PHYSICIAN'S GUIDE to Pain Management and Addiction

Discussion in 'Opiate & Opioid addiction' started by Richard_smoker, Apr 5, 2006.

  1. Richard_smoker

    Richard_smoker Gold Member

    Reputation Points:
    Sep 19, 2005
    from U.S.A.
    Pain management and addiction

    Steven D Passik, PhD
    Kenneth L Kirsh, PhD

    UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.1 is current through December 2005; this topic was last changed on May 20, 2003. The next version of UpToDate (14.2) will be released in June 2006.

    INTRODUCTION — Approximately one-third of the population in the United States has used illicit drugs, and an estimated 6 to 15 percent have a substance use disorder of some type [1-3]. As a result of this high prevalence, and the association between drug abuse and life-threatening diseases such as AIDS, cirrhosis, and some types of cancer [4], problems related to abuse and addiction are encountered commonly in palliative care settings. In diverse patient populations with progressive life-threatening diseases, a remote or current history of drug abuse presents a constellation of stigmatizing physical and psychosocial issues that can both complicate the management of the underlying disease and undermine palliative therapies. The interface between the therapeutic use of potentially abusable drugs and the abuse of these drugs is complex and must be understood to optimize palliative care.

    An overview of pain management in patients with substance abuse disorders is provided here. The management of pain in general and of cancer pain is discussed separately.

    EPIDEMIOLOGY — Substance abuse appears to be uncommon among the tertiary care population with cancer [1,2,5-7]. In 1990, only 3 percent of inpatient and outpatient consultations performed by the Psychiatry Service at Memorial Sloan-Kettering Cancer Center were requested for management of issues related to drug abuse [8]. This prevalence is much lower than the prevalence of substance use disorders in society at large, in general medical populations, and in emergency medical departments. A relatively low prevalence was also reported in the Psychiatric Collaborative Oncology Group study, which assessed psychiatric diagnoses in ambulatory cancer patients from several tertiary care hospitals [6]. Following structured clinical interviews, fewer than 5 percent of 215 cancer patients met the Diagnostic and Statistical Manual for Mental Disorders (DSM) 3rd Edition criteria for a substance use disorder [9].

    The relatively low prevalence of substance abuse among cancer patients treated in tertiary care hospitals may reflect institutional biases or a tendency for patient underreporting in these settings. Many drug abusers are poor, feel alienated from the health care system, may not seek care in tertiary centers, and may be disinclined to acknowledge the stigmatizing history of drug abuse. For all of these reasons, the low prevalence of drug abuse in cancer centers may not be representative of the true prevalence in the cancer population overall. In support of this conclusion, a survey of patients admitted to a palliative care unit observed findings indicative of alcohol abuse in over 25 percent [10]. Additional studies are needed to clarify the epidemiology of substance abuse and addiction in patients with cancer and in others with progressive medical diseases.

    Conversely, chronic pain appears to be common in patients under treatment for substance abuse. As an example, one study found that 37 percent of patients in methadone maintenance programs and 24 percent of patients in short-term inpatient substance abuse treatment programs reported chronic severe pain [11].

    DEFINITION OF ADDICTION IN THE MEDICALLY ILL Traditional definitions of addiction that include phenomena related to physical dependence or tolerance cannot be the model terminology for medically ill populations who receive potentially abusable drugs for legitimate medical purposes. A more appropriate definition of addiction notes that it is a chronic disorder characterized by "the compulsive use of a substance resulting in physical, psychological or social harm to the user and continued use despite that harm" [12]. Although this definition was developed from experience in addict populations without medical illness, it appropriately emphasizes that addiction is, fundamentally, a psychological and behavioral syndrome. Any appropriate definition of addiction must include the concepts of loss of control over drug use, compulsive drug use, and continued use despite harm.
    Even appropriate definitions of addiction will have limited utility, however, unless operationalized for a clinical setting. The concept of "aberrant drug related behavior" is a useful first step in operationalizing the definitions of abuse and addiction, and recognizes the broad range of behaviors that may be considered problematic by prescribers. Although the assessment and interpretation of these behaviors can be challenging, the occurrence of aberrant behaviors signals the need to reevaluate and manage drug taking, even in the context of an appropriate medical indication for a drug.

    If drug taking behavior in a medical patient can be characterized as aberrant, a "differential diagnosis" for this behavior can be explored. A true addiction (substance dependence) is only one of several possible explanations. The challenging diagnosis of pseudoaddiction must be considered if the patient is reporting distress associated with unrelieved symptoms. In the case of pseudoaddiction, behaviors such as aggressively complaining about the need for higher doses or occasional unilateral drug escalations indicate desperation caused by pain and disappear if pain management improves.

    Alternatively, impulsive drug use may indicate the existence of another psychiatric disorder, diagnosis of which may have therapeutic implications. Patients with borderline personality disorder, for example, can express fear and rage through aberrant drug taking and behave impulsively and self-destructively during pain therapy. One group reported a case in which one of the more worrisome aberrant drug related behaviors, forging of a prescription for a controlled substance, was an impulsive expression of fears of abandonment, having little to do with true substance abuse in a borderline patient [13]. Such patients are challenging and often require firm limit setting and careful monitoring to avoid impulsive drug taking.

    Similarly, patients who self medicate anxiety, panic, depression, or even periodic dysphoria and loneliness can present as aberrant drug takers. In such cases, careful diagnosis and treatment of these additional problems may obviate the need for self medication. Occasionally, aberrant drug related behavior appears to be causally related to a mild encephalopathy, with confusion about the appropriate therapeutic regimen. This may be a concern in the treatment of the elderly patient. Low doses of neuroleptic medications, simplified drug regimens, and help organizing medications can address these problems. Rarely, problematic behaviors indicate criminal intent, such as when patients report pain but intend to sell or divert medications.

    These diagnoses are not mutually exclusive. A thorough psychiatric assessment is important, both in the population without a prior history of substance abuse and the population of known abusers, who have a high prevalence of psychiatric comorbidity [14].

    In assessing the differential diagnosis for drug related behavior, it is useful to consider the degree of aberrancy. The less aberrant behaviors (such as aggressively complaining about the need for medications) are more likely to reflect untreated distress of some type, rather than addiction related concerns. Conversely, the more aberrant behaviors (such as injection of an oral formulation) are more likely to reflect true addiction. Although empirical studies are needed to validate this conceptualization, it may be a useful model when evaluating aberrant behaviors.

    — The spectrum of aberrant drug taking concept has been used as a guide to the assessment of problematic drug taking in several studies. Although the studies performed to date all involve small samples, they have shown the utility of the spectrum concept as an assessment tool yielding important implications for clinicians. These reports help clarify the meanings ascribed by clinicians to the various behaviors that occur during long-term administration of a potentially abusable drug, and ultimately may define the "red flags" for addictive behavior in a given population.

    ·One study examined the relationship between aberrant drug taking behaviors and compliance-related outcomes in 20 patients with diverse histories of substance abuse receiving chronic opioid therapy for nonmalignant pain [15]. During the year of therapy, 11 patients were adherent with the drug regimen and 9 were not. The patients who did not abuse the therapy were abusers of solely alcohol (or had remote histories of polysubstance abuse), were in a solid drug-free recovery as evidenced by participation in 12-step programs, and had good social support. The patients who abused the therapy were polysubstance abusers, were not participating in 12-step programs, and had poor social support. The specific behaviors that were recorded more frequently by those who abused the therapy were unscheduled visits and multiple phone calls to the clinic, unsanctioned dose escalations, and obtaining opioids from more than one source.

    ·A second trial examined the relationship between aberrant drug taking and the presence or absence of a psychiatric diagnosis of substance use disorder in 56 patients seeking pain treatment in a multidisciplinary pain program who were referred for "problematic drug taking." [16]. The patients who qualified for a substance use disorder diagnosis based upon a structured psychiatric interview were more likely to have engaged in unsanctioned dose escalations, received opioids from multiple sources, and have the subjective impression of loss of control of their prescribed medications.

    ·In a study performed at a major cancer center, self reports of aberrant drug taking attitudes and behaviors in samples of cancer (n=52) and AIDS (n=111) patients were examined by questionnaire [17]. Reports of past drug use and abuse were more frequent than present reports in both groups. Current aberrant drug related behaviors were seldom reported, but attitude items revealed that patients would consider engaging in aberrant behaviors, or would possibly excuse them in others, if pain or symptom management were inadequate. Aberrant behaviors and attitudes were endorsed more frequently by the women with AIDS than by the cancer patients. Overall, patients greatly overestimated the risk of addiction during pain treatment. Experience with this questionnaire suggests that both cancer and AIDS patients respond in a forthcoming fashion to drug taking behavior questions and describe attitudes and behaviors that may be relevant to the diagnosis and management of substance use disorders.

    Anecdotal accounts frequently shape the way clinicians view drug related behaviors. Some behaviors are regarded almost universally as aberrant despite limited systematic data to suggest that this is the case. As an example, a request for a specific pain medication or a specific route or dose may reflect a patient who is knowledgeable and assertive, favorable characteristics in other contexts, but is often greeted with suspicion on the part of practitioners. Other behaviors may be common in non-addicts and, though aberrant, may have little predictive value for true addiction. The finding that many non-addicted cancer patients use anxiolytic medications prescribed for a friend or other [17], for example, more than likely reflects the undertreatment and underreporting of anxiety in oncology patients than true addiction.

    — There is very little information about the risk of abuse or addiction during or after the therapeutic administration of a potentially abusable drug to patients with a current or remote history of abuse or addiction. Anecdotal reports have suggested that successful long-term opioid therapy in patients with cancer pain or chronic nonmalignant pain is possible, particularly if the history of abuse or addiction is remote [15,18,19]. One study, for example, showed that patients with AIDS-related pain were successfully treated with morphine whether or not they were substance users or non-users [20]. The major difference between the groups was that substance users required considerably more morphine to reach stable pain control.

    These data are reassuring, but do not obviate the need for caution. As an example, there is no empirical evidence that the use of short acting drugs or the parenteral route is more likely to lead to problematic drug related behaviors than other therapeutic approaches; nevertheless, it may be prudent to avoid such therapies in patients with histories of substance abuse.

    — Out-of-control aberrant drug taking among palliative care patients (with or without a prior history of substance abuse) represents a serious and complex clinical occurrence. The more difficult situations involve the patient who is actively abusing illicit or prescription drugs or alcohol concomitantly with medical therapies. Whether the patient is an active drug abuser, has a history of substance abuse, or is not complying with the therapeutic regimen, the clinician should establish structure, control, and monitoring so that they can prescribe freely and without prejudice.

    Multidisciplinary approach
    — A multidisciplinary team approach is optimal for the management of substance abusers in the palliative care setting. If available, mental health professionals with specialization in addictions can be instrumental in helping palliative care team members develop strategies for management and patient treatment compliance. Providing care to these patients can lead to feelings of anger and frustration among staff. Such feelings may unintentionally compromise pain management and contribute to feelings of isolation and alienation by the patient. A structured multidisciplinary approach can be effective in helping the staff better understand the patient's needs and develop effective strategies for controlling pain and aberrant drug use simultaneously. Staff meetings are helpful in establishing treatment goals, facilitating compliance, and coordinating the multidisciplinary team.

    Assessment — The first member of the medical team (frequently a nurse) to suspect problematic drug taking or a history of drug abuse should alert the patient's palliative care team, thereby beginning the multidisciplinary assessment and management process [21]. A physician should assess the potential of withdrawal or other pressing concerns and begin involving other staff (ie, social work and/or psychiatry) to begin planning management strategies. Obtaining as detailed a history as possible of duration, frequency, and desired effect of drug use is critical. Frequently, clinicians avoid asking patients about substance abuse because of fear that they will anger the patient or that they are incorrect in their suspicion of abuse. This stance can contribute to continued problems. Empathic and truthful communication is the best approach.

    The use of a careful, graduated interview approach is instrumental in slowly introducing the assessment of drug use. This approach entails starting the assessment interview with broad questions about the role of drugs (eg, nicotine, caffeine) in the patient's life, and gradually becoming more specific in focus to include illicit drugs. Such an approach is helpful in reducing denial and resistance.

    This interviewing style also may assist in the detection of coexisting psychiatric disorders. Comorbid psychiatric disorders can significantly contribute to aberrant drug taking behavior. Studies suggest that 37 to 62 percent of alcoholics have one or more coexisting psychiatric disorders, and the drug history may be a clue to comorbid psychiatric disorders (ie, drinking to quell panic symptoms). Anxiety, personality disorders, and mood disorders are the most common encountered [3,22]. The assessment and treatment of comorbid psychiatric disorders can greatly enhance management strategies and reduce the risk of relapse.

    Development of a treatment plan —
    Clear treatment goals are essential in managing aberrant drug-related behaviors. Depending on the history, a complete remission of the patient's substance use problems may not be a reasonable goal. The distress of coping with a life threatening illness and the availability of prescription drugs for symptom control can undermine the effort to achieve abstinence [23]. For some patients, "harm reduction" may be a better model. It aims to enhance social support, maximize treatment compliance, and contain harm done through episodic relapse.

    The following is important in establishing goals:

    ·Establish a relationship based on empathic listening and accept the patient's report of distress.

    ·Utilize non-opioid and behavioral interventions when possible, but not as substitutes for appropriate pharmacologic management.

    ·Consider tolerance, route of administration, and duration of action when prescribing medications for pain and symptom management. Preexisting tolerance should be taken into account for patients who are actively abusing drugs or are being maintained on methadone. Failure to address tolerance through proper dose selection and titration can result in undermedication and contribute to the patient's attempts to self-medicate. The use of medications with slow onset and longer duration (eg, fentanyl patch and sustained release opioids) may help reduce the risk of aberrant behaviors in those with addictive disorders. Patients who are perceived to be at high risk should not be given short-acting opioids for breakthrough pain.

    ·Frequently reassess the adequacy of pain and symptom control.

    Urine toxicology screening — Clinicians must control and monitor drug use in all patients, a daunting task in some active abusers. In some cases, a major issue is compliance with treatments for the underlying disease, which may be so poor that the substance abuse actually shortens life expectancy by preventing the effective administration of primary therapy. Prognosis may also be altered by the use of drugs in a manner that negatively interacts with therapy or predisposes to other serious morbidity. The goals of care can be very difficult to define when poor compliance and risky behavior appears to contradict a reported desire for disease-modifying therapies.

    Urine toxicology screening has the potential to be a useful tool both for diagnosing potential abuse problems as well as monitoring patients with an established history of abuse. However, urine toxicology screens are employed infrequently in tertiary care centers [24]. In addition, when they are ordered, documentation tends to be inconsistent regarding the reasons for ordering as well as any follow-up recommendations based on the results. In one survey, nearly 40 percent of the charts surveyed listed no reason for obtaining the urine toxicology screen and the ordering physician could not be identified almost 30 percent of the time [24]. Staff education efforts can help to address this and may ultimately make urine toxicology screens a vital part of treating pain in oncology patients.

    Outpatient management — There are a number of additional strategies for promoting treatment adherence in an outpatient setting. A written contract between the team and patient helps to provide structure to the treatment plan, establishes clear expectations of the roles played by both parties, and outlines the consequences of aberrant drug taking. The contract may include the following:

    ·Inclusion of spot urine toxicology screens in the contract can be useful in maximizing treatment compliance.

    ·Expectations regarding attendance of clinic visits and the management of one's supply of medications should be stated. As an example, the clinician may wish to limit the amount of drug dispensed per prescription and make refills contingent upon clinic attendance.

    ·The clinician should consider requiring the patient to attend 12-step programs, and have the patient document his/her attendance as a condition for ongoing prescribing.

    With the patient's consent, the clinician may wish to contact the patient's sponsor and make him or her aware that the patient is being treated for chronic illness that requires medications (eg, opioids). This action will reduce the potential for stigmatization of the patient as being noncompliant with the ideals of the 12-step program. In addition, the team should involve family members and friends in the treatment to help bolster social support and functioning. Becoming familiar with the family may help the team identify family members who are themselves drug abusers and who may potentially divert the patient's medications. Mental health professionals can help family members with referrals to drug treatment and codependency groups as a way to help the patient receive optimal medical care.

    Inpatient management
    — The management of patients with active substance abuse problems who have been admitted to the hospital for treatment of a life-threatening illness both includes and expands upon the guidelines discussed above for outpatient settings. These guidelines aim to promote the safety of patient and staff, contain manipulative behaviors by patients, enhance the use of medication appropriately used for pain and symptom management, and communicate an understanding of pain and substance abuse management.

    ·The first point of order is to discuss the patient's drug use in an open manner. In addition, it is necessary to reassure the patient that steps will be taken to avoid adverse events such as drug withdrawal.

    ·For certain situations, such as for preoperative patients, patients should be admitted several days in advance when possible for stabilization of the drug regimen.

    ·It is important to provide the patient with a private room near the nurses' station to aid in monitoring the patient and to discourage attempts to leave the hospital for the purchase of illicit drugs.

    ·The team should require visitors to check in with nursing staff prior to visitation. In some cases, it may be necessary to search the packages of visitors in order to stem the patient's access to drugs.

    ·The team should collect daily urine specimens for random toxicology analysis and frequently reassess pain and symptom management.

    As with pain regimens, management approaches should be tailored to reflect the clinician's assessment of the severity of drug abuse. Open and honest communication between the clinician and the patient reassures the patient that these guidelines were established in their best interest. In some cases, these guidelines may fail to curtail aberrant drug use despite repeated interventions by staff. At that point, the patient should be considered for discharge; our experience suggests that this is only necessary in the most recalcitrant of cases. The clinician should involve members of the staff and administration for discussion about the ethical and legal implications of such a decision.

    Patients in recovery
    — Pain management for patients in recovery presents a unique challenge. Depending on the structure of the recovery program (eg, Alcoholics Anonymous, methadone maintenance programs), a patient may fear ostracism from the program's members or may have an increased fear regarding susceptibility to readdiction. The first choice should be to explore non-opioid therapies with these patients, which may require referral to a pain center [25]. Alternative therapies include the use of non-opioid or adjuvant analgesics, cognitive therapies, electrical stimulation, neural blockades, or acupuncture.

    If the pain condition is so severe that opioids are required, certain measures should be considered based on the outcome of a thorough assessment, the goals of care, and the life expectancy of the patient. In some cases, it is necessary to structure opioid use with opioid management contracts, random urine toxicology screens, and occasional pill counts. If possible, attempts should be made to include the patient's recovery program sponsor in order to garner their cooperation and aid in successful monitoring of the condition.

    CONCLUSION — With the pressure of regulatory scrutiny and the duty to treat pain but contain opioid abuse or diversion, clinicians may believe that they must avoid being duped by those abusing prescription pain medications. Although the differential diagnosis of aberrant drug-related behavior is complex, clinicians who hold this view tend to simplify the clinical implications to "addiction" or "not addiction." This is not in the best interest of either the patient or the clinician. If the fear of regulatory oversight makes practitioners feel as if they must be right, that they have to "see through" the patient's or family's denials to guard against the possibility of being duped, under-treatment and avoidance of prescribing can result. This unfortunate outcome is not demanded by existing laws or guidelines.
    The clinician has an obligation to be thorough, thoughtful, logically consistent, and careful (not to mention humane and caring), but not necessarily right. Clinical management can be tailored for the multiple possibilities that might be giving rise to the behaviors noted in the assessment, and asserting control over prescriptions can be accomplished without necessarily terminating the prescribing of controlled substances entirely. Although these situations defy simple solutions, knowledgeable clinicians can implement strategies that simultaneously address the need for compassionate care and management of problematic drug use.

    While the most prudent actions on the part of clinicians cannot obviate the risk of all aberrant drug related behavior, clinicians must recognize that virtually any drug that acts on the central nervous system, and any route of drug administration, can be abused. The problem does not lie in the drugs themselves. The effective management of patients with pain who engage in aberrant drug related behavior necessitates a comprehensive approach that recognizes the biological, chemical, social and psychiatric aspects of substance abuse and addiction, and provides practical means to manage risk, treat pain effectively, and assure patient safety.

    1. Colliver, JD, Kopstein, AN. Trends in cocaine abuse reflected in emergency room episodes reported to DAWN. Drug Abuse Warning Network. Public Health Rep 1991; 106:59.
    2. Groerer, J, Brodsky, M. The incidence of illicit drug use in the United States, 1962-1989. Br J Addiction 1992; 87:1345.
    3. Regier, DA, Farmer, ME, Rae, DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990; 264:2511.
    4. Wells, KB, Golding, JM, Burnam, MA. Chronic medical conditions in a sample of the general population with anxiety, affective, and substance use disorders. Am J Psychiatry 1989; 146:1440.
    5. Burton, RW, Lyons, JS, Devens, M, Larson, DB. Psychiatric consultations for psychoactive substance disorders in the general hospital. Gen Hosp Psychiatry 1991; 13:83.
    6. Derogatis, LR, Morrow, GR, Fetting, J, et al. The prevalence of psychiatric disorders among cancer patients. JAMA 1983; 249:751.
    7. Regier, DA, Myers, JK, Kramer, M, et al. The NIMH Epidemiologic Catchment Area program. Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 1984; 41:934.
    8. Passik, SD, Portenoy, R. Substance abuse disorders. In: Holland, JC, et al (Eds), Psycho-oncology, Oxford University Press, New York 1998. p.576.
    9. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders - III, American Psychiatric Association, Washington, DC 1983.
    10. Bruera, E, Moyano, J, Seifert, L, et al. The frequency of alcoholism among patients with pain due to terminal cancer. J Pain Symptom Manage 1995; 10:599.
    11. Rosenblum, A, Joseph, H, Fong, C, et al. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. JAMA 2003; 289:2370.
    12. Rinaldi, RC, Steindler, EM, Wilford, BB, Goodwin, D. Clarification and standardization of substance abuse terminology. JAMA 1988; 259:555.
    13. Hay, JL, Passik, SD. The cancer patient with borderline personality disorder: suggestions for symptom-focused management in the medical setting. Psychooncology 2000; 9:91.
    14. Khantzian, EJ, Treece, C. DSM-III psychiatric diagnosis of narcotic addicts. Recent findings. Arch Gen Psychiatry 1985; 42:1067.
    15. Dunbar, SA, Katz, NP. Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. J Pain Symptom Manage 1996; 11:163.
    16. Compton, P, Darakjian, J, Miotto, K. Screening for addiction in patients with chronic pain and "problematic" substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998; 16:355.
    17. Passik, SD, Kirsh, KL, McDonald, MV, et al. A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients. J Pain Symptom Manage 2000; 19:274.
    18. Macaluso, C, Weinberg, D, Foley, KM. Opioid abuse and misuse in a cancer pain population [abstract]. J Pain Symptom Manage 1988; 3:S24.
    19. Gonzales, GR, Coyle, N. Treatment of cancer pain in a former opioid abuser: fears of the patient and staff and their influence on care. J Pain Symptom Manage 1992; 7:246.
    20. Kaplan, R, Slywka, J, Slagle, S, Ries, K. A titrated morphine analgesic regimen comparing substance users and non-users with AIDS-related pain. J Pain Symptom Manage 2000; 19:265.
    21. Lundberg, JC, Passik, SD. Alcohol and cancer: a review for psycho-oncologists. Psychooncology 1997; 6:253.
    22. Penick, EC, Powell, BJ, Nickel, EJ, et al. Co-morbidity of lifetime psychiatric disorder among male alcoholic patients. Alcohol Clin Exp Res 1994; 18:1289.
    23. Passik, SD, Portenoy, RK, Ricketts, PL. Substance abuse issues in cancer patients. Part 2: Evaluation and treatment. Oncology (Huntingt) 1998; 12:729.
    24. Passik, SD, Schreiber, J, Kirsh, KL, Portenoy, RK. A chart review of the ordering and documentation of urine toxicology screens in a cancer center: do they influence patient management?. J Pain Symptom Manage 2000; 19:40.

    -Hope this sheds some insight onto the how's and wherefore's of physician attitudes and actions. Most pain patients should be very careful about how they approach their docs when trying to receive adequate pain management. As the name implies, this information is the most "uptodate" data on approaching the pain patient and deciding on the fine-line between proper pain management vs. opiate addiction. Be prepared to subject yourself to random urine drug screens and know the criteria for inclusion and exclusion from pallative therapy. -Dick
    Last edited by a moderator: Sep 10, 2017
  2. Katjie.2

    Katjie.2 Newbie

    Reputation Points:
    Feb 1, 2012
    49 y/o from Australia
    the medico's fear of drug misuse, following the user to a painful death.