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| Chronic Pain, Opioids and Addiction: Challenges and Controversies |
| Feature Articles - Treatment Strategies or Protocols | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Written by Mel Pohl, MD, FASAM | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Thursday, 04 October 2007 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Approximately 50 million Americans — one in six people — suffer from
chronic pain. Furthermore, 25 percent of them experienced pain that
lasted through the day in the previous month; and 10 percent
experienced the same pain for one year or more. Nationwide, chronic
pain causes more disability than cancer and heart disease combined and
costs $550 million annually in lost workdays.
Clinically, chronic pain is one of two types of pain — the other is acute pain. Acute pain immediately signals the nervous system that something needs attention, and it is relieved once the cause of that pain has been addressed. Acute pain is “useful” because it informs the individual that something is wrong, and the sufferer is able to identify and treat the source while avoiding doing further damage until healing occurs. Acute pain tends to be nociceptive in origin, meaning that it comes from receptors and pathways that rapidly transmit signals to the brain and nervous system, resulting in a quick response, e.g., withdrawal from a flame. Acute pain is time-limited, usually lasting a month or less, and is responsive to opioid medication and other therapies. In contrast, chronic pain is a complex disorder that persists for more than three to six months, has outlived its usefulness, and has biological, psychological and spiritual components. The cause of chronic pain often cannot be removed or treated, and it is generally associated with a long-term, incurable or in-tractable medical condition or disease. Chronic pain frequently has neuropathic origins and results from damage to the peripheral or central nervous system tissue or altered processing of pain in the central nervous system. In addition to the physical experience of pain, chronic pain can cause tremendous suffering, which is the brain’s emotional and psychological reaction to ongoing pain. The feelings of stress, anxiety, fear, frustration and helplessness that often accompany chronic pain typically intensify an individual’s experience and perceptions of pain.Chronic pain is growing in prevalence: individuals living with chronic pain increased nearly 40 percent in the nation’s workforce between 1996 and 2006. This figure is expected to continue to increase due to Americans’ sedentary lifestyles and our aging population. Ninety-five percent of these individuals’ chronic pain is treated not by specialists but by primary care physicians. These physicians are assisted in their work by the counselors, therapists and others who work with clients in chronic pain. Treatment of chronic pain Numerous pharmacological and non-pharmacological treatments for chronic pain exist, and there is no “one-size-fits-all” course of treatment. Over the last 10 years, opioid medications have gained acceptance as a form of treatment for chronic non-cancer pain, and they can be quite effective in diminishing pain. In fact, more than 100 million prescriptions were written for hydrocodone with acetaminophen in 2005, making it the most frequently prescribed medication that year. However, significant risks associated with the long-term use of opioids are dependence and addiction, although the exact relationship between opioid use for chronic pain and the likelihood of developing addiction remains unclear. What is clear is that the abuse of prescription painkillers by people who have chronic pain is growing. In recent years, the number of prescriptions written for opioid painkillers has increased dramatically. At the same time, over four million people in the United States meet the criteria for drug/alcohol dependence, and although estimates vary widely, as many as 25 percent of people who take medications chronically may develop abuse and/or addiction issues. For such reasons, opioid medications typically should be prescribed only when all alternative treatments, including the physical, psychosocial and pharmacological interventions presented in this article, have been exhausted. If opioids are prescribed, close monitoring is essential. If opioid requirement is increasing and pain is not responding, strong consideration must be given to discontinuing the opioid. If opiates are to be prescribed, physicians should have an “exit strategy” to facilitate withdrawal and discontinuation. Pain assessment To assess chronic pain, clinicians typically rely on client self-reports, utilizing a scale of one to 10 to determine pain levels (zero is no pain and 10 is the worst pain ever experienced). However, chronic pain clients may lose the ability to differentiate accurately between physical and emotional pain and may perceive emotional pain as physical pain (“on a scale of one to 10, my pain level is 20”). Additionally, reliance on self-report to determine appropriate utilization of medications is problematic, particularly in clients who have crossed the line into addictive drug taking (including those who are addicted to prescribed opioids). These clients take their medications for reasons other than physical pain. As a result, these self-reports may not accurately reflect their pain levels, but may be an attempt to get more medication and stronger drugs. Conversely, clients may present with pseudoaddiction, a condition in which a client’s pain is not being adequately treated. In this situation, the client seeks additional opioids to relieve her/his pain. Such medication-seeking behavior may appear to be just the same as addiction to the clinician. To accurately assess chronic pain and to distinguish from pseudoaddiction, clinicians must focus on more than the client’s self-report. They must also attempt to determine the source of the client’s pain, monitor for exacerbating factors including anxiety and depression, and create an individualized treatment plan. Chronic pain should be re-evaluated frequently, and clinicians will need to also find quantitative measures of pain; there are currently no readily available or reliable methods. Scales such as those described in Stephen Grinstead’s and Terence Gorski’s Addiction-free Pain Management: Relapse Preven-tion Counseling Workbook can assist clinicians in differentiating clients’ emotional and physical experiences of their pain, but there is no substitute for developing an ongoing, trusting and caring relationship with clients to assess pain levels. Treating pain without opioids When treating individuals with chronic pain, clinicians should focus on two main goals. The first goal is to increase the client’s comfort by reducing his/her experience of pain. The second goal is to increase the client’s ability to function, which includes stabilizing the client’s mood, strengthening coping abilities, increasing activity and ensuring that the client is able to sleep properly. Frequently, a combination of several treatments is most successful as best meeting both of these goals, but it may take time and a process of trial and error to determine the specific treatments that assist a particular client. One challenge is to earn clients’ trust and patience while undergoing this process. To do this, clinicians must educate clients as to the long-term benefits of such an approach. This includes helping clients to understand that a prescription for an opioid may provide immediate gratification and may be beneficial in the short-term, but that it may have unintended negative, and sometimes disastrous, long-term consequences. Pharmacological interventions Many pharmacological alternatives to opioid-based medications are available, and these medications can increase client comfort without creating the “foggy” mental state often associated with opioids and without opioids’ side effects or risks. Medications, including anticonvulsants, NSAIDS and muscle relaxants are just a few examples of medications that provide pain relief without opioids’ potential for addiction (see Table 1). To address the emotional components of pain, including depression and anxiety, the use of antidepressants may be appropriate. In addition to medications, many non-pharmacologic treatments are available. These treatments, which range from exercise to cognitive-behavioral therapy, frequently afford pain relief and increased functionality while providing clients with a sense of control over their chronic pain. Clinicians can work in conjunction with other professionals and their client to devise an individualized program that combines several types of therapies specific to the client’s condition. Move it or lose it Many clients living with chronic pain have reduced mobility due to their inability to participate in some physical activities, and often, to their fear of aggravating their pain. Consequently, even simple exercises may increase clients’ mobility and blood flow/oxygen in the extremities, and thus their general feelings of well-being and functionality. Physical therapists can provide clients with exercise protocols, hydrotherapy and strength training (including, but not limited to, core strengthening, Pilates and weight training) that provide safe ways for clients to improve their physical condition and reduce pain. Stretching programs such as Yoga and Chi Kung may have similar effects, helping clients to safely increase their mobility and quality of life. With their focus on breathing and conscious movement, these programs may also help clients to reconnect with their bodies in a positive, rather than pain-related, manner. Additionally, recent studies have shown that some clients with chronic pain have low levels of endorphins in their spinal fluid. The use of acupuncture needles to stimulate nerve endings may activate the brain reward systems that release endorphins. Studies of the spinal fluid post-acupuncture indicate increased levels of endorphins. This is just one example of acupuncture’s potential for assisting in the reduction of pain in some clients. Another option, particularly for those with back and neck pain, is chiropractic treatment. Chiropractors typically manipulate the spine and surrounding muscles and joints, re-adjusting their position to increase proper alignment and reduce stress and pressure, which can lead to decreased sensations of pain. Chiropractic can also include therapeutic and rehabilitative massage and exercises, and it may help boost endorphin levels and stabilize the spine, improving mobility and diminishing pain for individuals. It is increasingly supported by research as having short- and long-term pain reduction benefits. Another therapy to consider for clients with chronic pain is Transcutaneous Electrical Nerve Stimu-lation (TENS). This therapy sends small electrical pulses through the skin to nerve fibers, concentrating on certain areas of the body. These electrical pulses result in changes in the muscle tissue, including numbness, which can generate short-term pain relief. TENS can be useful in blocking the sensation of pain in some clients. Psychosocial interventions Jodie Trafton, Ph.D, describes multiple studies that demonstrate how clients’ beliefs about their pain are directly related to the severity of pain. For example, one study informed its subjects that an “experimental pain-reducing cream” (actually a placebo) was being tested on them. This study found that individuals’ reports of pain from an electrical shock to the wrist were greatly reduced when the cream was used (Wager et al., 2004). Additionally, research has found that clients who focus on their pain and/or their limitations are more likely to report elevated levels of pain. For these reasons, it is important to help the client identify his/her beliefs about the pain and to assist the client to refocus his/her attention. Because many clients living with chronic pain have gradually limited the activities in which they participate, it is possible that this reduction in distractions has resulted in increased focus on their pain and constraints, thus increasing sensations of pain. This becomes a negative cycle for clients, in which increased pain causes clients to withdraw further from additional activities, and in which the experience of pain then increases. Consequently, it is important that clinicians include psychosocial interventions when creating treatment plans for clients. One approach is to address clients’ emotional responses to pain through cognitive-behavioral therapy, which has been demonstrated to be effective in reducing the experience of pain. Working with an appropriate therapist/counselor or group may help clients better understand their pain, including its source, and their beliefs about it and emotional reactions to it. The ability to differentiate between physical and emotional responses to pain reduces many clients’ experience of physical pain and may result in self-reports on the pain scale that are more indicative of actual physical pain. Cognitive-behavioral therapy also provides clients with tools, such as relaxation methods, to help individuals prepare for, accept and cope with pain. Clients engaged in therapy often report an increased sense of control over their pain and decreased anxiety and helplessness. Another helpful practice is meditation, which is an important component of pain management for many clients. Research demonstrates that individuals who meditate regularly experience reduced levels of anxiety, depression and pain. Both meditation and prayer help individuals to connect with their spirituality, which is an excellent source of relief for many with chronic pain. Clients may research and practice meditation on their own. They may elect to join a local meditation group or they may participate in a formal, meditation-based program such as the Stress Reduction and Relaxation Program (SRRP) created by Jon Kabat-Zinn, Ph.D. and located at the University of Massachusetts Medical Center. This is an eight-week course based on the premise that clients’ thoughts, beliefs and emotions are intrinsically connected to their physical well-being and that learning to control these thoughts and emotions through meditation can have a profound, positive impact on the experience of pain. In addition to the benefits of meditation, clients participating in such programs gain the support of a peer group of individuals sharing similar experiences of chronic pain. It may also be beneficial to identify dynamics in which a client is rewarded for his/her pain. For example, family members may unintentionally reward the client’s pain by doting on the individual or becoming overly protective when the client expresses pain. Clinical studies have found that the presence of a solicitous family member more than doubles activity in the cingulate gyrus, a part of the brain that perceives pain (Flor et al., 2002). It is important to note that this increase in pain is a physiological response and does not involve a conscious deception or exaggeration on the part of the client. Other clients who stand to gain in any way from their pain, such as those receiving disability benefits, may also subconsciously experience increased levels of pain. Consequently, it is important that clinicians help identify situations in which clients are being rewarded for their pain and provide the appropriate recommendations (i.e., counseling for family members, friends, employers and insurers) to alter these dynamics. Chronic pain and the family Clients are not the only ones whose lives are affected by chronic pain; the suffering of their family members and loved ones can be profound. Family members often feel trapped by their loved one’s medical problem, and they may find their own lives seem controlled by that individual’s illnesses. Many feel obligated to give incessantly, trying to care for and meet the needs of the individual, while experiencing little in return. Eventually, many family members feel helpless and depressed and their own lives become unmanageable as they develop unhealthy patterns of codependency and enabling. Family discord frequently becomes a major source of stress for both the clients and their loved ones and can be destructive to all involved. Consequently, family education and involvement in the treatment process are critical for success. Education helps reduce family members’ uncertainty about the causes of pain. Understand-ing proposed treatments and activities can help them to circumvent enabling behaviors and promote positive ones. Education can also help family members understand the less intuitive connections between themselves and their loved one’s pain, such as the aforementioned increase in the experience of pain that often results from the presence of a solicitous loved one. Because family members’ behaviors, particularly their enabling behaviors, act as major roadblocks to client recovery, regular time spent by the clinician with family members is beneficial to all. Use of opioids in addiction and chronic pain Opioids can enhance the quality of life for some people with chronic pain, relieving pain and restoring function. However, opioids are associated with many unpleasant side effects, such as constipation, sleep disturbance, itching and a general sense of living in a “fog,” as well as their potential for addiction. Additionally, long-term randomized clinical trials have not demonstrated the effectiveness or safety of opioid medications in the treatment of chronic pain beyond six weeks (Gagne 2006). Consequently, opioids should typically only be utilized with individuals who do not respond to any of the treatments listed above. Anyone who takes opioids chronically will develop tolerance, defined as the body’s adaptation to long-term exposure to a drug, resulting in reduced reaction to the drug’s effects. They also will develop physical dependence, defined as a state of physical reliance on a drug, in which an individual can only function normally when taking the drug and will experience withdrawal symptoms if abstaining from the drug. Therefore, abrupt discontinuation is dangerous. Pain-addiction syndrome Of the clients with chronic pain for whom opiates are prescribed, a significant percentage will eventually develop an addiction to their medication. Typically, this occurs over the course of time, as the client becomes first dependent on, then out of control with, his/her prescribed pain medication. Pain-addiction syndrome is the dual diagnosis for such individuals living with chronic pain and addiction. Most clients initially take opioids exactly as prescribed to relieve physical pain. However, long-term use of opioids to treat chronic pain activates the brain’s reward system, impacting the client’s brain endorphins (such as dopamine), and resulting in a feeling of being “high” (euphoric, energized, a sense of profound well-being). As the effects of the medications wear off, these clients become dysphoric, which is believed to be the result of endorphin depletion. Dysphoria results in the desire to repeat the dosage again and as levels above the prescribed dosage are ingested, symptoms not originally intended by the prescribing doctor usually develop. Clients may begin to take increasing amounts of medication to avoid dysphoria and to achieve positive feelings. Frequently, clients also begin to take their medications to relieve emotional pain, anxiety, fatigue and depression. These clients have crossed the threshold to active addiction. Clients with pain-addiction syndrome are frequently trapped in a downward spiral, as each disorder exacerbates the other. Many clients independently increase their dosages, which can lead to running out of medications before they can legitimately get their prescriptions refilled. Once a client has run out of medication, he/she may experience pain and withdrawal, and likely will either try to find other doctors, visit emergency rooms to acquire more medication (doctor shopping), or look for medications from alternative sources such as friends, the Internet or on the street. He/she may also participate in criminal activity such as forging prescriptions or calling in a prescription under a doctor’s name. Engaging in such illegal behaviors causes most clients to feel guilty, fearful and anxious. As a result, they may take more medication to avoid these feelings, and they may ingest other mood-altering substances such as alcohol, stimulants and sedatives to reduce emotional distress. As this cycle progresses, clients’ functionality is reduced and many clients become unable to work or participate in social and family activities. Chronic use of opioids may also cause hyperalgesia, an increased experience of pain. Data on this paradoxical physical effect shows: “the more opiate I take, the worse I hurt and the more and stronger medication I need.” Clients are not typically aware of this consequence of opioid use, and their unsanctioned dosage changes may create a vicious cycle of increased pain and increased use of painkillers. Predictors of addiction Prior to prescribing opioid-based medications, clinicians should assess clients for their likelihood of addiction, based on family history and other predictive factors and behaviors. Several tools exist that can assist clinicians in this task, such as Lynn Webster’s “Opioid Risk Tool Clinician Form.” It is also recommended that a doctor who prescribes opiates have a written agreement or contract with the client. These agreements should contain specific rules of the practice including: limiting the client to only one doctor; requiring promises from the client to keep all appointments; not to make weekend calls for medications; and not to request early refills. The agreement also should incorporate clear and logical consequences if the agreement is not upheld. These consequences should include provision for referral of noncompliant clients for assessment and possible treatment of a drug problem rather than simply “kicking out” such clients from a practice. Once opioids have been prescribed, clinicians should engage in ongoing monitoring of their clients, both to ensure that the desired results are being achieved and to ensure that the client is taking his/her medication appropriately. Dr. Russell Portnoy described certain behaviors that should make a clinician suspicious of a client’s abuse of or addiction to pain medications. These behaviors are divided into two levels of behaviors, detailed in Table 2. Low suspicion behaviors indicate that a client may be progressing toward addiction; high suspicion behaviors indicate that a client is engaged in aberrant medication seeking. The role of buprenorphine When pursuing opioid treatment with a client, clinicians may want to consider less commonly prescribed options such as the semi-synthetic opioid buprenorphine (Subutex, Sub-oxone). Buprenorphine has unique properties that make it less likely to create feelings of euphoria in clients and that prevent clients from needing large doses of the medication. Additionally, if clients take other opioid-based drugs while on buprenorphine, they are less able to feel the euphoric effects of these medications. Due to its unique properties, studies have found that buprenorphine is less likely to lead to addiction on its own than other opioid-based medications, although it still should not be used in individuals already living with pain-addiction syndrome. Buprenorphine is also used as a maintenance and/or withdrawal drug for individuals with an addiction to opioid-based drugs. It is not currently approved for chronic pain but may be prescribed “off label.” Support groups Twelve-step support groups are an integral component of recovery for addicts, but such groups may not address issues unique to clients recovering from pain-addiction syndrome. Often these clients are isolated in their dual problems and benefit greatly from peer support. These clients may wish to join an additional group to address their specific issues, particularly learning to live with and manage pain without opioids. In some areas, support groups specifically targeted to individuals living in recovery and with chronic pain already exist. In other areas, clients may help create their own support group or they may find support from existing, complementary groups such as Chronic Pain Support groups and Pills Anonymous groups. Clinicians should be aware of the significance of support groups to clients’ recovery and should be prepared to assist with local resources and information. If a group is not already available, clinicians might also consider starting a group for clients with pain-addiction syndrome. Relapse prevention Clients who are in recovery with pain-addiction syndrome often experience cravings for their drug of choice as physical pain, and they may have unique triggers that can lead to relapse. For example, it is not uncommon for a client to relapse simply by finding a pill in his/her belongings. It is also helpful for clients to anticipate high-risk situations, such as a visit to a doctor, a flare-up of pain and emotional issues that may arise. Developing a plan and support for each scenario can help prevent relapse. Conclusions Pain is a complex biological and psychological experience that manifests uniquely in each individual based upon his/her unique experiences, mindset, nature of injury (or disease process), psychosocial factors and much more. Each individual’s response to pain is varied and variable from moment to moment. Treatment of chronic pain includes physical, psychosocial and pharmacological methods and is best handled by a multidisciplinary team. Use of opioids should be reserved until other treatment options have been pursued, due to the problematic aspects of opioid use, including the development of tolerance, dependence and preoccupation/continued use despite negative consequences with family, job and social functioning, as well as overall decreased participation in life. If addiction has developed, the pain-addiction syndrome requires complex intervention that may best be done by detoxification from opiates followed by judicious use of medications or abstinence. Many clients do better off opiates than on them, but their care is complicated and requires a diligent and caring combination of treatments. Melvin I. Pohl, MD is a Board Certified Family Practitioner and the Medical Director of Las Vegas Recovery Center, and a major force in developing LVRC’s Chronic Pain Rehabilitation Program. He is a fellow of both the American Society of Addiction Medicine and the American Academy of Family Practice. He is a nationally known public speaker and co-author of The Caregivers Journey: When You Love Someone with AIDS and Staying Sane: When You Care for Someone with Chronic Illness. References Angst, M.S. and Clark, J.D. 2006. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology 104 (3):570-87. Ballantyne, J.C. 2006. Opioids for chronic nonterminal pain. South Med Journal 99 (11):1245-1255. Baron M.J. and McDonald, P.W. 2006. Significant pain reduction in chronic pain patients after detoxification from high-dose opiates. Journal of Opioid Management 2 (5):277-282. Flor et al. Presentation at the 32nd annual meeting of the Society for Neuroscience, Orlanda, FL, November 3, 2002 Fishbain D.A., Rosomoff, H.L. and Rosomoff, R.S. Drug abuse, dependence and addiction in chronic pain patients. Clinical Journal of Pain, no. 8 (1992):77-85. Gagne, Jim, MD. 2006. Presentation on An Addictionist’s Jaundiced View or Treating Chronic Pain. Johnson, Rolley E., Pharm, D., Fudala, Paul J., and Payne, Richard. 2005. Buprenorphine: Considerations for Pain Management. Journal of Pain and Symptom Management 29 (3): 297-326. Mao J., Price, D.D. and Mayer, D.J. Mechanisms of hyperalgesia and opiate tolerance: a current view of their possible interactions. Pain no. 62 (1995):259-274. MedicineNet.Com: Chronic Pain. www.medicinenet. com/script/main/art.asp?articlekey=20502&pf=3&page=1 National Institute of Neurological Disorders and Stroke (NINDS): Chronic Pain Information Page, Condensed from Pain: Hope Through Research. www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm?css=print             
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