SCOTTSDALE, ARIZ. – Addiction specialists do see chronic pain patients who are so dependent on opiates that they require detoxification, but the question of whether such patients are “addicted” is difficult to determine clinically, two presenters said at a workshop at the annual meeting of the American Academy of Addiction Psychiatry.
One of the presenters said he prefers to detoxify these patients slowly and gently, using codeine. The other said he prefers a rapid method using naltrexone.
Many doctors have attempted to distinguish dependence from addiction, but the most clinically useful determination might be made by asking two questions, said Dr. Carl R. Sullivan of West Virginia University, Morgantown.
Does the patient misuse the medication or take it strictly based on the prescribed regimen? Is the patient honest about using the medication?
“I think that is a nice, easy way to look at it. If you see misuse and deceit, you are usually looking at addiction,” said Dr. Sullivan, who treats many chronic pain patients.
Dr. Sullivan also said he thinks chronic pain patients who truly become addicts are rare, and most who do have had substance abuse issues in the past.
“That seems not to happen very much,” he said. “Usually, if you are seeing addiction, and you think it is iatrogenic addiction, just look into the history a little bit.”
Still, both Dr. Sullivan and the workshop's other presenter, Dr. A. K. Roy, said they have little use for opiates in chronic pain. Other treatments such as tricyclics and physical rehabilitation are better.
Opiates can be somewhat effective at first, but after some patients have taken them for years, things begin to backfire, causing hyperalgesia and impeding functionality, said Dr. Roy, an addiction specialist who practices in Metairie, La.
“I have a concept that opiate use is temporary, though I don't know exactly what the definition of temporary is,” he said. “The liability for harm increases with the length of use.”
Dr. Sullivan said he has heard very articulate discussions on the rationale for switching opiate treatments periodically to avoid dependence and diminished efficacy. “To me, most of the time it just looks like … you are just switching a green M&M for a red one. There's just not that much difference.
“I'm not an opiate guy; I think there are so many better ways to deal with chronic pain.” he added.
More collaboration among pain medication and addiction treatment specialists might reduce the problems that some patients get into, but “some places I go they do everything but shoot guns at each other,” he said.
Of the approaches used for withdrawing a dependent patient from an opiate, Dr. Sullivan said he prefers to use a time-tested regimen using codeine that has mostly fallen into disuse. “I know it is an old-fashioned drug,” he said. “But it is very cheap and very effective, and it is a nice, short-acting agent.”
The advantage of the short-acting agent is that one can more precisely tailor the administration of the drug to symptoms. It also avoids a problem he has seen when longer-acting agents such as buprenorphine or methadone are used. That is, the drug effects can take several days to wear off, so patients who were thought to be fully detoxified start having symptoms days after the drug is stopped.
For the first 24 hours, the patient is given 30 mg of codeine every half hour, as needed, to stave off withdrawal symptoms. They also are given supportive medications, including a benzodiazepine and nonopiates for pain, if needed.
At the end of 24 hours, the total amount of codeine given is counted as the baseline dosage. That amount is then divided for dosing every 3–4 hours. The codeine is gradually scaled back over 10–14 days, Dr. Sullivan said.
Dr. Roy said he often prefers a rapid detox using naltrexone. It lets the patient have symptoms (with supportive benzodiazepine treatment), and results in a complete detoxification in 3–4 days.
It is not the very rapid detoxification that is done with anesthesia, but it is almost as rapid. Instead, it is a newer approach that has been pioneered at Loma Linda University and the Mayo Clinic with good reported results. When the patients are finished, they are no longer dependent and have no cravings, said Dr. Roy.
“This is not something I would do outside of a locked unit,” he said.
After detoxification, patients who are thought to have an addiction problem should then be referred to Alcoholics Anonymous, Narcotics Anonymous, or some other form of psychosocial support, Dr. Sullivan said.