Med/Psych Update

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

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

References

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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.

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Methadone is a potent analgesic primarily used to treat opioid addiction, but it also is used for CNCP and cancer pain. With chronic use, methadone lacks the euphoric effect of other μ opioids; however, it can increase the QTc interval and has a long, variable half-life. As a result, methadone conversion tables are considered unreliable.

Methadone also has been associated with a disproportionate number of prescription opioid overdoses and deaths; it is present in 30% of all overdoses treated in emergency departments.⁴ Although methadone constitutes 5% of all opioid prescriptions in the United States, it is associated with one-third of opioid-related deaths, which is more than heroin and cocaine combined.¹⁴ Most methadone deaths occur within the first 7 days of initiating therapy, which suggests that patients were started on too high a dosage, were titrated too quickly, or had overestimated their tolerance.⁴ Reasons for methadone-related deaths are multifactorial and include:

• physician error and lack of knowledge

• patient nonadherence

• unanticipated comorbidities

• polypharmacy

• obstructive sleep apnea

• third-party payer policies listing it as first tier because of its low cost.⁴

In a Swedish study of 60 patients taking methadone, 75% had good pain relief on an average dose of 81.5 mg/d, whereas 25% had only moderate pain relief at a higher average dose of 157.5 mg/d. The authors described a methadone syndrome that included sedation, weakness, lethargy, weight gain, sweating, and sexual dysfunction, and that decreased the quality of life in 50% of patients.²⁵ Another study found that among patients who died from sudden cardiac death and had methadone present in the toxicology screen, 45% were taking other psychotropics.²⁶ Researchers also found a synergistic effect with benzodiazepines and an independent risk of sudden cardiac death and recommended obtaining pulmonary function tests and an electrocardiogram before starting methadone therapy, especially at higher doses.

Buprenorphine is a schedule III partial ì agonist opioid with a bell-shaped dose-response curve with a ceiling effect on respiratory depression, making it safe with an overdose. Although it is indicated for opioid dependence maintenance, it has been used off-label to treat chronic pain. It causes less euphoria than many other opioids including methadone. Buprenorphine is 25 to 50 times more potent than morphine and has a half-life of 20 to 44 hours but can be abused.²⁷ It is available as a tablet, an injectable, and a 7-day patch. A combination of buprenorphine and naltrexone has a lower abuse potential,²⁸ is administered sublingually and can be prescribed only by certified physicians.²⁹ A subcutaneous implantable form of buprenorphine, which lasts 6 months, is under FDA review.³⁰

Bottom Line
Multidisciplinary care paired with psychological interventions and a treatment plan has some evidence of efficacy in treating pain in patients with chronic non-cancer pain at high risk of substance abuse. Physician education in both pain and addiction is paramount. Frequent supervision, screening, monitoring and careful selection of medications will help physicians optimize outcomes and reduce risks.

Related Resources

Agency Medical Directors Group. Intra-agency guideline on opioid dosing for chronic non-cancer pain. http://agencymeddirectors.wa.gov/files/opioidgdline.pdf.

Stevenson E, Cole J, Walker R, et al. Association of chronic noncancer pain with substance abuse treatment outcomes among a community mental health center sample [published online January 3, 2013]. Addictive Disorders and their Treatment. doi: 10.1097/ADT.0b013e31827b0cd9.

Drug Brand Names

Amitriptyline • Elavil Buprenorphine • Subutex

Buprenorphine/naloxone • Suboxone Codeine • Tylenol with Codeine, others

Desipramine • Norpramin Duloxetine • Cymbalta

Gabapentin • Neurontin Methadone • Dolophine

Milnacipran • Savella Morphine • Roxanol

Oxycodone • Percolone, OxyContin Pregabalin • Lyrica

Tapentadol • Nucynta Topiramate • Topamax

Tramadol • Ultram Venlafaxine • Effexor

Hydrocodone/acetaminophen • Vicodin, Lorcet, others

Disclosures

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Acknowledgements
The authors thank Zita Juska for her editorial assistance with this article.

Featured Audio
Mark Juska, MD, discusses strategies for treating patients with comorbid pain and substance use disorders. Dr. Juska is a Fellow, Department of Anesthesiology, Wayne State University, Detroit, Michigan.