North Sydney, Mon 22 Aug 2005
Dr Doug Gourlay
During the International Pain Conference, a meeting for 'locals' was convened by Professor Robert Batey of NSW Health at North Sydney on Monday 22 Aug 2005. We had an illuminating talk from one of the few specialists with expertise in BOTH pain management AND dependency, Dr Doug Gourlay of Mount Sinai Hospital, Toronto, Canada.
Our renowned speaker started with some definitions of addiction, physical dependency, tolerance, pseudo-addiction, with some prevalence figures in the general population.
We were given a logical approach to 'universal precautions' in opiate prescription patients. Infectious disease and dependency have some parallels: rather than isolating those already infected (eg. hepatitis, TB, leprosy) modern practice is to assume that all patients could harbour (or be victim to) infections just as all opioid recipients can sometimes demonstrate features of dependency. Thus we need to be alert and to respond with appropriate measures when needed.
Dr Gourlay reminded us of the difficulties in detecting high-risk patients on first consultation. While an accurate diagnosis is crucial to appropriate treatment, on-the-spot diagnoses are not always necessary or indeed possible in pain management and dependency. We have the benefit of seeing our patients' progress over time which allows a prospective diagnosis after accumulating more details of the patient's habits, history, examination and special tests. Predictors of progress in our field can be notoriously unreliable with some seemingly low risk patients displaying the most manipulative behaviour.
While most dependency diagnoses are made prospectively, one diagnosis we can only make retrospectively is 'pseudo-addiction'. In this, all the apparent features of addiction abate once the patient's pain has been addressed, whether physically, chemically and/or mentally. [If we postulate a 'psychic pain' and self-medication, this might be true of many dependency cases as well, since once they receive appropriate management any DSM criteria of addiction regress or even vanish.]
The items Dr Gourlay recommended we use in diagnosis included the CAGE features -Have you tried to Cut down? Do you get Annoyed by using too much medication? Do you suffer from Guilt? Have you taken medications early? 'Eye-opener' - as well as a number of other 'tell-tale' characteristics involving finances, work, drug seeking (eg. early requests for prescriptions), criminal behaviour and urine test results.
The 'tools' we have to use in dependency patients include (1) limiting quantities of medications ie. the frequency of pharmacy attendance (2) increasing doses of medications (3) utilising longer-acting forms of the appropriate medication (4) direct supervision of medication (5) supervised urine testing (6) treatment agreements � a drug diary. Dr Gourlay also reminded us not to stop opiates or benzodiazepines suddenly and that even high doses of one class of drugs will never suppress withdrawals from the other, although a transient improvement in symptoms might result. He gave a telling example of a new methadone patient denied benzodiazepines in early treatment despite a large habit. Most of our dependency patients have more than one drug habit.
Dr Gourlay has no hesitation in ordering urine tests on all his dependency patients. This includes pain management patients who have developed features of dependency - usually a small proportion, perhaps 10%. He reminded us that such testing needs to be done in a climate of trust and mutual respect. Results should never be used as a "gotcha!" manner nor used punitively. Like all pathology testing the results must only be used directly in the patient's interests. Direct observation, we were told, is not necessary in all cases but that some supervision, eg temperature testing or randomisation, is reasonable for compliance checking. We were given a compassionate and practical way to approach unexpected results. "Now I wonder if you can help me explain some unusual results we received on your recent urine specimen".
Another tool Dr Gourlay uses is a 'treatment agreement' ('never a contract') where the patient agrees to be frank about their drug use and that they will not use other sources of drugs, including prescribed medication, over-the-counter drugs or street drugs. Where they do, this should be discussed openly rather than be treated in a 'cat and mouse' manner in the therapeutic environment.
We were confronted with the statement that "no drug is addicting". Addiction requires an interaction between the drug, environment and individual. The vast majority of patients prescribed opioids never develop addiction. Dr Gourlay also said that opioids were often successful for patients with chronic non-cancer or neuropathic pain and always worth a 'trial' when other means had failed.
We were honoured to have the presence of Dr Joyce Lowinson and Dr Herman Joseph who were both associated with the early evaluation of methadone treatment at Rockefeller University in Manhattan from the 1970s.
After the main feature, we has a discussion of three complex case histories with comments from an expert panel comprising Bob Batey, James Bell, Peter Cox, John Currie, John Ditton, Paul Haber, Robert Graham and Adam Winstock. There was lively discussion over various difficulties in diagnosis and management in special circumstances, dependency, disabilities, children, alcohol, infectious disease, prejudice and other matters of mutual interest. The ethics and practicalities of urine testing was also covered.
Each case demonstrated some failings in early treatment despite warning signs being present. Each contained lessons in communications, diagnosis and a multidisciplinary, approach. There seemed some divergence of views from the panellists, but agreement with Dr Winstock that methadone is not a panacea and that psychological trauma also needs to be addressed.
For a poly-drug user on methadone for 18 years, it was surprising that with continued use of multiple opioids (pethidine and street heroin) she still was not prescribed sufficient methadone to suppress opioid use. She had also been drinking to excess and using benzodiazepines. Already taking 145mg, consideration of dose increases were not advised by all panellists. One even cautioned against consideration of blood level monitoring. It seems that some take the issue of high dose methadone in such cases to be potentially mischievous, even 'sending the wrong message' to the patient. Yet while no cure-all, we might expect that an appropriate methadone dose might reasonably be expected to suppress illicit opioid use after so long on treatment.
Dr Gourlay also stressed that in such cases, stabilising the substance dependency issues was essential before being able to deal with all the psychosocial issues that panel members had brought up ('setting boundaries'). Calling a 'case conference' is not much help if the patient cannot keep an appointment.
Dr Cox suggested admitting such complex patients to hospital as a strategy to sort matters out. Another panel member took the view that such efforts might just waste hospital resources and DG reminded us of the behavioural difficulties of such unstable cases in a general hospital setting, potentially creating resentment among staff.
Some implied a need to accept that certain situations are just not amenable to interventions. Yet in dependency practice, we often come across patients who used to be like these unhappy, unstable cases, and in whom various ministrations and time (especially the latter) have yielded stable, productive citizens in the long run.
Persistence on our part can reinforce the old saying that "when the student is ready, the teacher will appear" ... change is a process that occurs over time.
