Clinical and Health Affairs
Patients with Pain and Addiction
What's a Doctor to Do?
By Marvin Seppala, M.D.
Abstract
Significant improvements in the evaluation and treatment of pain have led to more prescribing of and increased pressure to prescribe a variety of potentially addictive drugs to patients who are suffering from acute and chronic pain. Although these drugs serve an important purpose, they present risks to patients who are in recovery from addiction, are currently addicted, or have a family history of addiction. This article presents an overview of the concerns physicians face when treating such patients and outlines strategies for safely using these drugs.
In medical school, we are taught very little about pain and even less about addiction. Yet pain is the most often-cited reason why people visit their primary care physician, with issues related to addiction not far behind. During the last decade, we have seen significant improvement in the evaluation and treatment of pain. This has put increasing pressure on physicians to prescribe opioids for relief. At the same time, there have been significant regulatory sanctions for those perceived to be prescribing too many pain killers too often. Most physicians have been fooled by a drug-seeking addict and are wary of being duped again. And people in recovery from addiction fear relapse if they are given opioids yet also risk relapse if their pain is not adequately treated. Not surprisingly, people with both pain and addiction are some of the most difficult patients to treat effectively. What’s a doctor to do?
Prevalence of Opioid Addiction
Pain is now considered the fifth vital sign, and physicians are more willing to use opioids to provide relief from pain. Accompanying this improvement in the treatment of pain is ample evidence of an increase in the number of people who abuse and are addicted to opioids. According to the Substance Abuse Mental Health Services Administration, 2.4 million Americans age 12 years and older initiated nonmedical use of prescription pain medication in 2004, and an estimated 31.8 million have done so during their lifetime.1 In 2001, there were more emergency room admissions for complications related to narcotic analgesic use than for heroin use.2 By 2004, emergency room visits resulting from narcotic pain reliever abuse had increased 163% since 1995.3 In 2002, methadone killed 103 people in Oregon—two more than heroin—making it the state’s most lethal drug.4 In Minnesota, opioid-related accidental overdose deaths in Hennepin and Ramsey counties increased from 69 in 2003 to 102 in 2005 and outnumbered those associated with any other illicit drug. Most of these opioid-related deaths involved heroin, although some involved oxycodone, fentanyl, or methadone.5 Increased access to such opioids has resulted in more people using them and, consequently, more people becoming addicted to them. Thus, in a primary care practice, the tension between providing a patient with adequate pain control versus the risk of fueling an addiction creates a dilemma that plays out every day.
The following cases illustrate some of the difficult situations physicians face.
A 42-year-old woman recently entered one of Hazelden’s residential treatment programs. She had been sober for 7 years after treatment for alcohol dependence. Following a minor surgical procedure, she was prescribed hydrocodone and was given little instruction beyond how often to take the drug and how much to take. She had described her history of alcoholism to the surgical team, but she was not concerned about opioids because her previous problem was limited to alcohol. Her use of hydrocodone after surgery rapidly escalated, and she started to see multiple doctors for the medication. After losing her job and going through a family intervention, she was admitted for treatment of opioid addiction.
In another case, an internal medicine physician requested assistance with a 27-year-old male heroin addict who came to her for treatment of pain associated with the multiple fractures he suffered in a motor vehicle accident. The patient was using heroin daily and described ongoing pain in his hip. My colleague did not know if her patient actually had pain, nor what to do about it. But she was sure that the patient needed addiction treatment.
Active addiction can be very difficult to identify, let alone diagnose. Collateral information is necessary; the history needs to be gathered not only from the patient but from friends, family, and other caregivers. Difficulties with job retention, legal problems, and marital trouble may suggest addiction. The medical staff needs to be able to identify opioid withdrawal and recognize other symptoms of addiction such as regularly coming in early for prescription refills, having multiple excuses for running out of or losing medications, and escalating the dosage much faster than the norm. Sometimes patients with chronic pain can exhibit behaviors similar to those of addicts when they are inadequately treated; but their activities are limited to obtaining more medication and usually do not result in the other psychosocial consequences of drug and alcohol addiction.
The Prescribing Challenge
In the general population, the risk of patients with acute and terminal pain developing an addiction to opioids is extremely small. But the risk to patients with chronic pain is believed to be significant, and patients with a history of addiction and even those with a family history of addiction are considered to be at highest risk.
People in recovery from addiction are prone to relapse when provided medications that have the potential for addiction, whether or not they have ever been addicted to that particular class of medication. As a result, they tend to be under-treated for pain, as they are often not given opioids. With attention to the potential for relapse and a treatment plan that accounts for this, however, physicians can reduce the risk of addiction and effectively relieve patients’ pain.6
People in recovery respond well to frank discussion of addiction just as they would to discussion of any other co-existing illness that could interfere with their medical care. They also greatly appreciate engaging with someone who has knowledge about addiction and the risks associated with certain medications because they are often afraid of these medications and the potential for relapse.
Prescribing opioids for patients in recovery or with a family history of addiction requires careful consideration. Our improving knowledge of the neurobiology of addiction reveals remarkable, long-term alteration of the reward system of the brain, leaving these patients at risk for addiction to recur.7 Animal studies and evidence from clinical practice reveal that even small doses of addictive substances can trigger relapse.8 Thus, pain relief without intoxication or euphoria can reinforce further drug use and trigger a relapse.
For those patients with active addiction, use of screening questionnaires, a formal evaluation, and a referral to addiction specialists are options to consider prior to providing opioid analgesics, unless their pain is acute. Talking with patients about addiction is difficult but necessary, and expressing concern about the potential of addictive disease should be done just as one would any other co-existing illness.
♦ Patients with Chronic Pain
Opioids should be used to treat patients with chronic pain who are in recovery from addiction only when absolutely necessary and after trials of other nonaddictive alternatives have failed. These patients often benefit from alternative and complementary treatments and nonaddictive medications. They may be hesitant to try opioids and need education describing the benefits of the medications, or they may be unaware of the potential for relapse and require information that will help them understand the risk in an accurate manner. All treatment efforts should include the patient enlisting the support of family members, friends, and fellow Alcoholics Anonymous or Narcotics Anonymous members and sponsors. Consistent and ongoing monitoring of behavior and risk is necessary to help reduce the likelihood of relapse. Most patients will recognize the necessity of these efforts and appreciate the attention to their recovery.
Patients with chronic pain and active addiction are the most complicated to manage. These conditions present risk to both the patients themselves and the practitioner. Experts agree that the successful diagnosis and treatment of chronic pain during active addiction is unlikely. Thus, referral to a pain and addiction specialist or clinic is advised.9
♦ Patients with Acute Pain
Patients with acute pain who are in recovery can be treated in much the same manner as anyone else, with the addition of discussions about risk for relapse, limits on medications, a strict dosing schedule, and establishment of a support mechanism that includes others. Although treatment of acute pain is often accomplished by prn dosing schedules, this can increase the relapse risk for individuals who are recovering from addiction because they are left to make decisions about powerfully addictive medications. Opioids should be avoided if possible. But if necessary, they should be prescribed for a limited period with no refills available without re-evaluation.
Treatment of acute pain for someone in the midst of addiction is difficult because they may require a higher-than-usual drug dose, and adherence to treatment plans is rare. The physician should view such situations as an excellent opportunity to address the addiction and refer the individual for further evaluation and treatment.
Reducing Abuse of Prescription Pain Relievers
Several strategies can help to reduce some of the problems associated with addiction and limit the confusion that exacerbates the possibility of drug abuse. When physicians agree to provide pain treatment, they need to make sure that they are the only medication prescriber and that the patient uses a single pharmacy. The patient should bring their prescription bottles to each office visit for a pill count. Physicians should communicate treatment plans and goals to the patient’s other care providers. And they should ask their patients if they have ever used the Internet to obtain medications. Although Minnesota does not have one, some states have prescription-drug monitoring programs that also help reduce the likelihood of someone using multiple physicians and multiple pharmacies to procure medication. When pain is complicated by addiction, or even a history of addiction, it is best to involve an addiction medicine specialist to help evaluate the patient and plan treatment.
If there is any concern about the possibility of addiction, the physician should pay attention to those behaviors that distinguish addiction: loss of control over the use of the substance, continued use of the substance despite adverse consequences, and preoccupation with the substance. This information may not be available upon initial evaluation, but attention to addiction and careful observation over time can help physicians identify and appropriately intervene with those patients who have addictive disease.
Gourlay et al. have described the following universal precautions for prescribing pain medications that provide a framework for treating pain, establish boundaries for the physician-patient relationship, and help to limit the potential for problems associated with addiction.9
1. Make a diagnosis with appropriate differential. The cause of the pain should be identified whenever possible and treatments determined accordingly. Co-morbid conditions such as addiction also need to be identified and addressed.
2. Conduct psychological assessments including for risk of addictive disorders. Understanding a patient’s history of substance use and his or her family history of addictive disease are requisites for evaluation and treatment planning. Physicians should also do urine testing for drugs on initial evaluation and during treatment. Collateral information from family and friends can be of great help when evaluating both pain and addiction.
3. Make sure you have the patient’s informed consent. The treatment plan as well as issues associated with addiction, physical dependence, and tolerance should be fully discussed with all patients.
4. Draw up a treatment agreement. A written contract that sets boundaries and establishes expectations for both the patient and the physician can be immensely helpful. The proper use of medications, refills, appointments, and other issues of adherence to the treatment plan should be clearly spelled out and agreed on. The agreement should establish ground rules that will be used to monitor behavior throughout treatment. And the contract should clarify the role of the physician and the patient, limit the potential for misinterpretation, and help the physician, patient, and others identify problems suggesting addiction early on.
5. Conduct a pre- and post-intervention assessment of pain and functioning. The goal of treatment should always include both relief of pain and improved function. Assessment prior to and after initiation of all treatment trials provides essential information for ongoing evaluation and decision-making. Treatments include all behavioral, psychological, and medical trials.
6. Provide appropriate medication trials. This may include trials of opioids and/or other adjunctive medications.
7. Reassess pain score and level of function. Reassessment should occur throughout treatment to help guide
decisions.
8. Perform regular assessment of the four A’s of pain medicine. Routinely assess analgesia, activity, adverse effects, and aberrant behavior.
9. Periodically review pain diagnosis and co-morbid conditions. Illness evolves and co-morbid conditions can change, requiring alteration of treatment.
10. Document everything. Care must be taken to provide a complete record of the evaluations, ongoing assessments, and all decisions regarding treatment.
Conclusion
Although opioids are the most potent analgesic agents available, they are highly addictive and powerfully reinforce drug use. As the best treatment for moderate to severe pain, they are prescribed regularly, although they have the potential to cause significant harm to those predisposed to addiction.
All physicians will have to address pain in their patients’ and in their own lives. It is our responsibility to do so safely and in an informed manner. This will reduce the risks to the patient of perpetuating addiction and to ourselves of medical and legal consequences. Improving our understanding of pain and addiction, relying on addiction medicine specialists for consultation and referrals, as well as using universal precautions when prescribing pain medicine will help improve the care that our patients receive and minimize the potential for problems associated with addiction. MM
Marvin Seppala is chief medical officer for the Hazelden Foundation. He works at Hazelden’s facility in Newberg, Oregon.
References
1. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Nonmedical users of pain relievers: characteristics of recent initiates. The NSDUH Report. Issue 22; 2006. Available at: http://www.oas.samhsa.gov/2k6/pain/pain.htm. Accessed July 28, 2006.
2. Drug Abuse Warning Network. Trends in club drugs in ED visits, National Estimates: 1994-2001. The DAWN Report; October 2002. Available at: http://www.oas.samhsa.gov/2k2/DAWN/clubdrugs2k1.pdf. Accessed July 28, 2006.
3. Office of National Drug Control Policy. White House’s National Drug Control Strategy Focuses on Prescription Drug Safety. Press release; 2004. Available at: http://www.whitehousedrugpolicy.gov/news/press04/030104.html. Accessed on July 28, 2006.
4. Methadone Use on Rise in Oregon. Associated Press; 2004.
5. Falkowski C. Drug Abuse Trends. Center City, Minnesota: Butler Center for Research, Hazelden Foundation; June 2006.
6. Seppala MD, Martin DP, Moriarty J. Pain-Free Living For Drug-Free People: A Guide for Pain Management in Recovery. Center City, Minnesota: Hazelden; 2005.
7. Hyman SE. Addiction: A disease of learning and memory. Am J Psychiatry. 2005;162(8):1414-22.
8. Shalev U, Grimm JW, Shaham Y. Neurobiology of relapse to heroin and cocaine seeking: a review. Pharmacol Rev. 2002;54:1-42.
9. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of pain. Pain Med. 2005;6(2):107-12.