Howard A. Heit

Buprenorphine New Tricks With an Old Molecule for Pain Management

Sublingual buphrenorphine is a unique opioid medication based on its pharmacokinetics and pharmacodynamic properties. It may be used “on label” as an alternative choice to methadone for the treatment of opioid addiction or “off-label” for the treatment of both acute and chronic pain. Because of high μ receptor affinity and resultant blockade, it has been suggested that this might interfere with the management of moderate to severe pain in patients on opioid agonist treatment. The following article will offer strategies and approaches to address some of these real and perceived challenges.

Pain and Addiction: Managing Risk Through Comprehensive Care

ABSTRACT The use of controlled substances, including opioids, in people who may suffer from concurrent substance use disorders presents challenges to the healthcare professional. Pain and addiction can coexist either as a continuum or separate comorbid conditions. 1 Success in the treatment of either condition requires an approach that encompasses the biopsychosocial needs of the patient. In pain management, controlled substances can be either the problem or the solution, depending on the healthcare professionals training and perspective. Not all patients on opioid pharmacotherapy do well. Some, with inadequate treatment responses, may actually improve on discontinuation of their opioids. Therefore, in any trial of pharmacotherapy, there must be a clear exit strategy as part of the treatment plan. The goal of this article is to explore the importance of making reasoned clinical decisions when faced with aberrant behavior, which is when the patient steps outside the boundaries of the agreed on treatment plan and is established as early as possible in the doctor–patient relationship. In this case, it is essential to separate the “motive” from the “problematic behavior” when trying to interpret the implications of aberrant behavior rather than simply applying a diagnostic label of addiction, which may or may not be correct.

The truth about pain management: the difference between a pain patient and an addicted patient.

Pain is undertreated in all parts of the world. Multiple barriers exist that prevent valid treatment of the pain patient. This paper will provide definitions of pain, addiction, physical dependence, tolerance, and pseudoaddiction that health professionals need to understand in order to treat pain. It will address how to differentiate between a pain patient and an addict when evaluating the patient for treatment. The physiological benefits of using long‐ versus short‐acting opioids will be presented. With proper education of the medical community, patients should receive humane and compassionate treatment of their chronic pain syndromes.

DSM-V and the Definitions: Time to Get It Right

Over the decades, the Diagnostic and Statistical Manual of Mental Disorders (DSM) [1] has made very important contributions to the mental health field in the classification of mental illness. However, as the manual is updated, some members of the American Psychiatric Association DSM-V Committee believe the word “addiction” is still too stigmatizing and argue that the term “dependence” should remain [2]. In our opinion, perpetuating this ambiguity is in no ones best interest. Much in the same way as we in addiction treatment hope our patients will come to see things “the way they are, not the way they wish they were,” the so-called “Golden Moment”[3], we would encourage the DSM-V committee to approach this unique situation as a “golden opportunity” to restore the term “addiction” to its rightful place in the medical lexicon. Unfortunately, while the terms “physical dependence” and “addiction” are often used interchangeably, they are not the same at all. In fact, a joint committee comprised of members of the American Pain Society, the American Society of Pain Medicine, and the American Society of Addiction Medicine, the Liaison Committee for Pain and Addiction, in 2001 developed consensus definitions for physical dependence, addiction, and tolerance that were approved by the governing bodies of each organization [4]. The key point here is that physical dependence is an expected , neuroadaptive consequence of chronic exposure to an agonist class of drug while addiction is a complex, multidimensional biopsychosocial phenomenon that occurs in at risk individuals …

The art and science of urine drug testing.

To the Editor: We read with interest the manuscript titled ‘‘Utility and Application of Urine Drug Testing (UDT) in Chronic Pain Management with Opioids’’ by Naffziger et al, Clin J Pain. 25(1), 2009. The article provides a summary of confounding variables that the authors quite correctly identify as likely to reduce the utility of any proposed treatment adherence algorithms based on the principles of pharmacokinetics (pK), pharmacodynamics (pD), and pharmacogenetics of opioids as applied to UDT interpretation. However, even if these variables could be adequately accounted for, we would still be challenged by a far more basic shortcoming of the use of UDTbased algorithms for monitoring treatment adherence: the inability to credibly assess steady state in the treatment of such a dynamic condition as chronic pain. In fact, one of the key concepts of these adherence algorithms is the assumption that at some point in the future, data (urinary drug concentration) can be compared with a point of time in the past, where the patient was assumed to be taking a known quantity of drug and so be at a ‘‘steady state.’’ This assumption of course is based on the patients’ own assessment of stability rather than any true pK/pD measurements. Chronic pain patients often adjust their dose of prescribed medication in response to changing levels of activity with no malicious or maladaptive intent. Although they may state that their pattern of use of medications is stable, this is often a statement made ‘‘on average’’ rather than a precise pattern of use. This is particularly evident with short-acting medications used in the treatment of breakthrough pain. Few patients or clinicians will appreciate how important the answer to the question ‘‘Are you using your medications exactly ‘as prescribed’?’’ may be, as it is from this information, that the baseline steady state data are derived. For example, if the baseline urinary concentration of drug X is 50 ng/mL on 100mg/d dose, and the current urinary concentration of drug X is 25 ng/mL, the prescriber might conclude, incorrectly, that the patient is now taking less drug X than they were at baseline. As the compliance algorithm is based on comparing points in the future against a known point in the past, inaccurate baseline data may lead to erroneous conclusions about whether the patient is taking more, less, or the same amount of prescribed medication as they were at baseline. Although the fear of regulatory scrutiny may be driving the need for compliance algorithms, neither the basic science nor the clinical complexity of the chronic pain patient currently allows for such use. As important a tool as UDT is in the treatment of chronic pain, it remains only one of many tools. To use the data beyond their capacity, is to be both scientifically and ethically dishonest. Interpreting UDT beyond the current scientific knowledge may put clinicians and patients at even greater medical and/or legal risk.

Tackling the Difficult Problem of Prescription Opioid Misuse

In this issue, Starrels and colleagues report on the effectiveness of opioid treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. These measures are be...

Trends in drug use from urine drug testing of addiction treatment clients

OBJECTIVE Urine drug testing (UDT) can play an important role in the care of patients in recovery from addiction, and it has become necessary for providers and programs to utilize specific, accurate testing beyond what immunoassay (IA) provides. DESIGN A database of addiction treatment and recovery programs was sampled to demonstrate national trends in drug abuse and to explore potential clinical implications of differing results due to the type of testing utilized. SETTING Deidentified data was selected from a national laboratory testing company that had undergone liquid chromatography tandem mass spectrometry (LC-MS/MS). PATIENTS/PARTICIPANTS A total of 4,299 samples were selected for study. INTERVENTIONS Descriptive statistics of the trends are presented. RESULTS In total, 48.5 percent (n = 2,082) of the samples were deemed in full agreement between the practice reports and the results of LC-MS/MS testing. The remaining 51.5 percent of samples fell into one of seven categories of unexpected results, with the most frequent being detection of an unreported prescription medication (n = 1,097). CONCLUSIONS Results of UDT demonstrate that more than half of samples yield unexpected results from specimens collected in addiction treatment. When comparing results of IA and LC-MS/MS, it is important to consider the limits of IA in the detection of drug use by these patients.

Specimen validity testing in urine drug monitoring of medications and illicit drugs: Clinical implications

OBJECTIVE To discuss the importance of specimen validity testing (SVT) in urine drug testing (UDT) and the clinical role it plays in identifying efforts to subvert the UDT process. METHODS A discussion of the clinical impact of SVT is presented. RESULTS A discussion of pH, specific gravity, creatinine, and oxidation for monitoring the adulteration of UDT samples is presented along with the clinical significance of such tests. SIGNIFICANCE SVT has a significant place in healthcare efforts to measure patient adherence, behavior, and honesty in communication with clinicians. SVT is typically ordered by treating clinicians who use the results to make therapeutic decisions regarding specific medical problems of their patient, including those related to medication and illicit drug use. In the absence of SVT, a healthcare provider may fail to identify a patients adulteration of their urine sample in an attempt at deceiving the provider. Moreover, the presence of some underlying medical conditions may obfuscate the UDT results.

Pain: Substance Abuse Issues in the Treatment of Pain

About 50 million Americans suffer from chronic pain [1]. As our population continues to age, this number is likely to grow, yet unfortunately, pain continues to be undertreated and poorly treated. Forty to 60% of people with severe pain in the context of life-limiting illnesses have difficulty getting their pain adequately treated [2–4]. Lost productive time and cost due to common pain conditions in the United States affects 13% of the total workforce and costs the nation

Clinical case discussion: chronic pain management.

61.2 billion per year [5]. Millions of persons with pain from chronic diseases such as arthritis, diabetes, headaches, and muscle disorders suffer and have difficulty finding and paying for qualified professionals willing to help them gain access to the medicines, physical and psychological therapies and surgical/anesthetic interventions that can help them lead higher quality and more productive lives. Chronic pain serves no useful purpose [6] once the underlying cause has been identified. It is no longer a useful clinical monitoring parameter, and it should be treated as effectively as possible. Unfortunately, pain has been and continues to be undertreated. One reason is ‘‘opiophobia,’’ which was first described in 1985. The author of that classic paper in which this termwas defined wrote, ‘‘American physicians markedly undertreat severe pain based on an irrational and undocumented fear that appropriate use will lead patients to become addicts.’’ [7] Moreover, some members of minorities who present to a healthcare professional with pain are inadequately treated due to clinicians’ concerns about concurrent addictive disorders or prejudice arising from racism, homophobia, and/or opiophobia [8]. Such undertreatment of pain violates the Hippocratic Oath. Pain is the most common reason that patients enter the healthcare system, commonly through visits to physicians’ offices, presentation at emergency departments, or by visiting community pharmacies [9]. Opioids remain the most effective analgesics that we have for most moderate to severe pain disorders, but these important medications do carry a risk of addiction. Opioids are not