Introduction
Increased utilization of opioids for chronic pain started in the late 1990s. Although evidence of long-term benefit was never documented, opioids were recommended, often as a first-line therapy, and titrated to high doses with no upper dose limits suggested. However, opioid efficacy for pain has failed to demonstrate long-term analgesia or functional improvements. Many patients who have been managed with high dose opioid regimens were impaired by side effects including sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression. Multiple studies have shown that opioid treatment results in decreased functional outcomes. , A randomized controlled trial published in 2018 demonstrated treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months.
Currently, there is an epidemic of drug abuse and mortality associated with prescription opioid use. Prescription drug misuse is also a leading source for all-cause and unintentional death. , . In fact, there were approximately 72,000 drug overdose deaths in 2017, two-thirds (47,600) of which were related to opioids. A large number of patients on long-term opioids have preexisting substance use disorders and/or psychiatric disease further complicating management. , As the opioid overdose crisis unfolds, it has become clear that the development of opioid use disorder (OUD) from prescription opioids is very common. In one study, the lifetime prevalence of OUD among patients receiving long-term opioid therapy was 41.3%. In that study the best predictors were age <65 years, current pain impairment, trouble sleeping, suicidal thoughts, anxiety disorders, illicit drug use, and history of substance abuse treatment. The CDC has predicted 25% of all patients on long-term opioid therapy have OUD. The risk of developing OUD is related to dose and duration of therapy.
Other addictive substances such as alcohol, marijuana, cocaine, kratom, and vaping also increase the risk of pain due to increased risk of accidents, falls, mental health complications, medical comorbidities, withdrawal symptoms, negative impact on neurotransmitters involved in the reward system (endorphins, dopamine, serotonin, and norepinephrine), sympathetic arousal, and sleep disorders. These substances on the brain interfere with sleep, decision-making, learning, and memory. Like opioids, dependence and addiction to these substances occur even if they were prescribed and/or used by patients to help with painful symptoms.
Definitions
It is helpful to look at the current definition of addiction to understand how this impacts our ability to formulate an effective treatment approach ( Table 9.1 ).
| Table1 . DSM-5 Diagnostic Criteria for OUD a and Example Behaviors | |
|---|---|
| DSM-5 Criteria | Example Behaviors |
| Describes constantly thinking about/needing the opioid |
| Unwilling to cut down or discontinue opioid use despite having a job where taking an opioid is dangerous (e.g., truck driver) |
| Needing to take more and more to achieve the same effect (asking for ↑ dose without worsened pain) |
| Feeling sick if opioid is not taken on time or exhibiting withdrawal effects (see QRD on withdrawal signs/symptoms) |
| Taking more than prescribed (e.g., repeated requests for early refills) |
| Has tried to reduce dose or quit opioid because of family’s concerns about use but has been unable to |
| Driving to different doctor’s offices every month to get renewals for various opioid prescriptions |
| Spouse or family member worried or critical about patient’s opioid use |
| Unwilling to discontinue or reduce opioid use despite nonfatal accidental overdose |
| Not finishing tasks at work due to taking frequent breaks to take opioid; getting fired from jobs |
| No longer participating in weekly softball league despite no additional injury or reason for additional pain |
a OUD DSM-5 diagnostic criteria: A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least 2 of the symptoms in the table above, occurring within a 12-month period.
The American Society of Addiction Medicine (ASAM) maintains that addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. They state that people with addiction disorders use substances or engage in behaviors that become compulsive and often continue them despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. (ASAM)
The terms addiction and substance abuse are often used interchangeably. However, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) released in 2013 combined “substance abuse” and “substance dependence” as “substance use disorder.” This is now the preferred terminology.
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In order to be diagnosed with Substance Use Disorder, the patient must meet at least 2 of the 11 criteria for the diagnosis
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A patient meeting 2–3 of the criteria indicates mild substance use disorder, meeting 4–5 criteria indicates moderate, and 6–7 indicates severe
Pathophysiology
The reward center, also called the mesolimbic dopamine pathway, connects the ventral tegmental area (one of the primary dopamine producing areas in the brain) with the nucleus accumbens (the area of the brain associated with reward and motivation) and the prefrontal cortex. This system provides reward for behaviors necessary for survival of the individual and the species such as food, water, nurturing, and sex. In individuals who are addicted, the drug, substance, or behavior becomes substituted for the behaviors necessary for survival and the ability to function. One of the factors driving this change is the impact on the dopaminergic reward system.
Vulnerability to developing addiction is multifactorial. This vulnerability is estimated to be 40%–60% genetic as well as associated with environmental factors related to exposure, availability, and psychosocial support. Exposure of addictive substances to the developing brain has also raised concerns over increased risk of addiction in those under 30 years of age. Medical and mental health comorbidities can also increase the risk of addiction. In addition, over the past several decades there has been increasing exposure due to medical use of opioids, benzodiazepines, and stimulants. , ,
Barriers to Treatment
While there are many reasons for continued use despite harm, the influence of acute and protracted withdrawal has a profound impact on the development and persistence of chronic pain and addiction. Acute withdrawal usually lasts for days and produces the opposite effect of the drug or medication taken. Protracted withdrawal from drugs or medications can last months and can create or exacerbate many chronic pain problems through the development of sleeping difficulty, anxiety, depression, difficulty thinking, generalized pain, and decline in function. ,
In a recent review of barriers and best practices related to SUD treatment, a key recommendation was “Co-location of SUD counseling and other services with primary care reduces the stigma of accessing a facility identified as treating SUDs, catches members in locations where they are more comfortable, and permits improved coordination between physical and behavioral health care.” There are many reasons for the underdiagnosis of substance use disorders which need to be addressed, especially when evaluating chronic pain patients who may have the potential for substance use or misuse Table 9.2 .
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Assessment
Screening questionnaires:
There are many screening tools to assess for substance use disorder. In a busy practice, it can be helpful to utilize the NIDA Quick Screening Tool available at https://www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf .
This tool asks about unhealthy alcohol use, nicotine use, nonmedical use of prescription medications, and use of illicit drugs in the past year. A positive response can then be followed up with further questions about recent use of specific drugs and medications. History and physical can help determine if there has been deterioration in ability to function, medical problems related to substances or psychiatric symptoms related to substance or medication misuse.
Urine Drug Testing
Urine drug testing can help understand what substances and medications a patient is taking and the potential impact on their health. It is, however, important to approach testing in a nonjudgmental manner with patients. It is also important to review with the patient that drug testing is done to improve safety and prevent future complications. Most drug screening is done through radioimmunoassay. This is less expensive and faster than gas chromatography, which is typically used as a confirmatory test when there are unexplainable results or potential false positives and negatives. Whenever there is a concern about test discrepancy, it is important to discuss unexpected results with the lab. ,
In primary care and pain clinic settings, observed urine drug screens are impractical and often unnecessary. However, when obtained, it may be helpful to check the validity of the urine sample by looking at creatinine, specific gravity, PH, and temperature (within 4 min of obtaining a specimen). A diluted specimen will have a creatinine less than 20 mg/dL and a specific gravity between 1.001 and 1.003. An adulterated specimen may have a PH less than 3 or greater than 11 or an unexplained urinary nitrate. Urinary temperatures less than 90 or over 100 can indicate an attempt to substitute a urine. It is also important to know typical detection times of the substances that are being tested. The substance with the shortest detection time is alcohol with a detection time of 7–12 h from last use. The substance with the longest detection time is chronic heavy use of cannabinoids with detection times that can last longer than 30 days. ,
Prescription Drug Monitoring Program
Querying the prescription drug monitoring program (PDMP) available in participating states can also be an important part of an assessment for substance use disorder. It can provide helpful information such as the type and number of controlled medications that are prescribed, the number of prescribers, and the presence of overlapping prescriptions. Like urine drug screens, information obtained when checking the PDMP should be used to improve patient safety and education when seeing patients with chronic pain at risk of addiction. ,
The understanding of addictive substances and medications is changing rapidly. There are a number of government websites that can help to keep clinicians up to date related to emerging drugs, impact on health, and treatment options. Table 9.3 outline the various websites available for more information.
| Organization | website |
|---|---|
| NIDA (National Institute on Drug Abuse) | www.drugabuse.gov |
| SAMHSA (Substance Abuse and Mental Health Services Administration) | www.samhsa.gov |
| CDC (Centers for Disease Control and Prevention) | www.cdc.gov |
| FDA (Food and Drug Administration) | www.fda.gov |
| Opioids.gov: US Department of Health and Human Services | www.opioids.gov |
| Office of the US Surgeon General | www.hhs.gov/surgeongeneral/index.html |
| NIAAA (National Institute of Alcohol Abuse and Alcoholism) | www.niaaa.nih.gov |
| US Department of Veterans Affairs | www.va.gov |
Management
Treatment options for patients with pain and addiction can be highly successful when key concepts are kept in mind. As with all patients with chronic pain, effective pain care involves attention to modalities that improve movement, address cognitive behavioral approaches to pain, treat comorbidities, and address lifestyle changes. These functional restoration approaches are core elements to treating both of these medical conditions. It is important to understand that treating pain and addiction in an integrated way allows for a more effective approach than treating each disorder in isolation. , ,
Addiction treatment is best individualized to meet the needs of the patient. It can also include family treatment options as well. When working with patients who have chronic pain, it is very helpful to familiarize yourself with treatment opportunities in your community and work together when pain and addiction treatment are not available in a unified clinic. Key components of behavioral approaches to addiction treatment can include strategies to modify attitudes and behaviors related to drug use, increase healthy lifestyles, setting and working toward goals to improve function, and learning coping skills related to stress and challenges that can be utilized rather than drugs. ,
Behavioral Interventions
Motivational Interviewing can be a useful tool to elicit behavioral changes related to both pain and addiction. It is person-centered and allows for discussion that evokes the motivation for change. It is the engagement in dialogue that ultimately improves involvement in and success with treatment. While there are many strategies related to this approach, key concepts include expressing empathy, avoiding arguments and confrontations, developing discrepancies between goals and current behavior, adjusting to resistance, and supporting self-efficacy. These concepts have now been shown to improve behavioral changes related to many chronic diseases.
There is also increasing evidence that contingency management (CM) interventions can be effective adjuncts to care in SUD programs. CM involves providing tangible rewards for abstinence and remaining in treatment. In Voucher-Based Reinforcement treatment, vouchers are given for each urine that is negative for illicit substances or unprescribed medication. The longer the duration of negative urines, the higher the value of the voucher. Vouchers can then be exchanged for a variety of rewards. Prize Incentive CM uses the chance of winning cash prizes instead of vouchers. ,
It is also important to integrate primary care into pain and addiction care as many comorbid medical conditions can also interfere with success. This can include optimizing treatment for underlying lung disease, heart disease, endocrinologic problems such as diabetes and thyroid disease, infectious diseases such as HIV disease and hepatitis C, and neurologic problems related to trauma or underlying neurologic disorders. Poor health in general will worsen chronic pain and a whole person approach is important for success.
In addition, self-help groups can be invaluable for many patients with addiction problems. While not for every patient, self-help groups can provide structure, goal-directed models for recovery, improve coping skills, and increase options for rewarding activities. They can also be an important resource for family, friends, and significant others. ,
The most common self-help programs are 12-step groups. The programs were originally proposed by Alcoholic Anonymous (AA) as a method of recovery from alcoholism but have now been adapted to include programs for all drug and behavioral addictions ( Table 9.4 ). The programs are organized around local groups where people meet to support each other and work through the 12 steps. Meetings are free, noncommercial, and open to anyone impacted by addiction. Some meetings are open to anyone interested in learning more such as healthcare professionals or community members. 12-step programs are available throughout the United States and internationally making meeting attendance possible during times of travel or relocation.
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