Challenges of Treating Chronic Pain in People with Opioid Dependence
As headlines about opioids focus on misuse of the drugs, physicians who treat patients with chronic pain are grappling with how to deal with opioid dependence. At the recent American Psychiatric Association meeting, pain specialists said that treating patients in pain who are dependent on opioids involves a delicate balance between managing pain relief and risk of drug abuse.
“One of the challenges is that we don’t have good estimates of how common it is for chronic pain patients to develop problematic opioid use” says Jennifer Potter, PhD, MPH, in the Department of Psychiatry at the University of Texas Health Science Center in San Antonio. “The vast majority of people with chronic pain do not go on to develop an opioid addiction, so it’s important for patients to understand that if this medication benefits you, it’s not necessarily a concern. We can’t let our response to the rise in prescription drug abuse to be denying access to all people in pain who can benefit from opioids. We need to build our understanding so we can manage our risk of drug abuse effectively.”
Rates for co-existing chronic pain and opioid addiction vary depending on where you look, Dr. Potter says. “For patients in a pain clinic, addiction rates are relatively low, but in a methadone or buprenorphine population, between 34 to 40 percent will have a chronic pain complaint,” she says.
A doctor treating a person for pain needs to look for potential risk factors for substance abuse, such as a personal or family history of other types of substance abuse or psychiatric disorders, Dr. Potter says. “If a person has one of these risk factors, they shouldn’t automatically be denied opioids, but they should be informed of the risk of dependence and be monitored for potential abuse.”
For some people with chronic pain, medication isn’t always the answer, says Dr. Potter, who is studying the treatment of opioid dependence and chronic pain through a grant from the National Institute on Drug Abuse. “There’s a false assumption that giving medicine makes pain go away, but in chronic situations that doesn’t always work,” she says. “Many people only get some reduction in pain.”
Non-Opioid Pain Treatments
Patients with substance abuse issues can be treated for pain in a variety of ways that don’t involve opioids, says Sean Mackey, MD, PhD, Chief of the Pain Management Division at Stanford University and Associate Professor of Anesthesia and Pain Management. “A multidisciplinary approach is needed to treat patients in pain who have substance abuse issues,” he says.
There are non-opioid drugs such as anti-epileptic drugs, antidepressants and anti-arrthythmic drugs, which can be effective in treating pain, Dr. Mackey says.
Patients can also be treated with psychological therapies, as well as physical and occupational therapy, he says. Many patients, however, do not receive a multidisciplinary approach to treating chronic pain because it generally requires the resources of an academic medical center. “Doctors who are treating patients without these resources need to collaborate with others who have the knowledge they don’t, either in addiction medicine or pain medicine,” Dr. Mackey advises.
If a doctor weighs all the options and determines that opioid treatment will work best for an opioid-dependent patient in pain, buprenorphine or methadone may be good options, he says. “Buprenorphine and methadone have strong analgesic benefits, and we commonly use them in this situation,” he says.
For a patient using methadone, one approach is to use a “blinded pain cocktail” in which methadone is ground up and mixed in with baclofen as a binding agent, with cherry syrup as a base. “We tell the patient what’s in it, but not how much,” Dr. Mackey says. “We closely track their quality of life measurements, and we can go up or down on the methadone accordingly. If we have a patient with clear control issues we only give out small doses at a time, or we hand it over to a trusted family member.” Mackey does acknowledge that the use of this tool is time and staff intensive and may be more than a small community practice can handle.
When treating patients with both chronic pain and a substance abuse disorder, Dr. Mackey advises making sure that they are receiving psychological counseling, either in a group or individually. “Many treatments we use in substance abuse overlap with chronic pain treatment—the psychological and behavioral skills are the same,” he says.
He also suggests an opioid contract for some patients, which establishes an understanding between patient and doctor that the patient will only receive opioids from that doctor, and from only one pharmacy. The patient may be asked to submit to urine drug screening, and is told that if their medication is lost it will not be replaced, and stolen medication will only be replaced if the person brings a police report.
“While even the most careful clinical pain management cannot eliminate risk of opioid misuse in patients with a history of addiction, good communication, knowledge of non-opioid treatment alternatives and appropriate monitoring and care in structuring opioid management can reduce risk significantly,” Dr. Mackey says.
I am curious about Dr. Potter’s statement on Opiate addiction. She says: “One of the challenges is that we don’t have good estimates of how common it is for chronic pain patients to develop problematic opioid use” but then she goes on to say the “vast majority of people with chronic pain do not go on to develop an opioid addiction.” How do you know? People seeking treatment for opiate addiction has exploded over the last decade, in Maine, going from 28 people per 100,000 to 338 people per 100,000. Most physicians use the 2009 AAPM/APS guidelines for prescribing but a close reading of those guidelines reveals that 16 out of the 21 experts are on the payroll one or more pharmacy company and their own guidelines, they rate as having very low evidence. So we are blithely prescribing highly addictive substances that can destroy whole communities based on little evidence and put forth by experts whose recommendations are tainted.
There is no evidence that people with non-cancer chronic pain can be safely and effectively treated with opiates over the long run. We have medically induced epidemic on our hands – we need to rethink our approach.
Great and accurate comments Valli Genevieve. All too many decisions to prescribe drugs is dependent on whether or not the prescribing individual has a vested interest as in, Stocks In Said Pharmaceutical Company. Ritalin is one of the most highly prescribed drugs on the market and is also a drug that is prescribed, in about 90 percent of the cases, where there is no evidence that it should be prescribed, and this is especially true in the incidence of this deadly drug being prescribed to children. The prescription rates on all pharmaceutical drugs are way up and I hate to be the one to say it, but I honestly do believe that doctors over-medicate and over-prescribe drugs, especially addictive drugs. Thanks, M. Jerome Ennis, MA/Addiction Therapist
@ Valli Genevieve…
Have you ever lived with chronic pain? I’m not talking about a creaky, arthritic knee. I’m talking about “can’t walk without the Fentanyl patch.” Or, had your second-grade daughter say to you, “Daddy, don’t use the cane today” as you walk them into school after their dental check-up?
There has to be a recognition not just lips service to the fact the opioid based pain meds result in tolerance.
The pain and treatment communities need to recognize that part of the treatment can and should include a process of reducing tolerance so that meds can be kept at a steady state and therefor the risk of addiction managed as well.
bUPRENORPHINE MAKES A TREMENDOUS ANALGAESIC FOR CHRONIC PAIN CONDITIONS THAT INCLUDE PROPENSITY TO OPIOID ADDICTION. THERE IS NO TOLERANCE INCREASE TO WORRY ABOUT, NO CONCERN FOR OVERDOSE (IF NOT MIXED WITH OTHER DRUGS) AND THE PATIENT IS LEFT WITH A SENSE OF EMOTIONAL NORMALCY. SINCE THERE IS A CEILING AFFECT TO GETTING “HIGH”, THERE IS NO POTENTIAL FOR ABUSE. TOO MANY ADDICTION PROFESSIONALS ARE MISINFORMED AND THINK THAT BUPRENORPHINE IS THE SAME AS METHADONE. THEY NEED TO BE EDUCATED.
I wonder if opinions and attitudes toward opioid analgesics would be different if healthcare providers as a part of their training, as well as government officials or other policymakers, had to endure several months of chronic pain. At that, it would be an unfair exercise because, unlike actual patients, the others would know there is an end in sight to their pain and suffering. Patients do not have that luxury and often worse than the pain itself is the lost hope of relief or lasting recovery from their daily agony.
While all of the concerns about opioid analgesic safety and the impact on public health are valid — to some extent — have the fears been elevated out of proportion with reality; considering there are more than 76 million chronic pain sufferers and an extremely small percentage of the population is misusing and abusing the medications.
Tolerance and addiction are not the same thing. I appreciate the comments by John Bancroft.
Recent publication of data showing the close proximity of emotional and physical pain receptor systems in the brain offer valuable insights. These are hinted at in this article, but not well addressed. Clearly assessing the role of the emotional pain and especially the incidence of fear seem a reasonable standard that might offer insights in treatment planning.
Hate to bring up the obvious, but in the US Pharmacopeia prior to 1942, cannabis was used as a very effective method to reduce opiate addiction. So, we already have a tool in our arsenal that has been shown to potentiate opiates so that smaller amounts can be used for the same analgesic effect, but because of our hair brained approach to public health, we don’t use it. Sad, really.
Funny, I looked through the whole article and I do not see any mention of the alternative analgesic that has the least side-effects, the safest profile, and the greatest potential for reducing the need for opiates. Yes, cannabis. The fact that it was not even mentioned in this discussion shows how completely distorted our public discourse is on this subject.
How about instead of over-relying on opioids, how about using, non-physically addicting, fewer side-effects, no death, safer alternantive cannabis. Proven to assist with pain related illness. We over prescribe and over-rely on opioid medications and though the tide could change from over use of opioids for pain to overuse of cannabis for pain, at the least, cannabis won’t kill you or cause over-whelming withdrawls and phsyical dependence. Whether you personally think cannabis should be legal or not, for whatever level of freedom, the bottom line is that it is a safer alternative to opioid pain management.
What are you all smoking? Doctors and Big Pharma can’t get rich off a plant! Have some pity for their suffering, would you? I know not all doctors are motivated by profit, but it is disappointing how many “need” to be subsidized by drug companies because their 6-figure income just won’t cut it without a little “boost”.