Fw: "Pain management and dependency" talk by Dr Doug Gourlay.

Preston Peet ptpeet at nyc.rr.com
Thu Sep 8 22:21:29 EDT 2005

----- Original Message ----- 
From: Andrew Byrne
To: ajbyrne at ozemail.com.au
Sent: Thursday, September 08, 2005 8:45 PM
Subject: "Pain management and dependency" talk by Dr Doug Gourlay.

Dear Colleagues,

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 

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 

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 

summary of meeting by Andrew Byrne .. [final sentence and several other 
corrections with thanks to Dr Gourlay]

   Dr Andrew Byrne MB BS (Syd) FAChAM (RACP)
   Dependency Medicine,
   75 Redfern Street, Redfern,
   New South Wales, 2016, Australia
   Email - ajbyrneATozemail.com.au
   Tel (61 - 2) 9319 5524  Fax 9318 0631


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