Counselor Magazine, the Magazine for Addiction Professionals - The Best Methods of Managing Pain in the Recovering Patient

CLASSIFIEDS
Turkish-American Substance Abuse Counselors Needed Certified/licensed substance abuse counselors fluent in Turkish are sought for a new Homeless Adolescent Rehabilitation Center in Gaziantep, Turkey. For more information, contact Dr. David J. Powell, This e-mail address is being protected from spam bots, you need JavaScript enabled to view it , 860 653-4470.

SUBSCRIBER LOGIN

News Briefs

Insomnia Linked to Substance Abuse in Adolescents

A study in the Oct. 1 issue of the journal Sleep shows that adolescent insomnia symptoms are associated with depression, suicide ideation and attempts, and the use of alcohol, cannabis and other drugs such as cocaine.

Findings suggest that the presence of insomnia in adolescents increases the risk of developing mental health problems and also may increase the severity of these problems. Results indicate that adolescents who had symptoms of insomnia were 2.3 times more likely to develop depression in early adulthood than adolescents without symptoms of insomnia. Specifically, at baseline, the insomnia group was more likely to use alcohol, cannabis, and non-cannabis drugs, and was more likely to suffer from depression, suicide thoughts, and suicide attempts. The insomnia group also had a greater risk of developing new incidences of depression and suicide attempts after excluding participants who suffered from these specific psychopathologies at baseline.

Polls

Can Recovering Drug Addicts Drink?

	Yes
	No
	I don't know

Special Offer

The Best Methods of Managing Pain in the Recovering Patient

Feature Articles - Treatment Strategies or Protocols

Saturday, 30 November 2002

Author's note: Treating a pain patient with a positive history of addiction is a team approach. Seldom can one health professional care for all the needs of such a patient. If the patient has difficulty adhering to the boundaries set in the initial agreement for opioid therapy of non-cancer/cancer pain or difficulty in coping because of biopsychosocial problems, the clinician often refers the patient to a counselor who is an integral member of the team. Therefore it is imperative the substance abuse counselor have a sound understanding of all aspects of pain management.

Pain is the most common complaint presenting to the clinicians office (Glajchen, 2001). Approximately 50 to 70 million people are under-treated or not treated for painful conditions (Krames & Olson, 1997). Currently available data suggest that 3-16 percent of the American population have addictive disorders (Savage, 1996). Therefore, based on these statistics, perhaps 5 to 7 million patients with the disease of addiction also have pain. The goal of pain treatment is to decrease pain and improve function while monitoring for any side effects. If this goal is not achieved by non-opioid and adjunctive analgesics in the recovering or actively addicted patient, can opioids be used to treat the pain?

To answer this question, this article will 1) Review the tenets of Alcoholics Anonymous (AA) and Narcotic Anonymous (NA) concerning the treatment of pain; 2) Define addiction, physical dependence, and tolerance; 3) Explain why long-acting or controlled-release (CR) opioids are the opioids of choice for chronic pain treatment and; 4) Discuss the initial evaluation and necessary boundaries when deciding to prescribe opioids to a patient with a history of addiction.

Certainly not all patients with chronic pain should be treated with opioids. The majority of these patients can be treated successfully with non-opioid analgesics such as aspirin, acetaminophen, nonsteroidal anti-inflammatory agents (NSAIDs), Cox-2 inhibitors, or muscle relaxants such as Baclofen or Tizanidine. One may also use adjunctive analgesics such as acute epileptic agents (Gabapentin) and/or low-dose antidepressants (amitriptyline, desipramine or nortriptyline) - both agents that are helpful for neuropathic pain. Physical therapy, ice, and heat can also be helpful. The treatment of pain must also include evaluation and treatment of any underlying psychiatric diagnoses such as anxiety, depression, bipolar disorder, or eating disorders. Non-restorative sleep; sexuality; and any social, economic, or environmental factors that affect the patient's holistic well being must also be part of the evaluation and treatment plan. If a history of addiction is positive, a program for starting or continuing recovery is mandatory for successful pain management.

Only after determining that other treatments have not relieved the patient's pain, nor improved the quality of the patient's life given the reality of his or her clinical condition, should the clinician consider prescribing opioids as a therapeutic trial. The clinician should never prescribe opioids on demand and only after being comfortable with his or her knowledge of addiction and pain medicine. If the clinician is not comfortable, then the patient should be referred to a healthcare provider who is knowledgeable about addiction and pain medicine.

John N. Chappel, MD, states that 12-step programs such as AA and NA are compatible with the treatment of all medical and mental disorders, including the use of opioids for the treatment of pain, and the treatment of pain should be considered essential as part of the treatment of addictive disorders (American Society of Addiction Medicine review courses). There is no mention in the 12-Step Program or the Big Book that the valid treatment of pain or any other mental, medical, surgical, or emergency condition is inconsistent with one working or continuing a program for recovery.

Drug addiction is a chronic relapsing disorder that involves multiple factors with the majority of relapses occurring during states of stress; drug availability; and re-exposure to environmental cues (sight, sounds, smells) previously associated with drug-taking (Koob & LeMoal, 2001). Undertreatment or no treatment of pain is a powerful stressor and consequently is highly likely to trigger relapse to addiction. It stands to reason that if the patient is in recovery and the pain is undertreated or not treated, the patient may go to the street for an illicit drug, or may take a legal drug such as alcohol to anesthetize him or herself to the pain.

Because the fear of addiction is one of the barriers to opioid pain management, the result can be under- or non-treatment of moderate to severe pain (Melzach, 1990). Therefore, it is imperative that the clinician understands the difference between addiction, physical dependence, and tolerance when prescribing opioids (see Table 1). If this distinction is not clear, a pain patient on opioids may be misdiagnosed with the disease of addiction when, in fact, he or she is physically dependent and tolerant, which is a normal physiological consequence of using opioids.

For example, a person addicted to heroin (Melzach, 1990) may be physically dependent, tolerant and addicted to the drug, but the use of the narcotic decreases his or her quality of life. A pain patient also may be physically dependent and tolerant to the opioid, but this patient is not addicted and the medicine improves his or her quality of life. Addiction to opioids in the context of pain treatment is rare in those with no history of addictive disorders (Portenoy & Savage, 1997). However, in those with a history of addiction, the relapse rate when treating with opioids is not known.

It is very important to choose the correct opioid to treat pain in the patient with the disease of addiction. The clinician can choose short-acting opioids such as codeine, oxycodone, morphine or hydrocodone; short-acting opioids such as oxycodone, morphine, or fentanyl in a controlled-release (CR) delivery system; or long-acting opioids such as methadone. The short-acting, CR, or long-acting opioids all may cause physical dependence and tolerance. The prescriber of opioids would want to minimize tolerance and abuse with the use of opioids. There is evidence that the use of CR opioids or a long-acting opioid is less likely to induce tolerance and abuse than a short-acting opioid (Garrido & Troconiz, 1999; Brookoff, 1993). This clearly would favor the use of a long-acting or CR opioid for the treatment of moderate to severe pain. Using a long-acting or CR opioid results in around-the-clock analgesia as a result of producing steady-state opioid blood levels over a 24-hour period. This prevents the "off and on" switch of fluctuating opioid blood levels that lead to euphoria alternating with cravings (Dole, 1988).

Morphine should not be the opioid of choice for patients with a history of heroin addiction, since heroin is metabolized to morphine (Braithwaite et al., 1995). Results of random urine drug tests, which should be part of the treatment plan, will be positive for morphine. The clinician will not know if the positive result was because of the prescribed morphine or a relapse with the use of heroin. A specimen that tests positive for morphine with the presence of 6-monoacetylmorphine (6-MAM), a heroin metabolite, is definitive proof of heroin use within the past 12 hours. However, because of its short half-life of 30 minutes, this metabolite is seldom found in the urine drug test (Inturrisi et al., 1984). Therefore, in this particular clinical situation one should choose the appropriate opioid such as methadone, which has been shown to have a lower potential for abuse than morphine (Garrido & Troconiz, 1999).

Once a decision is made to prescribe opioids, the pain patient, like all patients, should have a complete history and physical, including a review of pertinent past medical records and treatment successes as well as failures. The patient should be asked to provide the names of all other healthcare providers so that the providers can be informed that only one clinician is prescribing opioids and adjunctive medications to their patient. The patient also must be willing to obtain any additional consultations the clinician determines to be necessary to assist in the treatment plan. The patient should be informed of the risks of opioid therapy, which include, but not exclusively, such side effects as skin rash, constipation, sexual dysfunction, sleeping abnormalities, sweating, edema, sedation, or the possibility of impaired cognitive (mental status) and/or motor skills. The overuse of opioids also can cause decreased respirations. The patient who has a history of addiction should be informed that treatment with opioids may increase the possibility of relapse.

The patient in recovery or with active addiction must know that starting or continuing a program for recovery is mandatory if opioids are going to be prescribed. The patient should be asked to bring in receipts from attendance at AA/NA meetings; attendance also can be confirmed by talking to the patient's sponsor, family members, or friends.

Setting strict boundaries for the chronic pain patient with an addiction is an integral part of the treatment plan with opioids. The boundaries may reduce the relapse rate and certainly allow the clinician to make the diagnosis of relapse more easily. Additionally, they will allow a review and modification of the treatment plan, which certainly would include whether to continue the use of opioids to treat the patient's pain.

At the end of the first visit with the patient, the clinician should determine the boundaries and explain them. This can be done orally or preferably as part of a written agreement. The agreement becomes part of the medical record. The agreement should include both the clinician's and the patient's responsibilities for the treatment of pain with opioids. This agreement should be reviewed and discussed before any prescriptions are written. This agreement sets up the boundaries so that there is no confusion later in the treatment program. As the treatment progresses, the boundaries are tightened or loosened depending on the patient's ability to follow the written agreement. The boundaries are not intended to be punitive but should be used to monitor compliance with the treatment plan (see Figure 1 for a sample agreement).After the agreement is discussed with the patient and all questions are answered, the clinician and patient should sign the agreement. Note that language of the agreement allows the clinician the ability to be flexible with the patient. For example, the agreement states that under certain clinical situations the clinician patient/relationship may be terminated, not will be terminated. Do not use absolute terminology. This allows the clinician to adjust the boundaries for specific clinical situations.

Overall, opioid medication is not contraindicated to treat moderate to severe pain in the recovering or actively addicted patient. Once the clinician decides to prescribe opioids, he or she should select a long-acting opioid such as methadone or a CR opioid in order to achieve a steady-state blood level, which causes less positive reinforcement, tolerance, and abuse. Furthermore, it is essential for the clinician who prescribes opioids and adjunctive medications to set strict boundaries for the patient and to make clear that continued prescribing is dependent on adherence to the parameters set out in the agreement signed at the initial visit. The boundaries are not intended to be punitive, and, in fact, the same boundaries can be implemented in the pain patient without the disease of addiction. The boundaries are set so as to minimize the chances of the patient's relapse to his or her drug of choice or, if relapse does occur, to recognize it as soon as possible. This allows the prescriber to adjust the treatment plan appropriately for the patient. The dual goal is to decrease pain and increase function and to provide continual support for the patient's recovery from the disease of addiction.

Howard Heit, MD, FACP, FASAM, is board certified in internal medicine and gastroenterology. He is also certified in addiction medicine by the American Society of Addiction Medicine (ASAM). Dr. Heit was section coordinator and an editor on "Pain Management and Addiction Medicine" for ASAM's textbook Principles of Addiction Medicine. He is an assistant clinical professor of medicine at Georgetown University School of Medicine.

Table 1

Definitions Developed by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine

Addiction
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Physical Dependence
Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

Tolerance
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

Source: American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine. Definitions Related to the Use of Opioids for the Treatment of Pain, Glenview, IL, American Academy of Pain Medicine, 2001.

Figure 1
Agreement for opioid maintenance therapy for non-cancer/cancer pain
The purpose of this agreement is to give the patient information about the medications he or she will be taking for pain management and to assure that the patient and the physician comply with all state and federal regulations concerning the prescribing of controlled substances such as opioids.

The physician's goal is for the patient to have the best quality of life possible given the reality of his or her clinical condition. The success of treatment is dependent on mutual trust and honesty in the physician/patient relationship and full agreement and understanding of the risks of using opioids to treat pain.

1. A trial of opioid therapy with adjunctive analgesics can be considered for moderate to severe pain in order to reduce the patient's pain and increase function to give the patient the best quality life possible in view of the reality of his or her clinical condition.
2. One physician should be responsible for prescribing all opioid medications and adjunctive analgesics.
3. The patient should be informed of the risks of opioid therapy, which include, but not exclusively, such side effects as skin rash, constipation, sexual dysfunction, sleeping abnormalities, sweating, edema, sedation, or the possibility of impaired cognitive (mental status) and/or motor ability. Overuse of opioids can cause decreased respiration (breathing).
4. The patient should be informed that opioid medication causes physical dependence. Physical dependence means that if the opioid medication is abruptly stopped or not taken as directed, a withdrawal symptom can occur. This is a normal physiological response. The withdrawal syndrome could include, but not exclusively, sweating, nervousness, abdominal cramps, diarrhea, goose bumps, and alterations in one's mood.
5. Patients who have a history of addiction should notify the physician of such history since the treatment with opioids for pain may increase the possibility of relapse. A history of addiction does not disqualify one for opioid treatment of pain, but starting or continuing a program for recovery is a must.
6. Tolerance can occur with the use of opioid medication.
7. The patient should inform the physician of all medications he or she is taking, since opioid medications can interact with over-the-counter medications and other prescribed medications.
8. The patient will be seen on a regular basis and prescriptions given for enough medication to last from appointment to appointment, plus usually two to three days extra. This extra medication is not to be used without the explicit permission of the prescribing physician unless an emergency requires the patient's appointment to be deferred one or two days.
9. The patient must bring back all opioid medications and adjunctive medications prescribed by their physician in the original bottles, plus any other medicines prescribed by any other physician.
10. The patient should use one pharmacy to obtain all opioid prescriptions and adjunctive analgesics prescribed by the physician. The patient will indicate on this agreement the name and phone number of the pharmacy he or she is going to use. Pharmacy: __________________________ Phone number: _____________________
11. Any evidence of drug hoarding, acquisition of any opioid medication or adjunctive analgesia from other physicians (which includes emergency rooms), uncontrolled dose escalation or reduction, loss of prescriptions, or failure to follow the agreement may result in termination of the doctor/patient relationship.
12. The patient will communicate fully to the physician to the best of his/her ability at the initial and all follow-up visits his/her pain level and functional activity along with any side effects of the medications. This information allows the doctor to choose the right medication and dose for the patient.
13. The patient will not use any illegal controlled substances, such as cocaine, marijuana, etc. This may result in possible discontinuation of the doctor/patient relationship.
14. The physician reserves the right to perform random or unannounced urine toxicology testing. The presence of a non-prescribed drug (s) or illicit drug (s) in the urine can be grounds for termination of the doctor/patient relationship. Urine toxicology is not forensic testing, but is done for the benefit of the patient as a diagnostic tool.
15. The patient agrees that any refills of prescriptions for pain medicine or any other prescriptions will be done only during an office visit or during regular office hours. No refills of any medications will be done during the evening or on weekends.
16. The patient waives his or her right of privacy so that the physician can contact any health care provider, family member, pharmacy, legal authority, or regulatory agency to obtain or provide information about the patient's care or actions.

The above agreement has been explained to me by (prescriber), and I agree to its terms so that (clinician) can provide quality pain management using opioid therapy to decrease my pain and increase my function.

DATE: ___________________WITNESS: ____________________ PATIENT: ________________________

References
Braithwaite, R.A., D.R. Jarvie, P.S.B. Minty, D. Simpson. and B. Widdop. (1995). Screening for drugs of abuse. Annals of Clinical Biochemistry 32:123-53.
Brookoff, D. (1993). Abuse potential of various opioid medications. Journal of General Internal Medicine 8:688-90.
Dole, V.P. (1988). Implications of methadone maintenance for theories of narcotic addiction. JAMA 260:3025-29.
Garrido, M.J., and I.F. Troconiz. (1999). Methadone: a review of its pharmacokinetic/pharmacodynamic properties. Journal of Pharmacological and Toxicological Methods 42:61-66.
Glajchen, M. (2001). Chronic pain: treatment barriers and strategies for clinical practice. Journal of American Board of Family Medicine 14(3): 211-218.
Inturrisi, C.E., M.B. Max, K.M. Foley, M. Schultz, S. Shin, and R.W, Houde. (1984). The pharmacokinetics of heroin in patients with chronic pain. New England Journal of Medicine 310:1213-17.
Koob, G. F., and Michael Le Moal. (2001). Drug addiction, dysregulation of reward, and allostasis, Neuropsychopharmacology 24: 97-129.
Krames, E.S., and K. Olson. (1997). Clinical realities and economic considerations: patient selection in intrathecal therapy. Journal of Pain and Symptom Management 14:S3-S13.
Melzach, R. (1990). The tragedy of needless pain. Scientific American 262(2):27-33.
Portenoy, R.K., and S.R. Savage. (1997). Clinical realities and economic considerations: special therapeutic issues in intrathecal therapy - tolerance and addiction. Journal of Pain and Symptom Management 14(3):S27-S35.
Wise, R.A. (2000). Addiction becomes a brain disease. Neuron 26:27-33.