What to do when pain and addiction coexist

Clinicians should advise patients with pain to exercise in a manner that is gentle, gradually progressive, and avoids significantly increasing the patient’s pain.²² Some studies suggest exercise can improve outcomes in addiction treatment; it is speculated that enhanced self-esteem and the increase in endogenous endorphins may contribute.²³

Adding active treatments to the platform of self-care

Selection of specific procedures and medications for different pain problems is beyond the scope of this article, but it is worth noting that engagement in a biobehavioral self-care program provides a context that supports successful use of procedures and medication. For example, improved posture, muscular support of the spine, and proper biomechanics may reduce disc stresses that can produce recurrent pain after a successful epidural injection of steroids. Similarly, muscular trigger point injections are more likely to result in protracted muscular relaxation if a patient is engaged in regular stress management and stretching.

Similarly, when withdrawal-producing medications are eliminated, when stress, anxiety, and depression are addressed, and when the patient is physically conditioned, he or she may respond better to nonopioid pain medications.

Opioids for pain in substance use disorders

Opioids are rarely first-line medications for chronic pain treatment but they can be valuable components of care for some who have not responded to self-management, interventionalist procedures, and nonopioid medications. But use of opioids in chronic pain patients with addictive disorders requires exceptional care.

As you might expect, the risk of opioid misuse is higher in individuals with a prior history of substance use when compared with a person without this history. But the relative risk for people with different types of addiction is unknown. There’s the potential to become addicted to opioids, for instance, when an individual is in recovery from addiction to alcohol or marijuana. However, observation suggests the risk of addiction to prescribed opioids is more likely in patients with a past history of opioid addiction than other addictions. Duration of recovery is generally inversely related to the risk of relapse, so longer term recovery presents less risk than recent recovery.

Whenever possible, engage any patient with a history of addiction in an active addiction recovery program and have him or her co-managed by an addiction specialist if you plan to prescribe opioids. Patients in recovery from nonopioid addiction who require opioids for pain may benefit from tightening the structure of care. This may include:

• providing a smaller supply of medications at more frequent intervals;

• increasing supports for recovery from pain, addiction, and co-occurring disorders;

• increasing supervision including office visits, urine drug screens, and pill counts;

• selecting treatments carefully to limit reward (euphoria) when possible, as reward can trigger misuse; and

• assuring that the setting of care can provide optimal care coordination.²⁴

For those with a history of opioid addiction, the safest option for opioid therapy is engagement in an addiction treatment paradigm of opioid therapy. This will mean either buprenorphine/naloxone with a registered provider or methadone maintenance treatment through a licensed clinic in which medications will be tightly supervised and the patient engaged in psychosocial addiction treatment. Both types of opioid agonist therapy may provide some pain relief while providing pharmacologic treatment of opioid addiction and minimizing the risk of misuse and associated harm (such as overdose).

What’s your role?

The key roles of the primary care physician in managing chronic pain and coexisting substance use disorders are to (1) identify the variables that contribute to the patient’s experience of pain and use of substances, (2) encourage and support the patient as he or she tries to develop a self-care program, (3) strategically implement or refer for active treatment of the various contributing factors, and (4) see the patient regularly to monitor engagement in both self-care and active treatments and to revise the plan as needed.

Coexisting pain and addiction are among the most challenging scenarios encountered in primary care. Recovery is possible, but patience, time, flexibility, and consistent motivational support are critical. The process is often 2 steps forward, one step back, so clinicians and patients need to celebrate small victories.

References

1. McLellan AT, Lewis DC, O’Brien CP, et al. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284:1689–1695.
2. Chelimsky TC, Fischer RL, Levin JB, et al. The primary practice physician program for chronic pain (© 4PCP): outcomes of a primary physician specialist collaboration for community-based training and support. Clin J Pain. 2013 Mar 1. [Epub ahead of print].
3. Anderson D, Wang S, Zlateva I. Comprehensive assessment of chronic pain management in primary care: a first phase of a quality improvement initiative at a multisite Community Health Center. Qual Prim Care. 2012;20:421–433.
4. Pohl M, Smith L. Chronic pain and addiction: challenging co-occurring disorders. J Psychoactive Drugs. 2012;44:119–124.
5. Hasin DS, Stinson FS, Ogburn E, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64:830–842.
6. Compton WM, Thomas YF, Stinson FS, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64:566–576.
7. Clark MR, Stoller KB, Brooner RK. Assessment and management of chronic pain in individuals seeking treatment for opioid dependence disorder. Can J Psychiatry. 2008;53:496–508.
8. West SL. Substance use among persons with traumatic brain injury: a review. NeuroRehabilitation. 2011;29:1–8.
9. Khoury L, Tang YL, Bradley B, et al. Substance use, childhood traumatic experience, and posttraumatic stress disorder in an urban civilian population. Depress Anxiety. 2010;27:1077–1086.
10. Beck JG, Clapp JD. A different kind of co-morbidity: understanding posttraumatic stress disorder and chronic pain. Psychol Trauma. 2011;3:101–108.
11. Potter JS, Marino EN. How to avoid opioid misuse. Chronic Pain Perspectives. 2013;62(3):S2–S7.
12. Stanos S. Focused review of interdisciplinary pain rehabilitation programs for chronic pain management. Curr Pain Headache Rep. 2012;16:147–152.
13. Cheatle MD, Gallagher RM. Chronic pain and comorbid mood and substance use disorders: a biopsychosocial treatment approach. Curr Psychiatry Rep. 2006;8:371–376.
14. Chouinard MC, Hudon C, Dubois MF, et al. Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial. BMC Health Serv Res. 2013;13:49.
15. Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13.
16. McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine (Phila Pa 1976). 2002;27:2564–2573.
17. SAMHSA/CSAT Treatment Improvement Protocols. Rockville, MD: Substance Abuse and Mental Health Services Administration; 1993-. Available at: http://www.ncbi.nlm.nih.gov/books/NBK82999/. Accessed May 16, 2013.
18. Zeidan F, Grant JA, Brown CA, et al. Mindfulness meditation-related pain relief: evidence for unique brain mechanisms in the regulation of pain. Neurosci Lett. 2012;520:165–173.
19. Dakwar E, Levin FR. The emerging role of meditation in addressing psychiatric illness, with a focus on substance use disorders. Harv Rev Psychiatry. 2009;17:254–267.
20. Kaskutas LA. Alcoholics anonymous effectiveness: faith meets science. J Addict Dis. 2009;28:145–157.
21. Colameco S. Chronic Pain: A Way Out. Comprehensive Treatment & 12-Step Recovery Guide. Haddonfield, NJ: Stephen Colameco; 2012.
22. Nijs J, Kosek E, Van Oosterwijck J, Meeus M. Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise? Pain Physician. 2012;15(3 suppl):ES205–ES213.
23. Brown RA, Abrantes AM, Read JP, et al. A pilot study of aerobic exercise as an adjunctive treatment for drug dependence. Ment Health Phys Act. 2010;3:27–34.
24. Savage SR, Kirsch KL, Passik SD. Challenges in using opioids to treat pain in persons with substance use disorders. Addict Sci Clin Pract. 2008;4:4–25.