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12 Articles in Volume 17, Issue #2
Chronic Pain and Bipolar Disorders: A Bridge Between Depression and Schizophrenia Spectrum
Differences in Pain Management of Peripheral Vascular Disease and Peripheral Artery Disease
Duloxetine and Liver Function Tests
How Well Do You Know Your Patient?
Insurers End Policies Requiring Prior Authorization for Opioid Use Disorder
Letters to the Editor: Initiating Hormones
Managing Opioid Use Disorders and Chronic Pain
Opportunities and Challenges of Pain Management: The Family Physician’s Perspective
Pathways to Recovery From Co-Occurring Chronic Pain and Addiction
Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain
Treating Multiple Pain Syndromes: A Case Series Using a Functional Medicine Model
Treatment of Chronic Exhaustion and Chronic Fatigue Syndrome

Managing Opioid Use Disorders and Chronic Pain

Drug-seeking behaviors may be very similar to those presented in patients with inadequately controlled pain.

Recognizing and treating opioid use disorders (OUDs) among patients with chronic pain on long-term opioid therapy is challenging. “Drug-seeking” behaviors for an active OUD can be very similar to those behaviors in a patient who has inadequately controlled severe pain.

To better understand the nuances of managing pain in patients with OUDs, including those on medications such as methadone or buprenorphine, Practical Pain Management spoke to Dr. Alford.

Managing long-term use of opioids in patients with chronic pain.

For patients with chronic pain on opioid therapy who do require treatment for an OUD, what is the best strategy, how should chronic pain and pain flares be managed, and how can physicians help prevent relapse to active drug use?

[Editor's Note: To read Jordan L. Newmark, MD, clinical assistant professor, Division of Pain Medicine and Division of Addiction Medicine, Stanford University School of Medicine, strategies for weaning opioids; click here.]

Dr. Alford: The true rate of OUDs in patients with chronic pain is unclear, as evidence to date is limited in quality, uses ambiguous terminology, and shows conflicting results.1 A systematic review of 38 studies suggests opioid misuse rates of 21% to 29% and addiction rates of 8% to 12% in patients with chronic pain.2

Determination of whether the benefits of continued opioid prescribing outweigh the harms in these patients is based on patient reports and subjective observations. The right thing to do, Dr. Alford believes, is to fully assess and respond in a timely manner to clinical observations.

What are the biggest misconceptions among physicians regarding OUDs in patients with chronic pain?

Dr. Alford: A key issue is that certain aberrant behaviors in patients with chronic pain managed on opioids may be misinterpreted as signs of an OUD, when in fact the behaviors may be a result of poorly controlled severe pain and suffering. In some cases, the behaviors—unsuccessful attempts to try to cut down or cut back on opioids—may be caused by an OUD and/or inadequate pain control. Or perhaps the patient is spending a great deal of time trying to obtain opioids, because he or she cannot find a physician who is willing to prescribe them. There is much uncertainty and complexity surrounding these issues.

In fact, some of the 11 symptoms of an OUD in DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, 5th ed] could apply to a patient who is in severe pain (Table).3 Importantly, DSM-5 includes significant changes to the diagnostic criteria for OUDs,3 including the elimination of tolerance and withdrawal as criteria for patients taking opioids under appropriate medical supervision, inclusion of craving, and introduction of a new graded severity classification.

With the limitations to the DSM-5 in diagnosing OUD in patients with chronic pain treated with opioids, I often resort back to the 4 C’s:4

  • Loss of control: Patients may lose their prescription, self-escalate their dose, run out of the prescribed opioid early, continually call the on-call service, or show up at the emergency room for more medication. Patients with an OUD cannot take the opioid as prescribed.
  • Compulsive use: Patients exhibit preoccupation with obtaining the opioid as opposed to focusing on obtaining pain relief, and are opposed to trying other pain treatments despite continued severe pain. Sometimes I will reflect back to the patient, “You seem more focused on getting more medication than getting pain relief.”
  • Continued use despite the risk of harm: Patients may recognize that the opioid is causing adverse events and is not helping their pain, but they still want more.
  • Craving: If a patient is waking up in the morning and all he or she thinks about is having more opioids, this is worrisome.

Making a definitive OUD diagnosis may not be as critical as making a treatment change for patients with these worrisome behaviors. I tell patients: “My observations of your behaviors make me concerned about your safety. Whether or not this is an addiction may be unclear, but I can’t continue to prescribe opioids as I feel it would cause you more harm than good. So we need to do something else. If it turns out that you agree with me that you do have an addiction, I am happy to help you find treatment for this new problem.” Importantly, you are abandoning the opioid, and not the patient.

Another area of confusion among both physicians and patients (and their families) is regarding physical dependence and withdrawal. We know that patients on chronic opioid therapy will become physically dependent, and if the medication is stopped abruptly, the patient will experience withdrawal. This phenomenon is not addiction, but rather a biological adaptation to being on chronic opioid therapy. Addiction is the behavioral maladaptation presenting as the 4 C’s described above. Confusion over these terms is common.

How do you select the best medication for patients with OUD and chronic pain?

Dr. Alford: For patients with both chronic pain and OUD I usually prefer buprenorphine/naloxone (Suboxone) over methadone because I have a waiver [DATA 2000 waiver] to prescribe buprenorphine in my primary care practice, and I can treat both conditions simultaneously. Use of methadone is restricted to being dispensed at licensed methadone treatment programs. It is illegal to write a prescription for methadone for the treatment of an OUD.

Unlike methadone, which is a full opioid agonist with no ceiling effect, buprenorphine is a partial opioid agonist with a ceiling effect and thus is much less likely to cause severe respiratory depression or overdose. However, use of buprenorphine for the treatment of an OUD requires the patient to adhere to treatment in a less structured environment (ie, primary care) than with methadone—a setting offering daily observed dosing and monitoring. I prescribe buprenorphine every 1 or 2 weeks initially, and if the patient is stable and is able to take the medication safely, change to prescriptions every month.

If I am not convinced that the patient can take buprenorphine safely—for example, a patient with unstable mental illness, poly-substance use, or chaotic social environment—I prefer that the patient go to a methadone maintenance program where he or she can be observed and assessed every single day.

In terms of treating pain, it is important to understand the pharmacology and mechanisms of action of the various medications used to treat OUD. See also PPM's PainScan (Literature Review series) on Addiction Treatment & Relapse Prevention.

Methadone

Methadone is dosed daily for OUD treatment but its analgesic properties only last approximately 8 hours. There are 3 possible outcomes from methadone treatment for an OUD in a patient also suffering with chronic pain:

  • If pain is relieved all day with a single methadone dose, this suggests that the patient had withdrawal-mediated pain.
  • If pain is relieved for 8 hours following a methadone dose, with resumption of severe pain thereafter, the pain is probably opioid responsive. This patient may benefit from an additional nonopioid treatment (eg, nonsteroidal anti-inflammatory drug or gabapentin) or an opioid given later in the day when methadone’s analgesic effect wears off. This can be challenging because if you prescribe morphine or semisynthetic opioids, it may interfere with the methadone program’s ability, via urine drug testing, to differentiate relapse to heroin use versus morphine prescribed for pain. Use of a synthetic opioid such as fentanyl may be helpful in this instance. Equally important is to let the methadone clinic know what you are prescribing and why you are doing so. In addition, because patients on methadone maintenance usually are on doses that block the euphoric effects of co-administered illicit opioids (eg, heroin), there is a decreased likelihood that the patient will experience any reward (ie, euphoria) from the prescribed opioid analgesic.
  • If no pain relief occurs with methadone, the patient may be among the 50% of patients with chronic pain whose pain is not or is only minimally responsive to opioids.

Buprenorphine

Like methadone, buprenorphine’s analgesic properties last approximately 8 hours, and its OUD-treating properties last ≥ 24 hours. For patients without chronic pain, I would dose buprenorphine once a day for an OUD. In patients with an OUD and chronic pain, I dose buprenorphine 3 times per day (every 8 hours) to allow for 24 hours of coverage for both pain and addiction.

Naltrexone

Naltrexone (Vivitrol), which is an extended-release formulation approved by the Food and Drug Administration (FDA) for OUD treatment, is more complicated because it is a full-opioid antagonist. Thus, it is impossible for a patient receiving naltrexone also to be treated with an opioid for chronic pain because naltrexone will block the effect of the opioid. Thus, these patients require pain treatment with nonopioid medications and nonpharmacologic treatments (eg, cognitive behavioral therapy).

Are patients with OUD more sensitive to pain?

Dr. Alford: We know from experimental studies that patients with a history of OUD tend to be more sensitive to pain or less tolerant of pain than those without an addiction history.5-11 The question is what came first: Were they born with an altered and susceptible opioid receptor system and, therefore, were more likely to develop the addiction when they took a prescription opioid or heroin? Or was it their drug use over time that changed their pain receptors in such a way that now they are less able to tolerate pain? These questions remain unanswered.

The bottom line is that patients with a history of OUD seem to experience pain in a more intense way than do people without an addiction history. It is especially important that people with a history of addiction not feel stigmatized and that they be reassured that their pain will be aggressively managed despite their addiction history. While opioid analgesics may not be appropriate for some patients with an addiction history, we still need to use other strategies to aggressively relieve their pain and suffering.

See also a review of a recent study on the infuence on anxiety on patient OUD/MAT outcomes.

A recent study indicated that only approximately 20% of adults with OUD receive treatment.12 Is this low rate of OUD treatment also found in the chronic pain population?

Dr. Alford: I think the low number of individuals with OUD who are in treatment is irrespective of whether or not they have chronic pain, but rather has more to do with patients’ perception of whether or not they need treatment, lack of geographic access to treatment centers, and lack of financial access/health care coverage (see Sidebar).

Negative attitudes toward medications used to treat addiction are also an issue. Sometimes I will hear people say, “I don’t believe in methadone,” as if it is a religion. Evidence-based research has shown the efficacy of these medications. Like any other treatment for any other chronic disease, some patients will benefit and others will not. There is robust, high-quality research to show that medications used to treat OUD save lives, and we need to remember that.

What advice would you give to physicians on when they should taper opioids in a patient demonstrating aberrant behaviors?

Dr. Alford: Discussions with patients can be very uncomfortable and in some cases feel confrontational. Unfortunately, physicians may decide to write the prescription despite concerns and postpone the 10- to 15-minute difficult discussion for the next visit. I think what we need to do is to be able to make a conscious decision each time we write an opioid prescription that the medication is helping the patient more than it is harming him or her. If you are unable to state that to yourself, you really need to stop prescribing the opioid by tapering it if the person has physical dependence or by referring the patient to a medically supervised withdrawal setting (ie, detox program).

How has the Boston University Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program that you developed improved primary care physicians’ knowledge and confidence in safe opioid prescribing?

Dr. Alford: The free 2-hour, online, case-based SCOPE of Pain program is designed to help primary care providers assess whether opioids are appropriate for any given patient and how to safely and competently initiate, modify, continue or discontinue opioids when managing patients with severe chronic pain.

The program reviews opioid pharmacology; how to assess function and quality of life; how to assess for opioid misuse risk, including psychiatric comorbidities like depression, anxiety, and substance use; how to manage patients for safety and adherence with the use of agreements, urine drug testing, pill counts, and prescription drug monitoring programs; and how to assess and manage aberrant medication-taking behavior.

SCOPE of Pain emphasizes effective communication strategies for difficult clinical encounters around opioids and chronic pain, such as inheriting a patient on high-dose opioids, or addressing aberrant medication-taking behavior or an unexpected urine drug test result or unexpected finding on the prescription drug monitoring program. The SCOPE of Pain evaluation has been demonstrated to significantly increase participants’ knowledge, attitudes, confidence, and self-reported clinical practice in safe opioid prescribing.13

Last updated on: March 21, 2019
Continue Reading:
Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain

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