Co-occurring Disorders:
Pain, Depression and Substance Abuse
Walter Ling MD
Integrated Substance Abuse Programs
Fifth Annual Statewide Conference on Co-Occurring Disorders
October 3, 2006
Long Beach Convention Center
Long Beach, California
Scope of the Talk
• “What’s the big deal”? “Why bother with it”?
• How big a problem is it?
• How do we go about it?
• What can we do?
• A few specific tricks?
What’s the Big Deal?
• Common clinical problems
• Overlaps in neurobiology
• Confusing diagnosis
• Complicates treatment , presence of one predicts poor
treatment outcome of the other
• Strain on treatment systems and resources
What’s the Problem?
• Estimates of psychiatric co-morbidity among clinical
populations in substance abuse treatment settings
range from 20-80%
• Estimates of substance use co-morbidity among
clinical populations in mental health treatment
settings range from 10-35%
Differences in incidence due to: nature of population served
(eg: homeless vs. middle class), sophistication of
psychiatric diagnostic methods used (psychiatrist or DSM
checklist) and severity of diagnoses included (major
depression vs. dysthymia).
ECA DSM-III Diagnoses
(rates per 100 people)
1 Month
Any Alcohol, Drug or Mental Health
Any Mental Disorder
Alcohol Dependence
Drug Dependence
Regier, et al. (1990)
Lifetime Prevalence and Odds Ratios ECA Study
O th e r
D rug
3 6 .6 %
2 .3
5 3 .1 %
4 .5
3 .8 %
3 .3
6 .8 %
6 .2
 A n y a ffe ctive
1 3 .4 %
1 .9
2 6 .4 %
4 .7
 A n ti-socia l
1 4 .3 %
2 1 .0
1 7 .8 %
1 3 .4
4 7 .3 %
7 .1
A lco h o l
 A n y m e n ta l
 S ch izo p hre n ia
 A lco h o l
R egier, 1990
Chronic pain, Depression and Anxiety
• National Co-morbidity Study (8098 15-54 y.o. chronic pain
arthritic patients vs general population control)
Mood disorder: 27% patients vs 10% controls
Anxiety disorder: 35% vs 9%
Depression: 20% vs 9%
Generalized anxiety disorder: 7% vs3%
Panic disorder: 7% vs 2%
PTSD: 11% vs 3%
Odds of disability from chronic pain increase: anxiety (2.86);
depression (2.8);panic disorder ( 4.27)
The “ideal, but infrequent” patients for the separated
service delivery systems
The mental health service
The substance abuse service
• The uncomplicated schizophrenic
• The “plain” alcoholic
• The “simple” affective disordered
• The addict who uses only heroin
• The “pure” bi-polar patient
• The stimulant dependent individual
w/o other psych diagnoses
Drug Induced Psychopathology
Drug States
Symptom Groups
• Withdrawal
• Depression
• Anxiety
• Psychosis
• Intoxication
• Mania
• Chronic Use
Rounsaville ‘90
Likelihood of a Suicide Attempt
• Risk Factor
Increased Odds Of Attempting
• Cocaine use
62 times more likely
• Major Depression
41 times more likely
• Alcohol use
8 times more likely
• Separation or Divorce
11 times more likely
Facts about Suicide:
• 500,000 ER visits for attempts in 1997
• Four times as many US citizens died by suicide during
the Viet Nam War period than died as soldiers.
• Rates increase with age ( as do other causes of death)
CDC web site
• Suicide rate among addicts is 5-10 times that of non-addicts
Preuss/Schuckit Am J Psych 03
Less than than half of the women with interpersonal
trauma and co-morbidity will receive treatment that
addresses their trauma history and co-occurring
(Timko & Moos, 2002).
Comorbidity of Depression and Anxiety Disorders
50% to 65% of panic disorder
patients have depression†
70% of social anxiety
disorder patients have
67% of OCD
patients have
49% of social
anxiety disorder
patients have
panic disorder**
11% of social anxiety
disorder patients have
The Four Quadrant Framework for
Co-Occurring Disorders
Less severe
mental disorder/
more severe
abuse disorder
More severe
mental disorder/
more severe
abuse disorder
A four-quadrant conceptual
framework to guide systems
integration and resource
allocation in treating individuals
with co-occurring disorders
NY State; Ries, 1993; SAMHSA
Report to Congress, 2002)
Not intended to be used to
classify individuals (SAMHSA,
2002), but . . .
Less severe
mental disorder/
less severe
abuse disorder
More severe
mental disorder/
less severe
abuse disorder
DSM and ICD: The “Bibles”
Diagnostic and Statistical Manual of Mental Disorders*
Assessing for addiction in pain patients
Substance Abuse
• One or more within a 12 month
Failure to fulfill major role
Recurrent use in hazardous
Recurrent legal problems
Recurrent social or
interpersonal problems
Substance Dependence
• Three or more within a 12 month period
Abuse criteria, plus:
Persistent desire to control use
Larger amount/longer time than
Great deal of time spent in activities
related to use
*4th ed, APA, 1994
Pain and Depression
• What comes first?
- The antecedent hypothesis
- The consequence hypothesis
- The “scar” hypothesis
- “Pain-prone personality”
- Life experience and personal mastery
• Does it really matter?
Pain and depression make each other worse
Pain and Depression
• Between 30% and 60% of depressed patients have chronic pain
• Chronic pain patients who are depressed are 9 times more likely to
be disabled
This depression is responsive to treatment
Treatment lowers pain intensity and improves function and quality of
• Treatment needs to be adequate and sustained; combined
pharmacotherapy with behavioral therapy, aim to improve self
management, beware of increased suicide risks
Depression IS Pain
• Pain is second most common somatic symptom in
depression, second only to insomnia.
• Pain occurs in over 50% of depressed patients
• Common pain in depressed patients: headaches, facial
pain, neck and back pain, chest and abdominal pain and
extremity pain
• Pain often dominate clinical picture overshadowing other
depressive symptoms
Pain and Depression
• Pain is depressive equivalent
• Chronic pain leads to depression
• Circular relationship, vicious circle
• Common association and overlapping
• Common neurobiological substrate
• Psychological determinants critical
• Responsive to antidepressants
• Non-pharmacological strategies critical
Pain and Depression
• Two thirds of new neurological patients have pain.
• One third are depressed; 75% of them have pain.
• One quarter have both pain and depression.
• Neuropathy, neuromuscular disease, headaches.
• Sx persist at 3 & 12 mo. follow up
• Pain predicts depression at f/u and vice versa
• Odds of pain increase: female, depressed, NMD
• Odds of depression increase: CVD, Cognitive dis
Williams LS et al J Neuro Neurosurg Psych. 2003
Pain IS Depression
• Somatic cyclothymia
• Periodic melancholy
• Vegetative depression
• Masked depression
• Affective equivalents
• Depressive equivalents
• Variant of depressive disease
Pain and Depression
• Co-occurrence makes diagnosis difficult
• Pain patients tend to show more irritability,
anhedonia, loss of interest, reduced capacity to
experience pleasure.
• Depressed patients tend to exhibit more
dysphoria, early morning awakening,
indecisiveness, despair and suicidal ideations
Treating Co-morbid Pain and Depression
• Tricylclic antidepressants
Efficacy in neuropathic pain
• SSRI’s
Safety profile
• Dual-acting agents
Effective for depression and pain
Detke MJ 2002
Treating Co-morbid Pain and Depression
• Non-pharmacological treatment
- Cognitive behavioral treatment
- Operant behavioral treatment
- Biofeedback training
- Motivational interviewing
- Private emotional disclosure
• Integrating pharmacotherapy and behavioral
What happen when pain becomes chronic
• The one certain thing: treatment didn’t work
• Patient frustrated and lost faith in doctors
• Patient blamed for not getting better
• Lost “role”; becomes dependent on others
• Others must pick up slack and must provide support
• Patient feels neglected when others can’t do all
• Patient becomes anxious, angry and depressed
• Patient assumes life style of chronic pain
Chronic pain: identifying early risk factors
• Attitude and belief of pain
• Whose fault?
• Behavior and compensation issues
• Dx and Tx issues
• Emotions
• Family
• Work
Early signs of chronic pain
• Not healing as expected
• Perceived neglect or ill treatment
• Perceived management abandonment
• Not adequately treated
• Accident was some one’s fault
• Expanding Sx
• Sleep disturbance, anger fear
Opioid, Pain and Addiction:
Confluence of Events
• Under treatment of pain:
• Increasing availability of opioids:
• Rise in abuse of prescription opioids
New Demand:
Core competency in pain and in addiction
From Pain Relief to Addiction:
Opioids and the Faces of Janus
• Relieve pain
• Relieve pain and suffering
• Relieve suffering and misery
• Make you feel better
• Make you feel good
• Make you “high”
The Clinician’s Dilemma
• What God hath joined together, can man put
• What to do in the meantime to maximize pain
relief while minimizing abuse ?
Definitions: Addiction
• Addiction- primary, chronic, neurobiologic disease
characterized by behaviors that include one or
more of the following: impaired control over drug
use, compulsive use, continued use despite harm,
and/or craving
American Pain Society. Available at:
“Addiction is not taking a lot of drugs; it’s taking drugs and
acting like an addict.”—Alan Leshner
Characterizing Pain
• Pain: An unpleasant sensory and emotional experience
arising from actual or potential tissue damage or
described in terms of such damage
• It is always subjective; each individual learns the
application of the word (pain) through experiences
related to injury in early life—IASP
IASP = International Association for the Study of Pain.
Acute Versus Chronic Pain
Acute pain:
• Related to a particular event (eg
• Resolution expected within
Chronic pain:
• Cause not often easily
• CNS changes
• Not repeated acute pain
Acute pain: a sensation; what pain does the patient have?
Chronic pain: a life style: what patient does the pain have?
Pain in Addiction:
“More Than a Feeling”
• Feeling (sensory experience): pain
• Meaning (emotional and cognitive): suffering
Historical—early life
• Action—expression of the “word”: behavior
• Chronic pain is not having lots of pain; it is having pain and
behaving like a chronic pain patient
The Martyrdom of St. Sebastian by Hans Holbein (1516)
Chronic Pain and Addiction:
Common Overlapping Features
• Chronic pain
• Addiction
- Early trauma
- Early trauma
- Loss of mastery
- Loss of mastery
- Loss of control
- Loss of control
- Loss of sense of self
- Loss of self-efficacy
- Cognitive error
- Cognitive error
- “Personalization”
- “Nirvana”
- Overinterpretation
- Denial
Chronic Pain Common in Methadone Clinics
• Over 60% of methadone clinics patients experience chronic pain
Less employed; more disabilities
More medically and psychiatrically ill
Take more prescribed and non-prescribed drugs
Most feel under treated
Most believe prescribed opiates led to addiction
Most believe methadone is very helpful
Most have “problems most of their lives”
Most believe “always need something to feel good”
Ref: Jamison et al. (2000)
With respect to chronic opioid therapy and the
patient with chronic non-malignant pain,
• How does one identify addiction in the patient on
chronic opioid therapy?
• How does one identify the patient at risk for
becoming addicted to chronic opioid therapy?
Published rates of abuse and/or addiction in chronic
pain populations are ~ 10% (3-18%)*
• Suggests that known risk factors for abuse or addiction in the
general population would be good predictors for problematic
prescription opioid use
History of early substance use
Personal/family history of substance abuse
Co-morbid psychiatric disorders
*Adams et al., 2001; Brown, 1996;
Fishbain, 1986, 1992; Kouyanou et al., 1997
Who’s at Risk for Addiction and How to Tell?
• 4 Ways to identify patients at risk
- History—personal history and family history
- Screening instruments
- Behavioral checklists
- Therapeutic maneuver
Screening Instruments
• Several clinical tools are available that estimate risk of
noncompliant opioid use1,2,3
• The results determine how closely a patient should be
monitored during the course of opioid therapy3
- Scores implying a high risk of abuse are not reasons to deny pain
1 Webster, et alr. Pain Med. 2005;6:432.
2 Coambs, et al. Pain Res Manage. 1996;1:155.
3 Butler, et al. Pain. 2004;112:65.
Opioid Risk Tool (ORT)
Mark each box that applies:
Family history of substance abuse
Illegal drugs
Prescription drugs
Illegal drugs
Prescription drugs
• On initial visit
• Prior to opioid therapy
Personal history of substance abuse
• 0-3: low risk (6%)
Age (mark box if between 16-45 years)
History of preadolescent sexual abuse
Psychological disease
• 4-7: moderate risk (28%)
ADO, OCD, bipolar, schizophrenia
• > 8: high risk (> 90%)
Scoring totals:
Webster, et al. Pain Med. 2005;6:432.
Screener and Opioid Assessment for Patients in Pain
• 14-item, self-administered form, capturing the primary
determinants of aberrant drug-related behavior
Validated over a 6-month period in 175 chronic pain patients
Adequate sensitivity and selectivity
May not be representative of all patient groups
• A score of ≥ 7 identifies 91% of patients who are high risk
Butler, et al. Pain. 2004;112:65.
Aberrant Drug-Taking Behaviors: The
•Probably more predictive
Selling prescription drugs
Injecting oral formulation
•Probably less predictive
Aggressive complaining about need for
higher dose
Drug hoarding during periods of reduced
Requesting specific drugs
Acquisition of similar drugs from other
medical sources
Unsanctioned dose escalation 1 – 2
Unapproved use of the drug to treat
another symptom
Prescription forgery
Stealing or borrowing another patient’s
Obtaining prescription drugs from nonmedical sources
Concurrent abuse of related illicit drugs
Multiple unsanctioned dose escalations
Recurrent prescription losses
Passik and Portenoy, 1998
Patients Exhibiting Behaviors
Aberrant Behaviors
1 to 2
3 to 4
5 to 7
Number of Behaviors Reported
Passik et al. 2003
8 or more
Patients Exhibiting Behaviors
Aberrant Behaviors in Cancer and AIDS
1 to 2
3 to 4
5 or more
Number of Behaviors Reported
Passik et al. 2003
Therapeutic Maneuver: Is the Pain Patient
Drug-seeking or increased requests for pain medication
 Pathology/pain of new source
Detailed pain work-up
No new pain pathology
 Opioid dose
Unimproved functioning
Presence of toxicity
Addictive disease
Improved functioning
Absence of toxicity
Treating Pain with Opioids:
What Can We Expect to Achieve?
• Reduction in pain and suffering
Meaningful pain reduction (Analgesia; Pain)
Acceptable side effects (Adverse effects; Price)
• Improved functionality
Meaningful functional improvement (Activities; Performance)
No unacceptable aberrant behavior (Aberrant bahavior; “Pees”
The 4 A’s (Passik); the 4 “P’s”
Meaningful Pain Reduction:
How Much?
• Using a VAS or numeric scale of 0–10
(4–6 = moderate pain; 7–10 = severe pain)
• For moderate pain (mean = 6)
Meaningful reduction = 2.4 (40%)
Very much better = 3.5 (45%)
• For severe pain (mean = 8)
Meaningful reduction = 4.0 (50%)
Very much better = 5.2 (56%)
VAS = visual analogue scale.
Cepeda MS. Pain. 2003;105:151–157. [Evidence Level B]
Analogue Pain Scale
Evaluation of
Functional Restoration
• physical capabilities
• psychological intactness
• family and social interactions
• Relationships with healthcare professionals and
therapeutic outcomes
• degree of health care utilization
• drug use for symptom control
Remission of Addictive Disease
Improves Pain and Functionality
• Increased ability to comply with regimes
• Enhanced cognitive skills
• Able to use behavior modification techniques
• Improved social support
• Better management of neuropsychiatric problems
• Improved stress control
Meaningful Functional Improvement:
My Favorites
• Patient perspective of “improvement”
- Used to do, can’t do now, would like to do again
- Could be physical, social, recreational
- With friends, family, church, neighborhood
• Achievable, enjoyable, and meaningful
- Hobbies
- Volunteer work
Pain Behavior
• Pt behavior is total out put of
Emotional reaction to perceived “pain”
Modulation by internal neural mechanism
Modulation by external social mechanism (family)
Belief, Expectation, & Outcome
• What you believe and expect and do as a result are far more
important than what situation you’re in.
• Prayers and hope are useless if you don’t recognize the
• Behavior are largely self-fulfilling prophesies; if the sky falls,
it will fall on those who believe the sky is falling
• Pain is part of life, so is uncertainty
Dr. to Patients
• What are your concerns, worries, and goals for this visit?
• What condition you have, what will happen, what we can
expect, and why we recommend what we recommend
• Here are some specific strategies for Sx relief and for
high risk situations
• Let’s develop a plan for your future
Treating Neuropathic Pain
• Five first-line drugs:
5 % lidocaine patch
Opioid analgesics
Tricyclic antidepressants
NIH consensus panel Arch Neurology 2003; 60:1537-1540
Opioids for Neuropathic Pain
• Postherpetic neuralgia
Neurology 1998; 50: 1837-41(60 mg/d )
Neurology 2002; 59:1015-21 (controlled release ms 240 mg/d
• Diabetic neuropathy
Neurology 2003; 60:927-34 (120 mg Oxycontin)
• Phantom limb pain
Pain 2001; 90:47-55 (300mg/d)
• Peripheral and central neuropathic pain
NEJM 2003; 348: 1223-1232
• Why opioids are prescribed in this case
• What reduction in pain has been achieved
• What functional improvement has occurred
• Document acceptable side effects
• Document responsible medication use and absence of aberrant
Remember: 1.What is not written down didn't happen.
2.Your record will testify in public not what patients
you have but what doctor they have
• Pain and addiction: public health problems
• Opioids critical in both
• Demarcation is not always clear
• Pathophysiological and clinical overlaps
• Identifying risks: challenging, not hopeless
• Core competency in both pain and addiction
Treatment of Co-occurring Disorders
• Treatment System Paradigms
- Independent, disconnected
- Sequential, disconnected
- Parallel, connected
- Integrated
Treatment of Co-occurring Disorders
• Independent, disconnected “model”
Result of very different and somewhat antagonistic
Contributed to by different funding streams
Fragmented, inappropriate and ineffective care
Treatment of Co-occurring Disorders
• Sequential Model
Treat SA Disorder, then MH disorder
Treat MH Disorder, then SA disorder
Urgency of needs often makes this approach inadequate
Disorders are not completely independent
Diagnoses are often unclear and complex
Treatment of Co-occurring Disorders
• Parallel Model
Treat SA disorder in SA system, while concurrently treating MH
disorder in MH system. Connect treatments with ongoing
- Easier said than done
- Languages, cultures, training differences between systems
- Compliance problems with patients
Treatment of Co-occurring Disorders
• Integrated Model
- Model with best conceptual rationale
- Treatment coordinated best
- Challenges
Funding streams
Staff integration
Threatens existing system
Short term cost increases (better long term cost outcomes).
Thank you, thank you, and thank you…

Co-occurring Disorders: Pain, Depression and Substance …