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