Balancing the Needs of Pain Management and Addiction Medicine

Public and medical attitudes toward pain relief have been riding a pendulum for “millennia,” and today “the pendulum is going so far back in the direction of not treating pain and vilifying opioids that there may be very few advocates left for people in pain,” warned Steven D. Passik, PhD, the director of clinical addiction research and education at Millennium Research Institute, based in San Diego, CA.

Speaking at the 2014 annual meeting of the American Psychiatric Association in New York City, NY, on May 4, 2014, Passik cited several recent examples of successful combinations of personal psychotherapy, regular monitoring, and carefully titrated dosing that seem to control both pain and addiction. The goal, he said, is to “balance the principles of addiction management and the principles of pain management.”

However, pointing out that insurance rarely reimburses such methods of treatment, he asked rhetorically, “How are you going to pay for that? That’s anybody’s guess.”

To indicate the swings of the pendulum, Passik highlighted legislation and influential medical journal articles going back a century. These ranged from the federal Harrison Narcotics Tax Act of 1914, which regulated and taxed the production, importation, and distribution of opiates, to a 1946 editorial in the Journal of the American Medical Association sternly admonishing against giving injectable morphine to terminally ill cancer patients, to a letter to the editor of the New England Journal of Medicine in 1950 that claimed that opiates are not addictive based only on one case study.

Prescriptions for strong pain relief medications such as hydrocodone have been rising in the United States for the past two decades, according to Passik. Unfortunately, along with this trend, “we have trivialized the risk of addiction to individuals and to the people who are around the individuals,” he said.

The problem is not just that some patients are more susceptible than others to addiction. Even worse, their unused pills are easily accessible to their children and grandchildren, who may overdose themselves or sell them on the street.

Passik said downplaying the real risks of addiction “will blow up in our faces,” leading to harsher laws curtailing the availability of medications that some people truly need for pain management.

These problems call for a multifaceted program of risk management, Passik said. Among the key elements:

• Careful screening and risk assessment of patients who are being considered for opioids
• State-run data bases, to ensure that patients don’t acquire multiple prescriptions from many physicians
• A preference for small dosages of slow-acting medications
• Monitoring patients’ compliance, through such methods as urine screening and counting of pills and patches
• Patient education regarding safety precautions such as storage and drug-sharing
• Psychotherapy
• Abuse-deterrent formulations, such as crush-proof pills

Passik praised instruments such as the SOAPP (Screener and Opioid Assessment for Patients with Pain) assessment tool offered on the PainEDU.org website and a six-month trial that recently ended at the Department of Veterans Affairs Hospital in Philadelphia, which he described as “Weight Watchers for opioids.”

He also praised a small study of 40 patients in Virginia and New York by the National Institute on Drug Abuse, that tried a combination of methadone plus group and individual counseling.

He did have some encouragement for his audience. “This is where psychiatric practitioners could play a very significant role,” he urged.