproved uses of drugs or devices: Dr. Ziegler indicated that her presentation would include the discussion of quetiapine for agitation and insomnia; gabapentin, topiramate, duloxetine and tricyclic antidepressants for chronic pain. These drugs are not approved by the FDA for these uses in the United States.

Dr. Ziegler indicated that her presentation would not include the discussion of products that have not been approved by the FDA for any use in the United States at the time of printing.

This activity is supported by an independent educational grant from

©2008 MediCom Worldwide, Inc., 101 Washington St., Morrisville, PA 19067.
 

Introduction

When a patient receiving opioid treatment for chronic pain exhibits aberrant behaviors, the treating practitioner is faced with a diagnostic and management challenge. Some of these patients may be addicted, but addiction is far from the only consideration in the differential diagnosis. Other reasons that patients may be non-adherent and/or manipulative with their opioid medications include:

• Pseudoaddiction
• Undiagnosed comorbid psychiatric illness
• Somatization
• Chemical coping
• Diversion for profit or on behalf of a loved one

Pseudoaddiction is a term used to describe a condition in which a patient demonstrates aberrant behaviors, such as unsanctioned escalation of drug dosage, repeated requests for early refills, complaints of lost or stolen prescriptions, etc., which may be suggestive of addiction, but are actually symptomatic of inadequate pain control. The patient may also supplement the prescribed medication with illicit or recreational drug use, such as borrowing or buying another’s prescribed controlled substance analgesic, purchasing ‘street drugs,’ smoking marijuana, or drinking alcohol in excess to decrease the pain. When these types of behaviors are recognized by the clinician and the treatment plan is altered to manage the patient’s pain adequately, the behaviors resolve. In addition, both drug tolerance and hyperalgesia must also be considered as possible causes of pseudoaddictive behaviors. Patients prescribed to long-term opioid therapy may eventually show signs of hyperalgesia or become opioid tolerant. Under these circumstances, pain increases despite an increase in opioid analgesic dosing. If these conditions are not recognized and if the opioid prescription remains unchanged or the dose is not reduced, the patient may seek increased pain relief by using illicit or poor judgment options to minimize the pain.

The next three causes of nonadherence are related, since all involve aspects of the patient’s emotional and mental stability. However, they need to be differentiated, because effective treatment approaches are different.

Undiagnosed psychiatric illness, such as bipolar disorder, major depressive disorder, panic disorder, severe generalized anxiety disorder and psychotic disorders, can all distort and impair the individual’s judgment and impulse control, magnify the severity of painful conditions, and make it difficult to ask for help or to discuss his or her symptoms openly with the health care provider. Posttraumatic stress disorder (PTSD), for example, is characterized by the individual’s attempt to modulate re-experiences such as flashbacks, nightmares, and recurrent vivid and painful memories. Persons with PTSD often have a concomitant drug and/or substance misuse disorder. In clinical populations (focusing on either disorder), about 25-50% have a lifetime dual diagnosis of posttraumatic stress disorder and substance-use disorder. Patients with both disorders have a more severe clinical profile than those with either disorder alone, lower functioning, poorer well being, and worse outcomes across a variety of measures.

The Cluster B Personality Disorders - Borderline Personality Disorder, Narcissistic Personality Disorder and Histrionic Personality Disorder - all include substance misuse and/or abuse as one criterion for the diagnosis. Most persons with personality disorders who misuse medications are not suffering from the disease of addiction, but are demonstrating behaviors related to impulsivity, impaired judgment, and inability to tolerate strong affect. However, this condition needs to be assessed carefully to rule out a comorbid substance use disorder.

Chemical coping, on the other hand, refers not to an independent illness but to a group of behaviors in an otherwise stable individual who, under stress, may use a variety of substances to decrease the internal discomfort they are feeling. Such persons usually do not have a psychiatric diagnosis, but are lacking in mature stress management skills and are intolerant of inner conflict. Others may be feeling overwhelmed by the intensity of the current stress, whereas normally they are able to manage their usual stress level. Chemical coping is reinforced in our society, with nightly television ads suggesting that, when one doesn’t feel good or is experiencing some uncomfortable symptom, the appropriate response is to take a pill.

Somatization is the tendency of some persons to experience their emotional distress as a physical symptom or cluster of symptoms. Most chronic pain patients struggle with some degree of somatization which coexists with and amplifies their physical pathology. In cases where the patient has a strong tendency to somatize, and has access to pain medication via doctor’s prescription, nonadherence to dosages and frequency of medication use is very common and can be difficult to manage.

When true addiction, defined as a neurobiologic disease of compulsive use of an addictive substance in spite of harmful consequences to the user and society and influenced by genetic, psychosocial and environmental factors, is present, the patient will demonstrate some or all of the following cardinal signs and symptoms:

• Control problems, in which the patient takes more of the medication than he or she intended to take, or takes medication despite an awareness that it is not indicated by the physical symptoms present at the time
• Craving for the medication
• Compulsive continued use of the medication in unauthorized doses or frequency, accompanied by constant or near-constant preoccupation with the medication
• Continued use of the medication in spite of negative consequences, including overdose, deterioration of overall physical functioning, impairment of relationships, job performance, etc.

Determining if and when a patient is not responding well to opioid treatment for chronic pain is a complex process requiring comprehensive ongoing assessment, flexibility of the treatment plan, and willingness to consider all of the possible diagnostic variables. This process requires transparent and proactive communications by all parties of the health care team, including the pain management specialist, consulting physicians, the pharmacist and anyone else who may be asked to assess and monitor the patient’s care. It is often only through multiple observations that aberrant behaviors may be identified and “stories” may be deemed inconsistent. A multi- or interdisciplinary approach to pain management care helps to contain risk for this very reason.

Finally, it remains inappropriate and unethical for the treating professional or pain management practice to summarily discharge a patient who is demonstrating aberrant behaviors without formulating an alternate treatment plan based on a thorough diagnostic understanding of the patient’s condition, and arranging referral to an appropriate provider or facility for continued treatment. This principle is consistent with the Code of Medical Ethics (American Medical Association), Hippocratic Oath, and pain care standards established by The Joint Commission (previously referred to as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)).

The following cases are used to illustrate these points:

Case I: ADAM

Adam is a 32-year-old married white male, with two young children, who was on disability prior to the referral, but who had previously worked in management-level sales jobs (store manager of a retail outlet, district sales manager).

Adam had a history of multiple severe injuries in car wrecks and sports mishaps, with a total of 11 fractures and 20 surgeries, including three procedures on his lumbosacral spine, plus a recent cervical spinal fusion. He was referred by his pain specialist because of intractable pain despite high-dose opioid therapy, with frequent and recurrent aberrant medication-taking behaviors including one arrest for forgery of a prescription using the referring physician’s DEA number. He had never received treatment for a substance use disorder. His family members were also encouraging him to seek addiction treatment.

The patient had a long history of polysubstance misuse beginning in adolescence and including alcohol, marijuana, cocaine, methamphetamine, hallucinogens, and inhalants. Ironically he had used no opioids or benzodiazepines until he began pain treatment four years prior to this referral. During this four-year period he had seen five pain specialists and two psychiatrists.

At the initial visit, Adam reported his current drugs as:

• Diazepam 50-60 mg daily
• Oxycodone immediate-release 80-200 mg daily
• Oxycodone timed-release 80 mg twice daily
• Marijuana 2-3 joints daily
• Beer 6-18 per day on weekends with 2-4 beers on weekday evenings
• Variable and inconsistent doses of gabapentin, amitriptyline, cyclobenzaprine, escitalopram, quetiapine, ibuprofen, and aspirin

He acknowledged being noncompliant with his prescribed physical therapy (PT), structured exercise program and doctor visits. He often called for early refills or to replace a lost prescription. He admitted he was seeing other doctors (“doctor-shopping”), frequently visiting ERs, and forging or altering his doctor’s prescriptions.

Adam’s wife, while residing in another state with her family who were helping her both financially and with caring for her children, was threatening divorce. She said that she was afraid to stay with Adam because of his violent temper when he was drinking or when he could not get enough of his opioid medications. He had smashed furniture and thrown objects at her, and had been verbally abusive with his children. Adam denied any history of childhood abuse, but both of his parents were daily drinkers who also used marijuana. His brother was addicted to heroin.

Review of Symptoms: The patient had complaints in almost every system, especially back and neck pain, pain in the right hip, right shoulder, feet and knees. He rated his overall pain as 8 on a scale of 1 to 10, but did not appear to be in distress.

Physical examination: The patient had multiple surgical scars on his extremities, back, and abdomen that were well healed. Widespread tenderness and hyperreflexia, with abnormal gait with limp due to right hip pain were present. He acknowledged that opioids were not modifying his pain, and that benzodiazepines had not helped him sleep, but he kept hoping that taking more would work.

Detoxification: Once he began to demonstrate symptoms of opioid withdrawal, the patient underwent induction on buprenorphine hydrochloride (HCl) and naloxone HCl with an initial daily dose calculated at 20 mg, given in divided doses. He was also started on a phenobarbital taper starting at 60 mg three times daily and 240 mg at bedtime to manage withdrawal from alcohol and sedatives. When it was clear that he was having some breakthrough sedative and opioid withdrawal, he was started on gabapentin and tizanidine. Successful medical withdrawal from opioids and sedatives was uneventful and completed in 21 days. The patient was also started on naproxen and quetiapine 50 mg at bedtime. He was gradually switched from escitalopram oxalate to venlafaxine HCI.

A Pain Management Plan (Treatment Agreement) was developed specifying both the pharmacologic and nonpharmacologic interventions, dosage schedules, appointments with various practitioners, and agreement to refrain from unacceptable behaviors. The nonpharmacologic treatments were emphasized; including acupuncture, physical therapy with a specialist in posttraumatic musculoskeletal problems, weekly pain management group, and individual relaxation training.

Addiction treatment began in a partial day hospital setting with intensive cognitive behavioral therapy (CBT), addiction education, introduction to 12-step programs, expressive therapies (art therapy and movement therapy), and individual therapy. During his medical withdrawal and the first few weeks of the addiction treatment, the patient was quite resistant to identifying as a person with chemical addiction, justifying his drug use as necessary to deal with his severe pain. As his withdrawal symptoms eased and craving for drugs lessened, he was able to acknowledge that he used drugs and alcohol to deal with his pain despite the awareness that this was not working. He was able to identify with this as a cardinal feature of addictive disease, along with the various repetitive behaviors that had resulted in negative consequences (forging and altering scripts, refusing to try nonpharmacologic therapies, lying to his wife and children, spending money needed by his family to buy alcohol and drugs).

Adam was surprised to find that, as he progressed in multidisciplinary treatment, his pain became less intense, and he was able to participate in physical activities that had been impossible for him prior to entering treatment. He continued to have severe insomnia, despite trials of various nonreinforcing medications. Sleep hygiene training and use of a meditation tape prior to going to bed were more helpful than any of the medications tried. During the third month in treatment, dosages of gabapentin, quetiapine and tizanidine were gradually tapered and discontinued. Amitriptyline 50 mg nightly was started with some decrease in physical discomfort during the night but with minimal benefit in improving sleep quantity.

After completing three months of full-time treatment, Adam was able to transition to a less intensive regimen with weekly addiction continuing care group, PT once weekly, continued daily 12-step meetings and monthly visits with a psychiatrist for medication management and pain management. Working with his disability company, he transitioned into part-time employment in sales at a new car dealership. At the end of six months he was working 32 hours per week and doing well. His wife and children began short visits while he was in rehabilitation, and the patient and his wife had couples therapy monthly at first, then weekly after his wife agreed to move back into the home.

When Adam celebrated his one-year anniversary of recovery at his Alcoholics Anonymous home group, he spoke about the fear and shame that had prevented him from being honest with his pain doctors about his drinking and drug use. He said that prior to beginning treatment for his substance use disorder he could not conceive of living a drug-free life, but he had now been doing so with significant amounts of help for one year. Moreover, he had less pain, less anxiety and less depression than he had ever experienced taking prescription drugs while simultaneously drinking alcohol to excess and using illicit substances.

Discussion: This case illustrates the difficulty of making a diagnosis of addiction in patients with chronic pain who are not willing to provide the practitioner with accurate information about their current drug use and history of substance abuse. Anyone who undertakes treatment of chronic pain needs to be prepared to meet addicted patients, and must be armed with an understanding of the disease and some level of acceptance of certain facts, as detailed in Table 1.

        
          Table 1: Facts About the Disease of Addiction

• Patients with addiction lie.
• Patients with active addiction are often in denial of the reality of their situation, and may actually believe that they do not have a problem with substances, do not use more than anyone else, and can quit any time they choose.
• Patients with addiction have a brain disorder, which results in distorted perceptions, irrational thinking, altered memory function, impaired judgment and impulse control, and compulsive drug-seeking behavior.
• Patients with addiction would behave better if they could.

In this patient’s case, since the patient had started using drugs that alter the brain in early adolescence, and had grown up in a family with alcoholic parents, he had no concept of normal adult functioning and continued to operate with the mind of a bright, imaginative young teenager. Observing his behavior from this perspective, it seems more understandable, if no less frustrating, to his medical care givers and family members. His extreme intolerance of pain (physical and emotional) may be related in part to the development of hyperalgesia, but it is also primarily the response of his adolescent level of functioning. This may also explain why he has done so well in the 12-step program, where structure, specific direction and consistent support are meeting his needs as he works through the difficult process of emotional maturation.

Case 2: MELISSA

This 38-year-old, married Caucasian homemaker and mother of three, formerly an elementary school teacher, was brought in for evaluation by her husband after she had been discharged from a local pain practice due to “being an addict,” without any referral or plan for continued treatment. She had been receiving treatment at the pain practice for 18 months with diagnoses of fibromyalgia and migraine headaches. Prior to being discharged, her medications were controlled-release oxycodone 80 mg daily, fentanyl patches, hydrocodone for breakthrough pain, and butorphanol nasal spray for headaches as needed. For several months she had been requesting early refills due to running out of medications; making visits to the hospital 2-4 times per month with a severe headache, requesting injectable opioids; and having two urine drug screens positive for marijuana.

Melissa presented for an emergency appointment three days after she was dismissed by the pain doctor. At that time she was in severe opioid withdrawal with tremors, dilated pupils, piloerection, diaphoresis, and she was complaining of severe abdominal cramps, frequent watery diarrhea, and had vomited four times in the morning. She verbalized feelings of hopelessness and despair, but denied suicidal ideation or plan.

She was immediately admitted to the residential detoxification unit and started on buprenorphine, with a plan to complete a 21-day taper.

Despite her clear physical dependence on opioids, it was difficult to make a diagnosis of addiction in this patient. When a patient is being treated with opioids by a physician, one cannot use physical dependence or tolerance as diagnostic criteria. She had no prior history of substance abuse or dependence, and had never tried to cut down or stop using her medications. She stated that she used marijuana to treat the nausea caused by the opioids, and had not been using this drug prior to beginning pain treatment, although her husband was a daily user. She denied any current alcohol or other illicit drug use. She was compliant with attending group therapy and educational groups on the detoxification unit, but had difficulty identifying with the other patients or the description of progressive substance dependence being presented in the educational groups.

Melissa did relate strongly to the other patients who were attending the weekly pain management group, and was an enthusiastic participant. She felt that the therapist and other patients were the first people she had met that really understood the emotional and physical experiences of living with pain. With some reluctance, she did see the acupuncture practitioner and physical therapist for initial consults, expressing strong skepticism of their ability to help her with techniques that did not involve drugs. After initial consultations and discussions with her treating physician and other patients in the pain group, she agreed to begin a regimen of acupuncture and physical therapy, initially three times weekly, and massage therapy twice weekly.

When the initial evaluation by the treatment team failed to find indications of an addictive disorder, the patient’s treatment plan was changed. She was stabilized on a maintenance dose of buprenorphine HCl and naloxone HCl 8 mg twice daily, and was started on pregabalin 150 mg three times daily for her fibromyalgia. After several trials of triptan preparations to abort migraines, it was determined that she responded best to zolmitriptan disintegrating tablets 5 mg administered immediately upon onset of a migraine headache, with a repeat if needed in two hours. As a prophylactic intervention for migraine, a trial of topiramate 25 mg at bedtime was begun and gradually increased to 100 mg nightly.

Melissa was discharged from the detoxification unit after five days, and continued to see the addiction psychiatrist until the treatment plan was stabilized (approximately one month). She was then referred to a pain medicine specialist who was familiar with the use of buprenorphine in the treatment of pain and was comfortable working with the other professionals involved in her treatment. She continued to attend the weekly pain management group, and also saw the therapist from the group weekly for individual sessions in which relaxation training and guided imagery were found to be helpful. Frequency of acupuncture treatments and physical therapy sessions were decreased gradually to once monthly, but she continued to benefit from twice-weekly massage therapy. She also joined a fibromyalgia support group. At six months, Melissa had returned to work as a substitute teacher for approximately 20 hours per week.

After working with her therapist for five months, she finally began to talk about her history of childhood sexual abuse by her father’s brother beginning at age six. Her family members had not believed her when she tried to tell them about the abuse, which continued until age twelve. The sexual abuse became a new focus of psychotherapy, and she began seeing a new therapist who specialized in treating childhood trauma. She stated that it was other women in the fibromyalgia group who, by talking openly about their childhood abuse histories, gave her the courage to open up about this lifelong shame-based secret.

Discussion: This case illustrates the concept of pseudoaddiction in which Melissa behaved “like an addict” due to inadequately treated pain. The previous pain doctor was not able to recognize this pattern because he was not looking for it, was not well-informed about the most effective approaches to assessing aberrant medication-taking behavior, and had a judgmental attitude about addiction.

This patient also had undiagnosed psychological issues which did not come to light until well into the new, more comprehensive approach to treatment for her chronic pain. These issues were not causally related to the pain itself, but may well have contributed to the aberrant behavior patterns. Whereas the addict may engage in these behaviors due to increasing tolerance, craving for more of the drug and compulsive drug taking, this patient’s behaviors were motivated by her inability to be open with the doctor due to longstanding psychological patterns. She had great difficulty asking for help, probably because her early life experiences had taught her that she would not be believed or would be blamed.

Another important aspect of this case is its ethical ramifications. The patient was “discharged” from the practice where she had been receiving treatment with no plan for continued treatment, no referral and no source for the medication upon which she was physically dependent. The term “discharge” implies that the patient has either fully recovered, requiring no continuing care, or has been involved in the development of a plan of continuing treatment with specific referrals, appointments, and sufficient medication to prevent a crisis before the new practitioners are seen. In this case, “discharged” is a euphemism for “thrown out.”

Whether a practitioner reacts with anger, disgust or a sense of futility in the face of a patient’s behavior, he or she is still obligated by medical ethics and simple human compassion to follow through on the commitment to “Do No Harm.” Even when a patient refuses to cooperate with the discharge planning process, the professional must provide appropriate recommendations and referrals. Addiction providers have a term for the fairly common phenomenon illustrated by this case, in which none of these obligations were fulfilled: Dumping.

When a patient is “dumped” or “thrown out” of a practice, he or she is not only without care but without hope. The experience of being thrown away leaves an individual with a sense of worthlessness and a belief that she is beyond salvage. This patient was fortunate in having a husband who did not see her in this way, and took action to get help for her. Too often a patient in this predicament will have no such supportive person or system to intervene, and the outcome can be tragic.

In this patient’s case, her experience of rejection and abandonment by the pain doctor was a re-enactment of her childhood experiences, with parents rejecting her claims of abuse and refusing to step in to stop it. This reinforced her beliefs in her own worthlessness, as well as her inability to trust that anyone would believe her. It prolonged her silence about her abuse for many months, preventing her from getting all of the help she needed.
 

Summary and Suggestions

When patients demonstrate compliance with their opioid dosing regimen it generally means that the patient will derive benefit from the therapy. Alternately, frequent episodes of severe aberrant behavior are generally associated with therapy that may result in harm to the patient and may indicate active addiction. Recent study data suggest that patients with chronic pain who are prescribed to opioid pain relievers demonstrate a frequency of opioid use disorders four times higher than that of general population samples (3.8% vs. 0.9%). The study also provided quantitative data linking aberrant drug behaviors to opioid use disorders.

Some patients are not perfectly compliant and may show some form of aberrant behavior but are not diagnosed as addicts nor are they acting with criminal intent. The true nature of patients exhibiting this type of behavior is complex and not often easy to recognize or address. What can practitioners do to better identify patient with a moderate to high risk of abuse and how can they contain risk of abuse, misuse, addiction, and diversion in patients to whom they prescribe opioid pain medication?

1. Use a multi- or interdisciplinary approach to care whenever possible. Observation of the patient by multiple parties may identify aberrant behaviors more quickly and with greater precision than those observations made by only one practitioner.
2. Assess the pain and the patient comprehensively. Ensure that pain is being treated effectively. Comorbid conditions must be diagnosed and treated as separate entities. Use assessment and monitoring screener tools to obtain an objective measure or degree of risk of drug misuse (eg, Opioid Risk Tool, SOAPP, urine drug monitoring). Practitioners should be aware of their own prejudices, and use of a tool that provides an objective measure helps to balance the interpretation.
3. Become acquainted with the Universal Precautions in Pain Management guidance and use the precautionary guidance as a care template. Universal Precautions in Pain are not meant to be a one-size-fits-all standard model of care solution, but were written to provide navigation to practitioners who may be unsure of a treatment approach.
4. Incorporate a treatment agreement into the overarching treatment plan. The agreement should be developed and designed with the patient’s full knowledge and input, but does not serve as informed consent. Goals and restrictions of treatment should be documented. At onset of opioid therapy, consequences in response to a lapse in compliance must be clearly outlined and an exit from the treatment plan should also be formulated prior to a crisis event.
5. Physical tolerance and drug dependency cannot be used as reliable markers of addiction. These conditions may indicate presence of opioid tolerance, hyperalgesia, or pseudoaddiction.
6. Patients with chronic pain and comorbid conditions need a multimodal approach to care. Nonpharmacologic therapies and therapies targeted to specific and multiple diagnoses are required in order to achieve a high level of compliance resulting in optimal pain relief.
7. Always individualize the treatment to the patient. Treating chronic pain requires diligence and patience from the practitioner; simply writing one or multiple prescriptions is not always the answer. Getting to really know the patient through open and honest communications, and through assessment and continuous monitoring, are essential steps in risk containment. Customizing therapy is often challenging, time consuming and sometimes frustrating, but the potential benefits that are achieved by both patient and clinician far outweigh these challenges.

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Penelope P. Ziegler, MD, FASAM