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?
your message made my day!! Someone actually gets me and what i’m going through..god bless
There is as much, if not more, evidence that patients with chronic non-malignant pain can be treated long term with opiates without risk of becoming addicted. This is a great review of the literature from a very well respected pain researcher and clinician, Howard Fields…http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073133/
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.
AMEN ! Now that should be made into law.
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”.
What about puffer fish, bee, spider, and cobra venom based “drugs ” to name a few?
I read several articles of cobra venom in patches so it’s all day relief. ..which if you have chronic pain the biggest problem is the up and down of pain…. and abuse starts with relating livable pain with meds and bad pain as NEEDING meds… I also read these venom based meds are widely used with great success in Asia,Europe and Canada. ..plus they are cheap.
I think we need to investigate these drugs… its natural and non addictive.
20 years daily opiod prescribed. last 10 sick on buprenorphine. Recently diagnosis ankylosing spondylitis and in now it’s “sorry we thought you were faking your poison and pill seeking, but you’ll have to live with it.” I should not suffer, I am an honest single parent. I just want to go on duragesic but no one will help I am easy to die
I have a damaged steell rod on my entire spine. Back,arm and legpain. I went from codiene to oxy to fentanyl to booze.
I no longer drink at all but the back pain coupled with severe withdrawals leaves me with nowhere to go cgo but in a coffin.
Nobody was born with chronic pain or drug addiction. They learned it. Opiate dependence is based on tolerance and withdrawal. If you have these, you are dependent or addicted. The best way to treat pain is with carefully monitored pain medication, being opiate or non-opiate and good education for substance abuse. If you are abusing any drugs or medication, there is a reason you are doing so. Substituting marijuana for opiates is substituting one addiction for another. It is not any better. Don’t kid yourselves.
If someone has sever chronic pain and has been an opiate addict and now refuses opioids is there an alternative? I have read through everything but monitoring an opiate is not even an option for me. I am poverty stricken and do not have the resources to pay for extensive studies and pain clinics. Please help
I suffer from chronic pain, I have most of my life. In the last half dozen years it’s become so bad that I have had to take daily pain medication.
I’ve had surgeries, steel in my back, spinal fusion etc. …twisted spine, deterioration etc..
In addition I’m fortunate enough to have decent insurance that would cover a spinal cord stimulator implant. I can’t imagine the amount of pain medication I would need without it. Even with it my pain level is substantial.
I also do other things DAILY. Heating pad and/or ice pack every morning when I take my medication and use heat/cold in afternoon or evenings as well. I have an inversion table to help decompress my spine. NOBODY can say I am not trying multiple things to help relieve my pain. I only have a few vertebrae left that aren’t fused at the bottom of my back and I really don’t want to lose that tiny bit of mobility that I have left until/unless it’s unavoidable. …not that a single doctor I’ve seen can guarantee that fusing (fill in procedure here) will remove the pain and not lock it in or make it worse.
Now the *Pain Management Center* I go to, a large one, is basically telling me that the state of Texas is craping on them and saying that the patients have to be stepped down / off pain meds if it isn’t *fixable* and only treated as chronic. Insanity. I’m at a total loss as to what I’m going to do or where I should look next.
For 1 to 2 years I’ve had my pain managed and been able to function and at least do part time jobs. Now after only one month of this ‘stepping down’ of Morphine and other medications I’m using a cane quite frequently just to get around. Even laying in bed and trying to sleep more than a few hours without waking up in pain is out of reach.
This foolish ‘war on drugs’ and ATTACK ON THE DOCTORS has to stop. It’s killing the actual patients that NEED help. It’s causing people to suffer NEEDLESSLY because doctors are afraid that their license will be pulled or they will be hauled off in cuffs because SOMEONE ELSE is abusing the system.
Doctors shouldn’t be punished for doing their job or having compassion. The state/gov should concentrate on real drug problems and let the medical field do it’s job.
Attacking the medical industry will only cause more suffering of patients, INCREASE illegal drug traffic and cause MORE people to be UNABLE to work and pay TAXES because they can’t manage their pain.
I’ve worked mostly 12 hour shifts all my life and now I can barely get out of bed in the morning and make it to my heating pad in the living room because MY DOCTORS are paying the price for a BROKEN system that can’t do it’s job.
Small edit for above message: “only treated as chronic” should have been “only treated as Acute”, or ‘occasionally’ treated, like it was a flare up of some kind.
Something I have always found very strange is all the people I have witnessed firsthand who are absolutely against the use of opiates in pain management except in extreme cases e.g. at deaths door from cancer etc. UNTIL they are for whatever reason dealing with severe pain, THEN it’s ugh ah cough,scratch head……well THIS is different I HAVE TO HAVE THEM. LMAO Ohhhh aint that sweet? THEY are “special”.
i have lived with cronice pain for 4years i had a 14 hour back surgery with rods and pins i will be in so much pain i will be in tears at night when i wake up it takes me 2 hours to move i live with my pain at all time 5 and night 8 9 my doc stoped my pain meds i can hardley get out of bed all you people who are out there never living with pain i mean every day and night i have6 grand children i can only may be hold for a few min go to park with them i sit on bench with my pain meds i can atleast walk with them a little bit my wife is disabled i can not get dis becouse she will loose here ssi here med is over 2000 a month so i get 0 but over qualfy for it so not only do they take my pain med away but screw me i worked all my life im 48 years old but you doc had to live with this for 1 hour you would do the same i hat the pain med but takes my pain down so i still can have some life but would rather make me feal like a druggie when im in tears asking for reliefe i think a lot of it is wor on drugs i hope thoes people go thrue the hell there putting me thru or want you to go see a shrink just becouse they can not fix you or they are the one who messed you up in the first place