Gourlay and Heit proposed a universal precautions method of opioid treatment for all pain patients.15 That includes:
• seeking differential diagnoses and comorbidities
• doing a baseline addiction assessment with UDS and PDMP evaluations
• obtaining informed consent for pain management
• creating pre- and post-treatment goals for pain and function
• evaluating the 4 “As” (analgesic response, increased activity, adverse events, and aberrant behavior)
• reviewing the evolution of the pain and comorbidities
• continuous documentation.5
Other helpful strategies include the Oregon’s SMART (Specific, Measurable, Action-oriented, Realistic, Time-Dependent) goal-setting, which helps physicians negotiate functional goals with patients and plan an exit strategy for those whose quality of life does not improve with opioids.5 Clinicians also can consider a sequential treatment model where patients with severe substance abuse and pain are detoxified of illicit drugs and alcohol before starting pain management. This approach is more effective if the pain is secondary to a more severe substance abuse problem that is not correlated to physical pain and acute rather than chronic.16
Psychotherapeutic interventions
In another VA study, a collaborative care intervention (CCI) combining education, self-efficacy, pain management, and feedback was not impeded by a history of SUD. The authors recommended CCI, stepped care, integrated interventions, and relapse prevention and stressed the importance of social support.17
A 10-week cognitive-behavioral therapy (CBT) program involving 44 patients enrolled in an integrated pain management program for recovering substance abusers found 50% of CNCP/SUD patients were opioid-free at 12 months.16 A combination of medication reduction and education resulted in less pain, increased functioning, decreased emotional distress, and less self-medicating. Additionally, patients reported 35% overall reduction in pain severity based on the McGill Pain Questionnaire but only 25% of patients showed a reliable improvement in their pain. Treatment changes lasted 1 year.16
A meta-analysis of psychological interventions such as CBT, behavioral treatment (BT), and self-regulated treatment (SRT) indicated that CBT and BT are moderately effective at lowering work-related disability and pain intensity for chronic low back pain alone or with multidisciplinary care and moderately lowered work-related disability. CBT had a moderate to large effect, while SRT with biofeedback and relaxation techniques had a large effect on lowering pain intensity. SRT also was shown to lower depression. Return-to-work rates were better with multidisciplinary care that included psychological interventions. These psychological interventions for chronic low back pain lowered self-reported pain, pain interference, depression, and disability while increasing quality of life; the largest effect was on pain intensity.18
A review by Williams et al19 analyzing the effects of BT and CBT on various outcome measures, including chronic pain, found small to moderate benefits for disability, mood, and catastrophic thinking with CBT, which lasted up to 6 months. Only weak improvements in pain were seen with CBT immediately after treatment. BT had a beneficial effect on catastrophic thinking but only right after treatment. CBT’s overall effect in these patients was positive, and changes lasted up to 6 months.
Pharmacologic treatments
Before and during opioid therapy, psychotherapy, physical therapy, and occupational therapy should be used with adjuvant medications appropriate to the pain condition, such as anticonvulsants (gabapentin, pregabalin, topiramate) and antidepressants including tricyclic antidepressants (amitriptyline, desipramine) and serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine, milnacipran).12 When considering opioids for patients with CNCP/SUD, adverse effects and safety is a primary consideration. Benzodiazepines generally should not be used with opioids because of their synergistic sedating effects.5
Opioids are misused more often by overingestion than by altering the delivery route, yet most efforts to create tamper-resistant medications has focused on
snorting or injection, which are considered more dangerous. Current tamper-resistance strategies include:
• creating a hard shell to prevent crushing and altering the medications
• chemical combinations, using agonists and antagonists such as buprenorphine combined with naloxone
• prodrugs, which become activated only in the GI system
• implants or patches.20,21
One prodrug in phase-I testing, compound PF329, becomes activated only in the GI tract by exposure to trypsin. Because it also contains trypsin inhibitors, overingestion will not lead to toxicity.20 These types of technologies may take years to develop and integrate into our therapeutic armamentarium.
If choosing opioid treatment for patients with CNCP/SUD, initially consider weak opioids such as codeine and tramadol.22 Tramadol, a partial μ agonist and weak inhibitor of serotonin and norepinephrine reuptake, is not a controlled substance and is indicated for moderate to severe pain; however, reports of its abuse potential are beginning to emerge. Tramadol has a frequency of abuse and withdrawal of approximately 2/100,000 patients taking the drug.23
Tapentadol has a dual mechanism of action—it combines a potent opioid agonist with a norepinephrine reuptake inhibitor—and is a schedule II medication. The norepinephrine and serotonin reuptake inhibition properties of tramadol and tapentadol can lead to undesired side effects and are less likely to be abused. Dart et al24 found tapentadol immediate release has the lowest abuse rate of all the opioids they studied, well below oxycodone and hydrocodone.