Treating Patients with Pain and Addiction Issues

Based on your clinical experience, what are some important things to know about the treating patients in pain with co-existing addiction issues?

Daniel P. Alford, MD, MPH, FACP:

Daniel P. Alford is a General Internist, Primary Care Physician at Boston Medical Center and an Associate Professor of Medicine at Boston University School of Medicine. He is the Medical Director of the Boston Medical Center Office-Based Opioid Treatment program and the Massachusetts Department of Public Health MASBIRT (Massachusetts Screening, Brief Intervention, Referral, and Treatment) program.

This is a very challenging but not uncommon problem. It is important to start with the understanding that people with past or current addictions can also suffer from chronic pain. As with any patient suffering from chronic pain, you would want to try using non-opioid analgesics first. However, like other chronic pain populations, their chronic pain can be resistant to non-opioids yet responsive to opioids. In my primary care practice, I have treated many patients with addiction and chronic pain. Treating both the addiction and the chronic pain concurrently is crucial. Unfortunately, most primary care settings cannot provide both forms of treatment. In my practice, I tell patients that for me to treat their pain with opioids they must also be engaged in addiction treatment such as attending substance abuse counseling or 12 step meetings. I require them to bring me or my nurse documentation verifying their active engagement in addiction treatment at each primary care visit and before any medication refills. I also require a release to allow joint communication between me and their substance abuse treatment providers. Ideally I will call the substance abuse treatment provider during the primary care visit to reinforce to the patient that I take their addiction treatment seriously. This arrangement is best discussed before beginning opioid treatment. When these discussions occur after treatment as been initiated, it likely becomes confrontational, that is, the patient feels that he/she is being accused of something.

I think that a written patient controlled substances agreement is a clinically useful tool, even though its utility has never been validated. Agreements outline both your responsibilities as the health care provider as well as the patient’s responsibilities. This provides important structure to your treatment. Patients know when and how they are to obtain medication refills as well as how they will monitored such as urine drug tests and pill counts. Urine drug testing confirms that my patient is taking the opioids I prescribed as well as not taking other controlled or illicit substances not prescribed. I ideally these drug tests should be random and supervised but this is generally not possible in primary care settings. In my practice patients know that they will need to leave a urine specimen at each visit. Because by definition, addiction is associated with loss of control and compulsive use, patients who are addicted will eventually have an abnormal drug test or show some other aberrant drug taking behavior. I call this the “primary care advantage” that is, as opposed to urgent care or specialty settings, because we have a long-term relationship with these patients, we will pick up on aberrant behaviors over time. Often times I will ask my patients to tell me what I will find in their urine, that is, will I find any surprises. Sometimes they even tell me about substances that I don’t test for! I also do occasional pill counts and ask my patients to bring in their pills for every visit. I do this to monitor overuse and diversion (selling medication). Although this is tedious, it provides good information. I use a pill tray to count the pills. I will often give patients a prescription for a one month supply of medication and ask them to return in 3 weeks thus having to count only a weeks supply of medication rather than 3 to 4 weeks of pills. If a patient forgets to bring in their pills, I will ask him or her to come in the following day and have my nurse conduct the pill count.

A separate and special group is patients with chronic pain who are on methadone maintenance treatment. These patients are often on high dose methadone taken once per day. Because the analgesic properties of methadone only last 6 to 8 hours, any pain relief obtained will not last all day. In order to determine if the patients pain is opioid responsive I ask them if they get pain relief 30 to 60 minutes after their methadone dose and how long that relief lasts. If they get pain relief but it only last for 6 hours, then I believe their chronic pain is opioid responsive and the patient might benefit from additional opioids later in the day. If they get pain relief all day, I believe their pain is likely opioid withdrawal mediated pain that does not require additional opioids. If they get no relief from the methadone dose, I believe their pain is opioid resistant and would not benefit from opioid analgesics. If you prescribe opioid analgesics to a patient on methadone maintenance treatment it is important to communicate with the methadone program since your prescribed opioids may interfere with their urine drug test monitoring. Lastly it is important to remember that patients on methadone maintenance are often on methadone doses that are greater than 80 mg which creates “narcotic blockade”, that is, any potential euphoria from prescribed opioids is blocked and thus decreases the risk of opioid analgesic overuse for purposes of feeling high.

I don’t fault primary care doctors who don’t feel comfortable taking on such a challenging population. Both addiction and pain management education are limited in most medical schools and residency training. In addition, many physicians feel uncomfortable with the confrontational interactions that occur with setting limits or stopping opioid therapy. My staff knows that we do not tolerate unacceptable behavior. Unfortunately most specialty pain clinics don’t want to be responsible for long term opioid therapy and are often uncomfortable managing patients with addictions, so this is a job is often left to primary care physicians.

Lastly physicians need an exit strategy if the opioids are not improving pain or functional outcomes over time. It is okay to taper a patient off opioid analgesics if they are not benefiting the patient or are possibly causing harm. With careful patient selection, use of patient agreements and careful monitoring strategies I have had success in treating patients with concurrent addiction and chronic pain in my primary care practice.