Editor's Note: This editorial by Dr. Peggy Compton, and the three papers in this issue by Drs. Webster, Fishbain, Zacny, and their colleagues, initiate the Opioids, Substance Abuse & Addiction Section ofPain Medicine.
Under the leadership of section co-editors Steve Passik, PhD, and Lynn Webster, MD, PhD, and their distinguished colleagues, this section will inform our readership about this critically important area of our scholarship and clinical management. Avoiding Harm“Do no harm”— primum non nocere—is probably the best-known mandate implied by (but not literally stated in) the original Hippocratic Oath. Although it is debated in certain modern contexts (i.e., abortion, capital punishment, end-of-life issues), this tenet is reflected in medical practice to the degree that healthcare is increasingly guided by evidence-based guidelines that are both effective and safe (i.e., do no harm). Unfortunately, an ongoing clinical practice with the potential to cause much harm to patients with chronic pain is that of discharging them from opioid therapy because of concerns about opioid-analgesic abuse or addiction.Like diabetes or heart disease, addiction is a chronic progressive disease that, if present and left untreated, may result in significant morbidity and death. Reactive discharge from opioid-analgesic therapy because of concerns about opioid addiction or abuse can do significant harm, not just at the level of the individual, but also affecting families, the healthcare system, and the society at large.
Such practice should be avoided. Defining Addiction in Patients with Chronic PainClearly, not all discharges from opioid therapy are due to the presence of addictive disease (or substance-use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Addiction concerns arise when the patient appears to be drug seeking, noncompliant with opioid therapy, or using other illicit drugs. Yet, none of these behaviors provide evidence of addiction, and patients may be wrongly discharged secondary to medication-misuse behaviors that actually reflect pseudoaddiction (drug-seeking behaviors based on inadequate pain relief, a poorly treated Axis I or II psychiatric disorder, or general noncompliance with therapy.After following a large sample of patients with chronic pain during 1 year of opioid therapy, recent data from our Veteran's Administration (VA) pain clinic showed that up to 28% were discharged for “medication misuse” behaviors. It is unknown how many of these opioid-misusing patients actually met psychiatric diagnostic criteria for a substance-use disorder, but these discharges clearly captured a certain proportion of patients with untreated addictive disease.Difficulties in determining the prevalence of opioid addiction in patients with pain are not simply because of a lack of sophistication on the part of practitioners, but more often a result from clinical challenges inherent in identifying addictive disease when the drug of abuse is medically prescribed. Standardized diagnostic criteria (DSM-IV-TR) for opioid addiction in pain-free populations have proven to be invalid or difficult to apply in the context of chronic pain and therapeutic opioid prescription.Because they have sanctioned access to their opioid medications, patients with pain who become addicted to these drugs may be less likely to suffer the legal, employment, family, and social consequences typically associated with, and partially diagnostic of, a substance-use disorder.
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Figure adapted from Compton and Athanasos, and Weaver and Schnoll.If an upward opioid dose titration is successful with respect to functional outcomes (i.e., improved ability to participate in activities of daily life, fulfilling social roles, and enhanced quality of life), it becomes evident that addictive disease is not an issue, as the presence of untreated addictive disease precludes improved functionality in the patient. Possible explanations for drug-seeking or aberrant medication-use behaviors in these patients include pseudoaddiction (drug-seeking secondary to undertreated pain, therapeutic dependence (drug-seeking secondary to anxiety about having an adequate supply of medication, or an untreated or poorly managed psychiatric disorder.Alternatively, if the patient does not improve with increased opioid provision, the possible presence of addiction becomes more likely. An individual addicted to his or her pain medication will, by definition, be unable to control medication cravings and use, will continue using despite negative consequences (including the threat of discharge from pain treatment), and will often seek out new sources of more medication. In other words, with increased access to opioid medication, addiction will ultimately be revealed, and pain will never be well managed. A lack of functional improvement could also indicate that the patient suffers from a pain syndrome that is relatively nonresponsive to opioid therapy, as with certain types of neuropathic pain.
If the latter is true, tapering of opioids while alternative relief strategies are implemented should be relatively uneventful and even desired by the patient. If the patient is highly resistant to or unable to comply with the withdrawal of opioids, addiction may be motivating opioid use. Managing Addiction in Patients with Chronic PainRegular monitoring and thoughtful assessment of potential indicators of addiction in the patient with chronic pain form the cornerstones for its effective management. Once identified, the practitioner has the opportunity to intervene in the progression of addictive disease, thereby improving pain relief as well as general health outcomes. Unfortunately, a more common response to detection (or even suspicion) of addiction in a patient with pain is to discharge the individual from treatment, with perhaps a referral to an addiction-treatment program.It is understandable that practitioners are motivated to “wash their hands of” these patients, e.g., pragmatic concerns about the time/costs associated with treating these complex patients, perceived regulatory scrutiny, and patient noncompliance with the treatment regimen support terminating opioid therapy.
Yet, summarily discharging these patients who may suffer an untreated and ultimately fatal disease (addiction) is, to this author, not only unethical but a source of significant harm.Any time a medication is prescribed, it is the responsibility of the prescribers to have a working understanding of the potential adverse consequences of the pharmacotherapy. If they are unable to manage these adverse effects themselves, they should knowledgeably refer patients to qualified specialists who can better treat the untoward response.In this sense, any practitioner prescribing opioids for chronic use should be accountable for having a management strategy in place if addiction should become evident. Providing daily opioids without suitable addiction expertise or support in place puts both the pain-management practitioner and patient at risk for poor outcomes.Managing addiction within the clinical context of chronic opioid therapy prescribed for pain does not require the pain-management practitioner to become an addiction specialist. However, rather than discharging the patient, a thoughtful and working partnership between addiction and pain specialists should be developed, with the pain practitioner continuing treatment for pain while also playing a role in addiction treatment.Merely discharging the patient with a referral for addiction treatment provides little opportunity for follow-up, and can result in both untreated pain and addiction. Few resources for referral exist with the necessary expertise and capabilities required to treat addiction within the context of opioid therapy for chronic pain, either in the pain- or addiction-treatment systems. Furthermore, adequate addiction treatment in the United States can be difficult and expensive to access, because public facilities often have waiting lists, and insurance companies may dictate and capitate coverage for addiction services.
For all of these reasons, it is incumbent upon the pain-management practitioner to take more of an advocacy role in the management of addiction, with the knowledge that doing so will ultimately result in better chronic-pain outcomes.If addiction is strongly suspected, involvement of an addiction specialist or a formal treatment program should be considered. Some degree of substance abuse services are offered via insurance companies and Medicaid. However, rather than immediately sending the patient directly to an addiction-treatment program, it might be more appropriate to refer the patient to a psychiatrist for confirmation of the diagnosis.If the patient does meet the diagnostic criteria for a substance-use disorder, addiction-treatment strategies can be planned and implemented with input from the psychiatric consultant. Rather than discharging patients from opioid therapy at this point, the practitioner should make an ongoing pain treatment contingent on active participation in addiction treatment.Here are specific strategies that the pain-management practitioner can use to support and participate in treating addiction while continuing to address a patient's pain-relief needs:.While waiting for or after initiating addiction treatment, the patient should be frequently seen to monitor health and safety. In doing so, the practitioner can ensure that a follow-up occurs with the addiction referral and can evaluate the degree to which the patient is engaged in treatment.
This also provides an ideal opportunity to deal with the ambivalence the patient is likely to feel about considering addiction treatment.Attendance at local 12-step program meetings can be very helpful at this time and continuing throughout the treatment. These meetings are free and readily accessible in most communities, and most of them welcome patients with opioid problems (with or without alcohol problems). Encourage the patient to explore different meetings, as the subculture or milieu of each can vary, and it may take a few tries before a comfortable match is found.
Attendance can help solidify a patient's commitment to stop addictive drug use, and most addiction-treatment programs use Alcoholics Anonymous principles and groups to some degree.An inability to control medication use is a cardinal sign of addictive disease, so to support recovery efforts, the practitioner can assist the patient by putting controls in place with respect to opioid access. Opioids can be dispensed in smaller amounts and without refills; a responsible relative or friend can dispense the medication, and/or urine toxicology screens can be more strictly monitored. Controlled environments (e.g., residential settings) help many drug-addicted persons cease aberrant drug use. The patient should understand that these controls are put in place to support addiction treatment and not to be punitive.Once the patient initiates addiction treatment, the practitioner should become familiar with the addiction-treatment plan.
Is it an outpatient program or residential? Are urine toxicology screens regularly assessed? To what degree are motivational, cognitive behavioral, and supportive services provided? Becoming knowledgeable about the expectations and interventions of the addiction-treatment program enables the pain-management practitioner to assess participation and progress, which should be noted in the patient's chart during each visit.Addiction-treatment approaches relating to opioid addiction are of great concern to pain-management practitioners. Certain addiction-treatment programs refuse patients who are taking opioid analgesics and demand the withdrawal of opioids as a part of therapy.
In others, patients may receive a substitution opioid (e.g., buprenorphine or methadone). In these cases, discussion of and agreement on the treatment plan by both the addiction- and pain-treatment practitioners are essential.Treatment for addiction does not necessarily prohibit the continuation of opioid medications for pain, if these are used responsibly and effectively. Often, a resistant addiction-treatment provider will be more willing to work with the patient on chronic opioid therapy if assured that the pain-management practitioner will continue to oversee the pain treatment and help monitor the patient.Pain practitioners should take advantage of the screening, brief intervention (motivational interviewing), referral, and treatment (SBIRT) initiative from the U.S.
Substance Abuse and Mental Health Services Administration. This helps train and provide reimbursement to general practitioners for engaging in addiction-related services in non-addiction-treatment settings. The federal government has developed two alphanumeric billing codes for these services to receive Medicaid reimbursement:.H0049 Alcohol/Drug Screening—Alcohol and/or Drug Screening.H0050 Alcohol/Drug Service Brief Intervention, per 15 minutesMoving standardized addiction services into the general or pain practitioner's office is a landmark change in substance abuse treatment, and is based on compelling data from multiple sources warning of the consequences of alcohol and drug addiction on the health of the US population. Motivational interviewing strategies employed in the office-based brief intervention will be useful for the practitioner for multiple situations in which behavioral change is indicated such as with therapy for chronic pain.The possible presence of psychiatric disorders (particularly depression and anxiety) should be evaluated, and preexisting psychiatric disorders should be reassessed. An effective management of psychiatric disorders improves treatment outcomes for both addiction and chronic pain.In that these patients are particularly complex, treating concurrent mood or anxiety disorders may be beyond the scope of practice for most pain-management practitioners, and referral to a psychiatrist could be warranted. If the patient is diagnosed with a psychiatric disorder, the pain practitioner should assess for symptoms on a regular basis and briefly note results of assessments in the patient's chart.There are multiple screening tools available via the Internet for pain practitioners to use for assessments.
Along with this, the practitioner should help ensure that the patient is involved in psychosocial services that might be available to patients with chronic pain such as behavioral therapy and support groups.ConclusionThe guidance in this paper is offered to encourage pain clinicians' participation in, as opposed to withdrawal from, addiction treatment for the chronic pain patient. The underlying premise of the analysis is that by not managing active substance-use disorders in pain care, effective pain management cannot be achieved and the chronic lethal disease of addiction will continue to progress.