Challenges of Treating Chronic Pain in People with Opioid Dependence

As headlines about opioids focus on misuse of the drugs, physicians who treat patients with chronic pain are grappling with how to deal with opioid dependence. At the recent American Psychiatric Association meeting, pain specialists said that treating patients in pain who are dependent on opioids involves a delicate balance between managing pain relief and risk of drug abuse.

“One of the challenges is that we don’t have good estimates of how common it is for chronic pain patients to develop problematic opioid use” says Jennifer Potter, PhD, MPH, in the Department of Psychiatry at the University of Texas Health Science Center in San Antonio. “The vast majority of people with chronic pain do not go on to develop an opioid addiction, so it’s important for patients to understand that if this medication benefits you, it’s not necessarily a concern. We can’t let our response to the rise in prescription drug abuse to be denying access to all people in pain who can benefit from opioids. We need to build our understanding so we can manage our risk of drug abuse effectively.”

Rates for co-existing chronic pain and opioid addiction vary depending on where you look, Dr. Potter says. “For patients in a pain clinic, addiction rates are relatively low, but in a methadone or buprenorphine population, between 34 to 40 percent will have a chronic pain complaint,” she says.

A doctor treating a person for pain needs to look for potential risk factors for substance abuse, such as a personal or family history of other types of substance abuse or psychiatric disorders, Dr. Potter says. “If a person has one of these risk factors, they shouldn’t automatically be denied opioids, but they should be informed of the risk of dependence and be monitored for potential abuse.”

For some people with chronic pain, medication isn’t always the answer, says Dr. Potter, who is studying the treatment of opioid dependence and chronic pain through a grant from the National Institute on Drug Abuse. “There’s a false assumption that giving medicine makes pain go away, but in chronic situations that doesn’t always work,” she says. “Many people only get some reduction in pain.”

Non-Opioid Pain Treatments

Patients with substance abuse issues can be treated for pain in a variety of ways that don’t involve opioids, says Sean Mackey, MD, PhD, Chief of the Pain Management Division at Stanford University and Associate Professor of Anesthesia and Pain Management. “A multidisciplinary approach is needed to treat patients in pain who have substance abuse issues,” he says.

There are non-opioid drugs such as anti-epileptic drugs, antidepressants and anti-arrthythmic drugs, which can be effective in treating pain, Dr. Mackey says.

Patients can also be treated with psychological therapies, as well as physical and occupational therapy, he says. Many patients, however, do not receive a multidisciplinary approach to treating chronic pain because it generally requires the resources of an academic medical center. “Doctors who are treating patients without these resources need to collaborate with others who have the knowledge they don’t, either in addiction medicine or pain medicine,” Dr. Mackey advises.

If a doctor weighs all the options and determines that opioid treatment will work best for an opioid-dependent patient in pain, buprenorphine or methadone may be good options, he says. “Buprenorphine and methadone have strong analgesic benefits, and we commonly use them in this situation,” he says.

For a patient using methadone, one approach is to use a “blinded pain cocktail” in which methadone is ground up and mixed in with baclofen as a binding agent, with cherry syrup as a base. “We tell the patient what’s in it, but not how much,” Dr. Mackey says. “We closely track their quality of life measurements, and we can go up or down on the methadone accordingly. If we have a patient with clear control issues we only give out small doses at a time, or we hand it over to a trusted family member.” Mackey does acknowledge that the use of this tool is time and staff intensive and may be more than a small community practice can handle.

When treating patients with both chronic pain and a substance abuse disorder, Dr. Mackey advises making sure that they are receiving psychological counseling, either in a group or individually. “Many treatments we use in substance abuse overlap with chronic pain treatment—the psychological and behavioral skills are the same,” he says.

He also suggests an opioid contract for some patients, which establishes an understanding between patient and doctor that the patient will only receive opioids from that doctor, and from only one pharmacy. The patient may be asked to submit to urine drug screening, and is told that if their medication is lost it will not be replaced, and stolen medication will only be replaced if the person brings a police report.

“While even the most careful clinical pain management cannot eliminate risk of opioid misuse in patients with a history of addiction, good communication, knowledge of non-opioid treatment alternatives and appropriate monitoring and care in structuring opioid management can reduce risk significantly,” Dr. Mackey says.

Learn More About the Opioid Epidemic

Addiction and deaths from heroin, fentanyl and other opioids are ravaging the nation. Learn more about what’s happening and how you can take action now.

307 Responses

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    Terry D.

    May 9, 2017 at 9:07 PM

    I have an issue with the way some Emergency Rooms stereotype patients, as “drug dependent”, based on a person’s trips to the ER. I went to the ER wrenched over in abdominal pain, and was taken in right away. They gave me pain medication, did some blood tests, and sent me home. Two days later, I again had abdominal pains, and asked the ambulance driver to take me back to the hospital, but this time I was treated differently. I was left lying on the Gurney crying in pain for over an hour, and the nurses were so rude to me; I couldn’t understand it, very odd like Dr. Jekyll, and Mr. Hyde! They gave me some pain medication, a blood test, and some x-rays, and sent me home again. This was already twice, that I had been to the hospital, and yes it happened a third time, but this time I thought I would play it safe, and get a second opinion, so I asked the ambulance driver take me to another hospital. I got to the ER, and they took me in right away, and they did some testing, and again it was normal, so they gave me some pain medication, and sent me home. At this point I didn’t know what to think; this had been going on for almost a week now, and Ok, it happened a fourth time, but this time I told the ambulance driver to take me back to the first hospital, because this is where it all started. Now the paramedics are finding it hard to believe me, so they take back to the first hospital, and the nurses were still rude, and I couldn’t compose myself anymore, so I gave one of the rude nurses a piece of my mind. I told her that I’ve been in and out of their hospital for a week now, only to be given pain meds, and sent home; I’m getting sick of it, and I want something done, now! A Dr. immediately came over, and I explained to him what the hospitals were doing to me; by giving me pain medication, doing a little testing, and sending me home, because nothing appeared to be physically wrong with me, so he ordered a cat-scan. When It came back, the Dr. told me that he was going to admit me to the hospital, because my urinary track was partially blocked with 9mm kidney stone, and I will have to have surgery to remove it. It has been two years, and I’m still, really pissed off about it. I trusted these people with my life, but they kept kicking me out on the curb, and denied me proper medical care, because their minds were made up that I was an addict. I don’t trust ER’s anymore, because of this, and I realize now they treated me nice the first time because there were no drugs in my system when they tested me.

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      Renona Sausser

      May 31, 2017 at 5:26 AM

      It sounds to me like you might have a case of negligence. I wish I had looked into it when I had just had back surgery. One of the nurses had removed my catheter before my organs had been revived. I had to beg her to put it back and she wanted to argue with me. What patient is going to beg for a catheter? After putting it back, I filled the urine bag and she couldn’t believe it. Then later that evening, the nurses wanted to set me up on a bed pan and I got upset because my doctor said I was NOT to sit upright. One nurse replied that she didn’t know that I had back surgery. Seems to me that she had no business being in my room if she wasn’t going to read my chart first.
      This was not the end of it either. The assistant Surgeon changed my pain medication and I wished I had asked what they were injecting me with beforehand because I couldn’t even tell them to stop. I felt like I was falling into a dark hole. I couldn’t speak and I immediately threw up profusely. My body began to jerk all over, I felt like I was being ripped open in my chest and it was on fire. Then I began hallucinating. No one was in the room while I experienced all this and the fear was overwhelming. I was in the hospital for eleven days and they never changed my IV. This was the beginning of my chronic pain and I was put on Hydrocodone, then Morphine, then Methadone and now Suboxone. I take the smallest dosage that I can but if I have to go to Emergency for a flair up from gallstones or something, they won’t treat me for the pain. So I know exactly what you are going through. The back surgery failed and I live with pain every day. The doctors can cause pain and prescribe pain medication but then they won’t take the responsibility. I am 66 years old and why should they care if I continue to take an opiate at my age if I am only taking the bare minimum dosage to get by. Anyway, I just thought you might want to find out if there was negligence on the part of the hospital for not finding your kidney stone sooner which caused you unnecessary pain and disrespect. My situation happened in 2003 so it’s too late for me to do anything about it. I don’t mind if you use my story as a reason to investigate it.
      Good luck.

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      Thick n lovely

      July 21, 2017 at 3:06 AM

      That pisses me off for you! They don’t take time to hear you as they are not listening. This happens at regular doctor visits for me.

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