Focus on Substance Use Problem

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Unfortunately, too often, there is a potentially harmful practice of discharging patients with chronic pain from opioid therapy because the clinician is concerned about opioid abuse or addiction (Compton, 2008). Patients in each of the above stages deserve to have their pain treated adequately and clinicians need to understand how this can be achieved.

Goal

The learner will be able to appropriately and sufficiently treat, refer, or comanage pain patients who have untreated addiction, are in current addiction treatment, or are in recovery from addiction.

Objectives

After completing this course, the learner will be able to:

Objective A. Manage Pain in Patients with Untreated Addiction

Take patient's addiction into consideration when managing pain patients who have untreated addiction

Use sensitive interviewing techniques to ask about all drug use
Conduct urine drug testing for the prescribed medication and other drugs, screening/assessment tools, as well as pill counts to identify patients with active addiction
Evaluate pain symptoms to determine their relationship to the substance abuse (e.g., withdrawal symptoms, opioid-induced hyperalgesia, rebound phenomenon), consulting with or referring to a specialist if needed
Develop a treatment plan that relies on alternatives to addictive pain medications if possible
Refer for treatment in a controlled or structured environment if addictive medications are needed
Require patients to be actively involved in addiction treatment in order to receive a pain medication prescription (when necessary for patient safety)

Objective B. Optimize Treatment

Determine optimum dosing and duration of pain treatment for patients who are currently in addiction treatment or in recovery

Determine adequate dosing and duration of pain medication for patients who are currently in treatment for addiction to opioids or other substances
Determine the adequate but lowest dose and duration of pain medication that is likely to be effective to treat the pain
Consult with a specialist regarding safe and effective medications to use in a patient on buprenorphine or methadone
Consider referral to a specialist if high doses of pain medication are required in a patient who is maintained on buprenorphine or methadone

Objective C. Minimize Risk for Abuse and Relapse

Employ strategies for minimizing risk of abuse and relapse in someone who is in addiction treatment or in recovery

Weigh concerns for minimizing risk for addiction against pain management
Prescribe less-addicting pain medications whenever possible
Choose medications that provide stable blood levels (long acting, slower onset) if appropriate
Prescribe scheduled doses rather than "as needed" when appropriate
Determine the appropriateness of non-opioid pain medications alone or in combination with opioids
Determine the appropriateness of non-pharmacological treatments, such as cognitive-behavioral therapy, physical therapy, and complementary and alternative medicine (CAM) treatments
If addictive pain medications are needed, prescribe them for a short time period and schedule frequent follow-up visits
Recommend intensification of relapse prevention activities
Consider enlisting the help of a trusted other person to dispense daily medication
Establish a plan for follow-up to evaluate pain and verify correct use of pain medication
Provide ongoing care management of patients with substance use disorders co-occurring with pain
Develop and use treatment agreements and exit strategies
Co-manage patients with specialists and other healthcare providers (described in detail in core course)

Objective D. Recognize Abuse and Relapse

Employ strategies for recognizing abuse and relapse in someone who is in addiction treatment or in recovery

Use sensitive interviewing techniques to inquire about patient's cravings or thoughts about using substances again
Provide ongoing care management of patients with substance use disorders co-occurring with pain
Identify behavioral red flags suggestive of substance abuse and/or relapse to addiction
Monitor pain medication use through pill counts

Objective E. Address Misuse/Addiction

Address misuse/addiction to prescribed pain medications if it occurs

Discuss consequences and alternatives to current treatment with the patient
Document misuse in the patient's medical record, including type, quantity, and duration of substances used
Tighten and revise treatment agreements in accordance with new treatment plan

Case Studies/Standardized Patients

Untreated Addiction

Herman Heroin - 44YOWM

Chief Complaint: Acute pain due to foot fracture
Narrative: Herman is open about his long-standing heroin addiction. He broke his foot this weekend and it was treated in an emergency clinic.
Opioid Issue: Active heroin addiction and acute pain from trauma
Relevant Past Medical, Psychosocial, Family History: Has been through rehab many times, but in recent years has repeatedly refused addiction treatment
Objectives Covered: A

Sickle Cell Sam - 30YOBM

Chief Complaint: Feels achy, skin feels sensitive to the touch
Narrative: Sam has been in remission from sickle cell anemia for 8 years. He avoids taking NSAIDs because he heard that they can cause liver problems in people with sickle cell anemia. However, he takes "Demerol and some other things" daily to "prevent" a sickle cell crisis. Sam says that a past doctor told him that this was a good idea.
Opioid Issue: Possible active addiction and acute pain from possible opioid-induced hyperalgesia
Relevant Past Medical, Psychosocial, Family History: Gets his opioids from his grandmother, who is in treatment for several chronic pain conditions
Objectives Covered: A

In Addiction Treatment

AA Jones with Spinal Pain - 42 YOWM

Chief Complaint: Spinal pain without detectable cause
Narrative: AA is in treatment for alcohol addiction and is on naltrexone.
Opioid Issue: On naltrexone therapy and develops severe pain not sufficiently responsive to non-opioid treatment
Relevant Past Medical, Psychosocial, Family History: Successfully abstinent for over a year; wife quit all alcohol use to support him
Objectives Covered: B, C

Bill Badbreak in Treatment for Opioid Addiction - 19 YOBM

Chief Complaint: Acute severe pain due to leg fracture
Narrative: Bill is currently in addiction treatment for prescription opioid addiction. He says he is not allowed to take any potentially addictive pain medications.
Opioid Issue: Needs non-opioid therapy for moderate pain
Relevant Past Medical, Psychosocial, Family History: Brother successfully completed treatment in the same drug-free facility last year
Objectives Covered: C

Nettie Knee Replacement - 52YOWF

Chief Complaint: Pain in knee that needs replacement surgery
Narrative: Nettie needs a double knee replacement as soon as possible. She has a history of addiction to heroin and prescription opioids but has been successfully maintained on methadone maintenance therapy for the past 8 years (with one relapse early in treatment) and recently switched to buprenorphine treatment (8 months ago). Nettie is concerned about having post-surgical pain but also afraid of relapsing back into addiction if she is prescribed pain meds.
Opioid Issue: On addiction treatment maintenance therapy and has relapsed to addiction in the past
Relevant Past Medical, Psychosocial, Family History: Addicted to prescription opioids after surgery 8 years ago; heroin addiction started 3 years later
Objectives Covered: D, E

In Recovery From Addiction

Saul Surgery - 55YOWM

Chief Complaint: Needs pain management after upcoming surgery
Narrative: Saul is a former heroin and methadone addict. He has been clean for 10 years - has not used pills, heroin, or alcohol during this time. He needs pain management for his upcoming hip replacement surgery. The surgeon anticipates that the pain will be severe and recommends opioids for at least the first 5 days following surgery to control the pain.
Opioid Issue: Formerly addicted to heroin; anticipated severe postoperative pain
Relevant Past Medical, Psychosocial, Family History: Lives alone but has many good friends in recovery
Objectives Covered: B, C

Regina Recovered - 62 YOWF

Chief Complaint: Severe pain from self-diagnosed frozen shoulder
Narrative: Regina was formerly addicted to prescription opioids after a previous episode of frozen shoulder on the other side 10 years ago. She has been in recovery for 5 months. She started treating pain herself by taking "some old pills I had lying around." She ran out and asks for a prescription for oxycodone.
Relevant Past Medical, Psychosocial, Family History: Recently widowed, lack of social support
Opioid Issue: Need to rule out relapse to addiction
Objectives Covered: D, E

Pain and Addiction Framework

Pain and Addiction Courses

Core Courses: Initial Assessment • Initial Prescribing • Ongoing Management • Avoiding Diversion

Clinical Application Courses: Focus on Pain Conditions • Focus on Substance Use Problem

Standardized Patients: Pain and Addiction Standardized Patient Example 1

Pain and Addiction References