Med/Psych Update

Chronic non-cancer pain and substance use disorders: Challenges and strategies

Current Psychiatry. 2013 July;12(7):35-41

Carefully controlled care can successfully treat both conditions.

References

1. Giordano J. Pain and addiction: words, meanings, actions in the age of DSM-5. Practical Pain Management. http://www.practicalpainmanagement.com/resources/ethics/pain-addiction-words-meanings-actions-age-dsm-5. November 1, 2010. Accessed May 28, 2013.

2. The Joint Commission. Facts about pain management. http://www.jointcommission.org/pain_management. Updated February 27, 2013. Accessed May 28, 2013.

3. Volkow ND, McLellan TA. Curtailing diversion and abuse of opioid analgesics without jeopardizing pain treatment. JAMA. 2011;305(13):1346-1347.

4. Webster LR, Cochella S, Dasgupta N, et al. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011;12(suppl 2):S26-35.

5. Miotto K, Kaufman A, Kong A, et al. Managing co-occurring substance use and pain disorders. Psychiatr Clin North Am. 2012;35(2):393-410.

6. Morasco BJ, Gritzner S, Lewis L, et al. Systematic review of prevention, correlates and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorders. Pain. 2011;152:488-497.

7. Edlund MJ, Martin BC, Fan MY, et al. Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP Study. Drug Alcohol Depend. 2010;112(1-2):90-98.

8. Moore TM, Jones T, Browder JH, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med. 2009;10(8):1426-1433.

9. Chou R, Fanciullo GJ, Fine PG, et al. Opioids for chronic non cancer pain: prediction and identification of aberrant drug-related behaviors. A review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guidelines. J Pain. 2009;10(2):131-146.

10. Starrels JL, Becker WC, Alford DP, et al. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152(11):712-720.

11. Morasco BJ, Duckart JP, Dobscha SK. Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. J Gen Intern Med. 2011; 26(9):965-971.

12. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):
113-130.

13. Office of National Drug Control Policy. Epidemic: responding to America’s prescription drug abuse crisis. http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf. Accessed May 28, 2013.

14. Kuehn BM. Methadone overdose deaths rise with increased prescribing for pain. JAMA. 2012;308(8):749-750.

15. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112.

16. Currie SR, Hodgins DC, Crabtree A, et al. Outcome from integrated pain management treatment for recovering substance abusers. J Pain. 2003;4(2):91-100.

17. Morasco BJ, Corson K, Turk DC, et al. Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain. J Pain. 2011;12(3):352-359.

18. Hoffman BM, Papas RK, Chatkoff DK, et al. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol. 2007;26(1):1-9.

19. Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;11:CD007407. doi: 10.1002/14651858.CD007407.pub3.

20. Moorman-Li R, Motycka CA, Inge LD, et al. A review of abuse-deterrent opioids for chronic nonmalignant pain. P T. 2012;37(7):412-418.

21. Stanos SP, Bruckenthal P, Barkin RL. Strategies to reduce the tampering and subsequent abuse of long-acting opioids: potential risks and benefits of formulations with physical or pharmacologic deterrents to tampering. Mayo Clinic Proc. 2012;87(7):683-694.

22. Substance Abuse and Mental Health Services Administration. Managing chronic pain in adults with or in recovery from substance use disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011.

23. Senay EC, Adams EH, Geller A, et al. Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur. Drug Alcohol Depend. 2003;69:233-241.

24. Dart RC, Cicero TJ, Surratt HL, et al. Assessment of the abuse of tapentadol immediate release: the first 24 months. J Opioid Manag. 2012;8(6):395-402.

25. Rhodin A, Grönbladh L, Nilsson LH, et al. Methadone treatment of chronic non-malignant pain and opioid dependence—a long-term follow-up. Eur J Pain. 2006; 10(3):271-278.

26. Chuh SS, Socoteanu C, Reinier K, et al. A community-based evaluation of sudden death associated with therapeutic levels of methadone. Am J Med. 2008;121(1):66-71.

27. Drug Enforcement Administration. Buprenorphine. http://www.deadiversion.usdoj.gov/drug_chem_info/buprenorphine.pdf. Accessed June 6, 2013.

28. Gordon A, Rashiq S, Moulin DE, et al. Buprenorphine transdermal system for opioid therapy in patients with chronic low back pain. Pain Res Manag. 2010;15(3):169-178.

29. Substance Abuse and Mental Health Administration. Buprenorphine. http://buprenorphine.samhsa.gov/about.html. Accessed May 28, 2013.

30. Ling W, Casadonte P, Bigelow G, et al. Buprenorphine implants for treatment of opioid dependence: a randomized controlled trial. JAMA. 2010;304(14):1576-1583.

Patients with chronic non-cancer pain (CNCP) and a comorbid substance use disorder (SUD) are difficult to treat. There is a lack of high-quality clinical trials to guide management. This article focuses on current research, guidelines, and recommendations to best manage these patients. We present an analysis of recent statistics, patient characteristics, screening methods, as well as a discussion of changes to DSM-5 regarding substance abuse and addiction (Box 1).¹

Opioid use and opioid-related overdoses have increased dramatically over the last decade (Box 2).^2-5 Opioids are the primary medication used to treat CNCP, but their use in patients with comorbid SUDs is controversial. It is crucial for psychiatrists and other clinicians to know how to best identify, manage, and treat patients with CNCP/SUD.

Risk factors for CNCP/SUD

Evidence regarding the efficacy of screening methods to identify patients with chronic pain who are at high risk for substance misuse is insufficient. Key risk factors for developing chronic pain may include:

• elevated psychological distress

• negative beliefs and expectations about pain

• pain fear and avoidance

• disability

• anger or hostility

• maladaptive coping strategies

• catastrophic behaviors.⁵

In addition, these individuals may have a spouse who enables the sick role behavior.

Risk factors for developing a SUD related to prescribed opioids include:

• a history of problematic substance use

• sedative-hypnotic use

• positive family history for substance abuse

• legal problems

• heavy tobacco use

• age <50

• major depressive disorder or anxiety.⁵

In a review of 38 articles, Morasco et al⁶ found low-grade evidence with mixed results in attempt to find a correlation among sex, depression, anxiety, and tobacco use with CNCP/SUD. Other data suggest that the risk of addiction once opioids have been started increases with long refill periods and opioid morphine equivalents >120 mg.⁷ A history of childhood sexual abuse also may be a risk factor for chronic pain and addiction.⁵

Prevalence

The prevalence of opioid abuse among CNCP patients ranges from 3% to 48%; the highest rates are found among patients visiting the emergency room for opioid refills.⁷ These patients are more likely to exhibit aberrant behavior with their medications and may be prescribed higher opioid doses than patients who have CNCP only. Adherent CNCP/SUD patients show no difference in response to pain treatment compared with those with CNCP alone.⁶ Approximately 11.5% of CNCP patients taking opioids demonstrate aberrant medication use.⁶

Screening: Which method is best?

Data are scarce regarding the best screening methods to identify patients with CNCP/SUD. A survey of 48 patients by Moore et al⁸ found the combination of a clinical interview and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is 90% sensitive in detecting CNCP/SUD. However, a systematic review by Chou et al⁹ found only 2 well-designed studies showing that the SOAPP-R weakly predicts future aberrant drug behavior and only 1 study showed that a high risk categorization on the Opioid Risk Tool (ORT) strongly increased the likelihood of predicting future abnormal drug-related behavior. Another well-designed study showed that the Current Opioid Misuse Measure (COMM) weakly raised the likelihood of detecting current aberrant drug behavior. No reliable data supported the efficacy of urine drug screens (UDS), pill counts, or prescription drug monitoring programs (PDMPs) for improving clinical outcomes.⁹ In a systematic review Starrels et al¹⁰ found only low-quality evidence supporting the effectiveness of opioid agreement contracts and UDS.

Treatment strategies

Once a patient with CNCP/SUD has been identified, it is important to categorize the severity of his (her) pain and substance use by using the decision tree (Figure) and screening tools such as SOAPP-R, ORT, and COMM. In a Veterans Administration (VA) study, only 35% of patients with an SUD received substance abuse treatment.¹¹ The 2009 American Pain Society/American Academy of Pain Medicine guidelines recommended that opioids should considered for patients with substance abuse, serious aberrant drug-related behaviors, or psychiatric comorbidities only if frequent monitoring and treatment plan and mental health or addiction consultation were in place.¹² These guidelines also recommended discontinuing opioids if repeated atypical behavior, substance abuse, diversion, lack of progress, or intolerable side effects occur. Repeated and more serious behaviors require a multidisciplinary team, expert consultation, therapy restructuring, and possibly discontinuation of opioids.¹²

The U.S. Office of National Drug Control Policy has created a council of federal agencies to spearhead the Prescription Drug Abuse Prevention Plan, which includes 4 major categories to reduce prescription drug abuse: education, monitoring, proper disposal, and enforcement.¹³ FDA commissioner Margaret Hamburg supports legislation to combine opioid education with Drug Enforcement Administration registration.¹⁴ The FDA began developing the risk evaluation and mitigation strategies in 2007 to educate physicians on proper prescribing of potentially dangerous medications.