Treatment of Chronic Pain and Co-occurring Opioid Addiction

During their Thursday session, titled “The Emerging Scientific Basis for Treatment of Patients with Co-occurring Chronic Pain and Prescription Opioid Addiction,” at the American Pain Society 29th Annual Scientific Meeting, Seddon Savage, MD, PhD; Walter Ling, MD; and Jennifer Sharpe Potter, PhD, MPH, discussed the latest evidence from National Institute on Drug Abuse clinical trials and key neurobiological concepts in effective pain management for patients with chronic pain who are also addicted to opioid medications.

The presenters also explored the “neurobiological basis and clinical phenomenology of prescription opioid addiction” in the context of pain management, risk factors for prescription opioid addiction in patients being treated for chronic pain, and options for “safe and effective treatment of pain in persons with co-occurring prescription opioid addiction.”

“There are many reasons why patients don’t adhere to prescription medication regimens on a routine basis,” said Seddon Savage, MD, PhD, associate professor at Dartmouth Medical School and director of the Dartmouth Center on Addiction Recovery and Education. In fact, “studies have shown about a 50% adherence rate for just about any medication regimen.” Seddon noted there are many variables associated with nonadherence, including the fact that patients often receive ambiguous or conflicting instructions from their physicians. Patients suffering from chronic pain and addiction can also face considerable cognitive challenges and psychiatric distress.

Nonadherence with opioids often takes the form of self-medication of pain, with patients using medication outside of the clinical treatment setting. Patients also misuse opioids by shifting or escalating the dose of medication they take in response to neuropathic pain, hyperalgesia, or increased tolerance (which can occur in some patients in some settings). Savage also noted that patients self-medicate for non-pain symptoms, including sleep disturbance and “psychiatric challenges.” Patients also misuse opioids due to what Seddon referred to as “the drug reward;” opioids activate the brain’s dopamine-releasing reward circuitry, reinforcing the drug-taking behavior. “Some drugs and dosing regimens induce greater reward than others,” Savagensaid, “and intermittant bolus doses have more opportunity for reward than stable doses.”

Risk factors for opioid misuse include active or past subtance abuse disorder, mental health disorder, younger age, family history of substance abuse disorder, and current unsafe alcohol use. Seddon said that although there are no good studies (due to disparate definitions and methodology) of the prevalence of misuse in opioid therapy, some data shows that the rate of identified abuse/addiction is around 3%. In patients who display aberrant drug-related behaviors that number rises to more than 11%.

Savage outlined several structural considerations for dealing with patients with a higher risk of misuse, with the most important being to empower the patient to optimize their control of treatment, with the clinician recommending valid approaches that incoporate physical treatment (exercise, etc), psycho-behavioral interventions, procedural interventions, and tailored medication regimen.

Savage pointed to the “Universal Precautions” approach to pain management developed by Gourlay, et al. that incorporates comprehensive evaluation, risk assessment and stratification, informed consent, treatment agreement including goals of treatment, regular monitoring of pain, and urine toxicology screens to provide optimal assessment and management with opioid medications. The key to safe analgesic opioid therapy in patients with addiction, said Seddon, is structured risk. “But when a structured risk approach fails, your options are to taper the opioid dose, provide alternative pain care, provide opioids in an addiction treatment paradigm, and, finally, buprenorphine.”

Pharmacologic and psychosocial strategies in patients with pain and opioid addiction

The second presenter, Walter Ling, MD, a board-certified neurologist and psychiatrist and director of the Integrated Substance Abuse Programs at UCLA, talked about pharmacologic and psychosocial strategies for treatment of patients with co-occurring opioid addiction and pain. He also discussed the nature of our perception of pain, reminding that not only is pain an “unpleasant sensory experience arising from the actual or potential tissue damage,” it also has an intense emotional element as well. Pain, said Ling, is always subjective, and “each individual learns the application of the word through experience.”

When pain becomes chronic, one thing is certain, said Ling: the treatment didn’t work. This causes patients to become frustrated and lose faith in their doctors, who in turn sometimes blame the patient for not getting better. Ling noted that patients with chronic pain lose their “role” and become dependent on others, which can cause patients to be anxious, angry, and depressed.

The challenges of treating patients with chronic pain arise from the differences between acute vs. chronic pain. “Acute pain is finite and medication plays a big role in treatment; chronic pain is daily and medication often doesn’t play as big of a role” in treatment, said Ling. Moreover, as Ling noted, it’s been said that “the acute pain patient suffers from something; the chronic pain patient suffers from nothing.” It’s that constant presence that is the hallmark of chronic pain, a trait it shares with addiction. In fact, Ling pointed out that there are several common overlapping features of chronic pain and addiction: early trauma, loss of mastery and control, loss of sense of self and self-efficacy, personalization, and “catastrophizing” (the patient feels like “the world is against them and everything is being done to them”).

Jennifer Sharpe Potter, PhD, MPH, assistant professor of psychiatry at the University of Texas Health Science Center at San Antonio, presented data from the National Institute on Drug Abuse (NIDA) clinical trial titled “Prescription Opioid Addiction Treatment Study (POATS),” which studied whether “the addition of individual drug counseling to the prescription of buprenorphine/naloxone along with Standard Medical Management improves outcome both during a) an initial four-week treatment with taper and b) a 12-week stabilization treatment for those who do not respond successfully to the initial treatment with taper.”

“When treating opioid-dependent patients with buprnorphine, the addition of enhanced medical management improves outcomes,” said Potter. The investigators found that gender, age, and race did not modify outcomes. Success was defined for this study as four or fewer episodes of opioid use per month and no positive urine screen.