The Challenge of Treating Patients With Chronic Pain and Addiction

Allison Gandey

May 11, 2010

May 11, 2010 (Baltimore, Maryland) — Patients with chronic pain and prescription opioid addiction are at risk of receiving inadequate care, say experts. Presenting here at the American Pain Society 29th Annual Scientific Meeting, specialists outlined how to strike the delicate balance between treating symptoms without fanning the flames of addiction in patients who are struggling.

"People with an active or past history of addiction may still require pain relief, and this doesn't mean we shouldn't use these medications to treat them," said session moderator Seddon Savage, MD, from Dartmouth Medical School in Hanover, New Hampshire. "It means that we must do so with awareness."

Dr. Savage said it is also important not to lump all opioid misuse together. "Problems with medication adherence are widespread and can happen for a variety of reasons," she noted.

Jennifer Sharpe Potter, Walter Ling, and Seddon Savage

Ambiguous or multiple instructions can lead patients astray, Dr. Savage pointed out. Cognitive challenges can also make it difficult for people to take medications correctly. The elderly, patients who are disabled, and those with traumatic brain injury or psychiatric distress may find it difficult to follow instructions.

Dr. Savage highlighted risk factors for opioid misuse. These include the following:

  • Active or past history of addiction;

  • A co-occurring mental health disorder;

  • Youth (especially males); and

  • Family history.

To define the characteristics of those with prescription opioid addiction, Jennifer Sharpe Potter, PhD, from the University of Texas Health Sciences Center at San Antonio, presented new data from a large multicenter study.

The National Institute on Drug Abuse analysis includes 274 patients with chronic pain. Investigators treated opioid-dependent patients with buprenorphine and naloxone. They wanted to know whether adding drug counseling to standard medical therapy would improve outcome.

The trial involved a 1-month drug taper followed by a 3-month stabilization period for those who did poorly during the initial taper.

Dr. Potter reports that most patients first started taking opioids to treat pain and not to get high. Although some continued taking the medication for pain, most continued to take the drugs inappropriately to avoid withdrawal symptoms.

Table 1. Reasons for First Prescription Opioid Use

Reason Patients, %
Pain 83.2
Get high 13.1

 

Table 2. Reasons for Continued Use

Reason Patients, %
Pain 22.6
Get high 13.9
Avoid withdrawal 56.5

 

Dr. Potter reports that drug counseling did not produce better outcomes than standard medical management. Successful treatment response during the initial phase of the trial occurred in just 6.6% of patients.

"This low success rate was not what we were going for, but it's not surprising," she said. Treatment success was defined as 4 or fewer days of opioid use per month, no positive urine screen results on 2 consecutive weeks, no other substance abuse treatment, and no opioid injections.

Almost half of the patients had a successful treatment response at week 12, but this benefit decreased again once the medications were tapered. The researchers found that reducing opioid use, whether initially or after a period of substantial improvement, led to nearly universal relapse.

"The take-home message is really that pain is a chronic relapsing disorder and must be treated as such," Dr. Potter said.

Opioid-dependent patients had a variety of sources for obtaining the drugs. Most bought from a dealer or got the medication from other patients.

Table 3. Opioid Sources in Last 6 Months

Source Patients, %
Bought from a dealer 84.2
Someone gave them 83.0
Bought from a patient who sells their medication 74.7
Legitimate prescription for pain 57.7
Stolen 44.1
Prescription from physician but no legitimate reason 30.6
Prescription from multiple physicians 23.6
Internet 8.9
Prescription from physician who prescribes illegally 3.4
Forged prescription 2.8
Other source 3.8

 

Dr. Potter pointed out that participants were seeking treatment for substance abuse, not pain, and the study had no control group. Her team is seeking to have these new data published in the coming months.

During an interview with Medscape Neurology, presenter Walter Ling, MD, from the University of California at Los Angeles, emphasized that patients benefit when neurologists draw on the experience of other specialists.

Dr. Ling started out in neurology, went into psychiatry, and is now a pain medicine specialist. Dr. Ling says he has been treating the same patients for decades and the crossover is noticeable. "The learning curve isn't horrendous," he said, "and it makes a big difference for patients."

In another session on prescription monitoring programs, Robert Twillman, PhD, from the University of Kansas, Lawrence, said there can be a tendency on the part of treating physicians to not prescribe for patients with chronic pain and a history of addiction. "I think this is akin to detecting high blood pressure and not treating it," he said. "Clinicians have an ethical obligation."

Dr. Savage has worked on advisory boards for Ameritox, Alpharma, MEDA, and REGISTRAT-MAPI. Dr. Ling has received funding from Reckitt Benckiser and Titan Pharmaceuticals. Dr. Potter has disclosed no relevant financial relationships. Dr. Twillman has worked with Merck.

American Pain Society (APS) 29th Annual Scientific Meeting: Abstract 301. Presented May 6, 2010.

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