Drug Dependency in Patients with Chronic Headaches Jose L. Medina, M.D. and Seymour Diamond, M.D. Hines V.A. Hospital, Hines, Illinois, Loyola University Stritch School of Medicine and Diamond Headache Clinic, Ltd., Chicago, Illinois. (Drs. Medina and Diamond) Reprint requests to Neurology Service (127) Hines V.A. Hospital, Hines IL 60141 (Dr Medina) Presented at the Eighteenth Annual Meeting of the American Association for the Study of Headache, Dallas, Texas, June 26, 1976. Accepted for Publication: 11/17/76 SYNOPSIS New patients seen during eleven months were questioned about intake of narcotics or common analgesics with barbiturates prescribed for the treatment of headache. Out of 2,369 new patients, 62 received both medications frequently for at least six months. Thirty-eight patients were taking a combination of common analgesics and butalbital for 0.5 to 40 years. Eight were dependent; six physically addicted, two psychologically dependent and two were abusers. Seventeen patients were taking codeine and six, propoxyphene for 0.5 to 35 years. No addictions occurred, but there were two codeine and one propoxyphere abuser. There is danger of dependency and abuse in patients with chronic headaches. (Headache 17:12-14, 1977) CHRONIC HEADACHES are distressful symptoms for patients and can prove irritating for the treating physician. This results in hasty analgesic prescription often requiring increasing doses. Soon, some patients add to their headaches a pharmacologic crutch, without which they cannot function. We have asked ourselves what happens to patients who, for long periods of time, take analgesics known to cause dependency. We have therefore studied all new patients in our Clinic to determine the frequency of drug dependence. PATIENTS AND METHODS From March 1, 1975, to January 31, 1976, we have examined 2,369 new patients for the treatment of headache. Patients included in this study were taking narcotics or a combination of analgesics and barbiturates and fulfilled the following criteria: (a) The medication was prescribed by a physician for the treatment of headache only; (b) The drug had been used for over six months; and (c) At least on four days per week. Patients were considered psychologically dependent when the desire to continue the drug was due to one or more of the following reasons: (a) for euphoria; (b) to reduce nervousness, tenseness or anxiety, or (c) to obtain feelings of increased physical or mental capacities. Physical dependence was present when an abstinence syndrome developed a few hours to 48 hours after the last dose and symptoms were relieved by the same medication. Abstinence syndrome was present if the patient had at least two of the following five symptoms groups; (a) anxiety, tenseness, irritability, agitation or shakiness; (b) sweating, lacrimation, rhinorrhea, gooseflesh, abdominal pain, loose stools or nausea; (c) fever, chills, shivering, muscle cramps or muscle twitching; (d) seizures; and (e) insomnia or night mares. We classified patients as abusers if no symptoms of psychologic or physical dependence were present, but the daily intake of medication exceeded by 50% or more the maximal recommended dose (Physicians' Desk Reference).1 Tolerance was present when the dose was increased because the patient became less responsive to medication. RESULTS Sixty-two patients fulfilled the criteria for inclusion in this study. Thirty-eight were taking a combination of an analgesic and barbiturate (Fiorinal); 17 codeine; 6 propoxyphene (Darvon); and 1, meperidine. Of ten patients (26%), who were treated with the combined medication, 2 were abusers, two psychologically dependent and 6

physically dependent. Two patients were abusers of codeine and one of propoxyphene. One patient on meperidine refused to answer questions. The duration of drug intake, average dosage per day, history of psychiatric illness, alcoholism or presence of tolerance are given in Table 1. DISCUSSION A single definition does not fit all drug dependency.2 Great confusion also exists in the use of the term by the public and drug abuse experts.3 In defining dependency in doctor-prescribed medications, we have sed the Diagnostic and Statistical Manual of Mental Disorders.4 Dependency is present when there is a compulsive use of the drug disproportional to the medical needs of the patient. We have added "drug abuser" when the patient was taking excessive amounts of medication but denied dependency. It is our belief that some patients are denying their dependence on drugs. We have limited our study to patients whom most physicians will consider mismanaged because of excessive and prolonged use of drugs. This selection accounts for the high frequency of dependence and abuse in this study. It was not our purpose to determine how long it is safe to give these medications, but to point to the danger of blind symptomatic treatment of chronic headache. Warning of drug dependence is given by manufacturers and we believe that most physicians are aware of this side effect. Nevertheless, a minority is responsible for the patting of the patients' shoulder as they are advised to learn to live with their headaches and prescribe analgesics which are frequently reordered on subsequent visits. Forty-nine patients (79.3%) in this study had mixed migraine and muscle contraction headaches, 9 (14.5%) migraine, and 4 (6.2%) muscle contraction headache. These headaches are eminently treatable. Therefore, an accurate diagnosis of the type of chronic headache with careful preventive treatment should be possible for all such patients. Nonproprietary Names and Trademarks Fiorinal-Sandoptal (butalbital), 50 mg.; caffeine, U.S.P., 40 mg.; aspirin, U.S.P., 200 mg.; and phenacetin, 130 mg. Darvon-Propoxyphene hydrochloride Percodan-Oxycodone hydrochloride, 4.50 mg. oxycodone terephthalate 0.38 mg.; aspirin, 224 mg.; phenacetin, 160 mg.; and caffeine, 32 mg. TABLE 1 DRUG INTAKE, PSYCHIATRIC HISTORY AND ALCOHOLISM IN ABUSERS OR DEPENDENT PATIENTS COMPARED TO NON-DEPENDENT OR NON-ABUSERS # OF PATIENTS Fiorinal**

Dependent or Abusers

Non-Dependent or Non-Abusers Propoxyphene Abusers

Codeine

RANGE AND MEAN DURATION OF INTAKE (YEARS)

AVERAGE DOSE (MG/DAY)

HISTORY OF PSYCHIATRIC ILLNESS

HISTORY OF ALCOHOLISM ILLNESS

TOLERANCE

10

1.1-14 (5.7)

325

2

4

6

28

0.5-14 (4.2) 5

190

2

0

3

650

0

0

0

0.5-12 (7.5) 1.5-4

207

3

0

0

855

1

0

1

1-35 (7.1)

95.6*

0

0

2

1

Non-Abusers

5

Abusers

2

Non-Abusers

15

* Two patients were taking oxycodone: 1 mg. oxycodone was considered equivalent to 10 mg. of codeine phosphate. ** Combination of butalbital, 50 mg.; caffeine, U.S.P., 40 mg.; aspirin, U.S.P., 200 mg.; and phenacetin, 130 mg.

REFERENCES 1.

Physicians' Desk Reference. 29th Edition, 1975.

2.

Eddy, N.B., Halbach, H., Isbell, H., and Seevers, M.H.: Drug dependence: its significance and characteristics. Bull. WHO 32:721-733, 1965.

3.

Drug Use in America: Problem in perspective. Second report of the National Commission on Marihuana and Drug Abuse, March. 1973.

4.

DSM-II: Diagnostic and statistical manual of mental disorders. 2nd edition. American Psychiatric Association, Washington, D.C. 1968.