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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.
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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.

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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