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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

Pathways to Recovery From Co-Occurring Chronic Pain and Addiction

Editor's Memo March 2017
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The role of opioids in chronic pain treatment has become increasingly controversial and includes important questions about who may benefit from long-term opioid therapy. While much chronic pain can be managed with nonopioid approaches, it is clear that some patients and providers find opioids a helpful component of ongoing pain treatment.

Others on opioid therapy, however, may experience loss of analgesia, declining function, persistent side effects, mood changes, increasing pain, escalating dose requirements, and/or diverse types of opioid misuse that can result in adverse consequences, including addiction or death. And across the US, misuse and diversion of prescribed opioids have contributed to a major public health crisis.

Managing opioid use disorder.

In order to support positive pain outcomes and reduce opioid-associated harm, it is critical that prescribers are prepared to identify and intervene appropriately when opioid misuse occurs, and at the same time be prepared to offer robust nonopioid approaches to pain management.

This issue of Practical Pain Management focuses on the challenges of managing chronic pain in patients who have developed opioid use disorders (OUDs). Dr. Daniel Alford describes different presentations of opioid misuse, discusses the difficulty of determining causes for the misuse with certainty, and provides guidance on the pharmacologic treatment of OUDs in the context of chronic pain. Dr. Jordan L. Newmark identifies important tools for monitoring opioid therapy that can help track the benefits and risks of opioid therapy and discusses alignment of provider and patient goals with respect to continuing or discontinuing opioids. Dr. Robert Rich Jr. provides a primary care perspective on decisions to continue or taper opioids and describes a patient-centered approach to discontinuing opioids when indicated.

Seddon R Savage, MD, MS, offers a guest editorial on opioid use disorders.Seddon R. Savage, MD, MS

Common threads in these articles include an appreciation of the multidimensional nature of pain and the complex challenges of managing chronic pain in the context of co-occurring OUDs. The authors also note the importance of continuing to care for patients when opioids are discontinued and to engage them in alternative approaches to pain treatment. If there is anything positive in our current opioid challenges, it may be the renewed emphasis on the importance of multidimensional care in addressing complex chronic pain, including pain associated with co-occurring OUDs.

Recognition of chronic pain and addiction as chronic conditions with complex biopsychosocial dimensions has the promise to improve the care of patients with these co-occurring conditions. To successfully treat other chronic illnesses, such as diabetes and heart disease, we address both biological and psychobehavioral factors and aim to manage, not cure the condition: We educate patients about diet; encourage exercise and weight loss; provide medications; treat secondary problems; and, importantly, motivate patients to be active in self-care. Such multidimensional management has been demonstrated to similarly improve outcomes for patients with pain,1 addiction,2 and co-occurring pain and addiction.3

Addiction has long been viewed as a chronic, potentially relapsing disorder from which patients may recover but are not generally cured. Patients with chronic pain and their care providers, however, often continue to search for a cure for pain indefinitely, understandably hoping to find a definitive injection, medication, or surgery that will end their suffering.

However, while some chronic pain is due to ongoing tissue injury (eg, degenerative arthritis, inflammatory conditions, etc), pain also can be sustained by non-nociceptive factors in the absence of ongoing identifiable tissue damage. If a remediable cause is not found, transition to a primary goal of managing the pain may be both more realistic and more helpful than an exclusive focus on a cure. Although active treatments such as interventional procedures and medications may have important roles in ongoing treatment, engaging in active self-care can help patients thrive with improved function and quality of life. This can be especially important when chronic pain and opioid or other substance use disorders co-occur.

A number of self-management skills can empower patients to effectively address both pain and OUD, among them cognitive behavioral therapy (CBT), meditation, group support, and exercise. CBT aims to reduce physical and psychosocial triggers or reinforcers of pain or drug use, and helps patients adapt thoughts, feelings, and behaviors to reduce symptoms and improve quality of life. Patients with chronic pain and/or OUD often feel overwhelmed, so CBT breaks problems into small, manageable pieces to achieve targeted goals, supporting a sense of mastery and improved self-esteem.4,5

Meditation/deep relaxation approaches, often components of CBT, deserve special consideration. Growing evidence suggests meditation can alter neural processing to reduce pain and reduce addiction-related craving.6,7 Whereas scientists debate the nuances of different approaches (eg, mindfulness, mantra-based meditation, progressive muscle relaxation, autogenic training, hypnosis), evidence indicates even limited practice can significantly affect pain and recovery from OUD. Simple-to-learn, daily meditation practice can have profound effects on pain and OUD recovery and well-being.

Self-help groups such as Alcoholics Anonymous (AA) and Narcotic Anonymous (NA) are among the most established approaches to addiction recovery.8 The use of the 12 steps and traditions has evolved to address chronic pain as well,9 and Chronic Pain Anonymous (CPA) groups are spreading across the country.10 Other positive support groups can be accessed online through organizations such as the American Chronic Pain Association ( Both CPA and the American Chronic Pain Association offer access to groups (in person, online, and by telephone) in different regions of the country.

Last updated on: September 26, 2017
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Letters to the Editor: Initiating Hormones

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