Managing a patient's pain is difficult enough, given growing concerns about the addictive potential of an often-used medication for chronic pain: opioids.
But what if the patient is already addicted to opioids, or some other substance?
The complexity and difficulty grow.
Yet managing pain is still possible, said Martin Cheatle, a pain psychologist who studies chronic pain and substance use disorders. He is director of pain and chemical dependency research at the Center for Studies of Addiction, director of behavioral medicine at the Penn Pain Medicine Center, and an associate professor of psychiatry at the University of Pennsylvania Perelman School of Medicine.
He spoke to us recently about pain management and addiction.
How many people are we talking about, and what's the basic issue?
It's been estimated that 30 percent of adult Americans suffer from chronic pain – chronic, non-cancer pain. It's a huge population.
What's been debated is how many of the people who are treated with opioid therapy develop a true opioid use disorder, or OUD. We don't call it addiction anymore. The literature on the prevalence of OUD in legitimate patients with pain who receive opioids is very muddy. Estimates range from less than 1 percent to 40 percent.
Why? For one thing, making a diagnosis of opioid misuse and abuse in the pain population is very tricky. Definitions of abuse and OUD vary from study to study.
Basically, there's misuse, abuse, and a use disorder. Misuse is defined as using a therapeutic agent for what it's intended, but not as prescribed. Perhaps you take it more often, or take more of it, than the physician prescribed. Abuse is using a therapeutic agent for something other than what it was therapeutically intended for. Opioids have strong anti-anxiety effects and strong anti-depressive effects; they can help with sleep. But using them primarily for these conditions, that's abuse.
A use disorder is when people are out of control. They have cravings for the drug because of non-pain effects. It's like an alcoholic who at 4 p.m. can hardly wait to get home to get that first dose. Also, those with use disorders compulsively use the drug and have negative consequences of the use. For example, their use of the substance leads to the inability to fulfill vocational or personal obligations. That's a different kind of phenomenon from someone who misuses or abuses.
Experts have established more sensitive criteria for making the diagnosis of OUD, but one could argue that the criteria are not fully applicable to people legitimately prescribed opioids for pain. But recent well-vetted data indicate that among people prescribed opioids for chronic pain, about 8 percent to 12 percent develop an opioid-use disorder. Even so, if you take 8 percent to 12 percent of a large number of patients on opioids, it's not inconsequential.
Are we seeing an increase of opioid addictions in the U.S.?
Yes, and the reasons for this increase is a confluence of a number of factors. Over the last several decades, we have over-prescribed opioids for conditions that didn't warrant it. That was partly due to aggressive advocacy efforts – some funded by the pharmaceutical industry – and a growing clinical mind-set that patients with pain were being undertreated.
It's also an effect of our training. The majority of pain care is delivered by primary-care providers. But many of them are not trained in core concepts of pain medicine. In both Canada and the U.S., veterinarians get more training in pain medication than their medical counterparts who treat humans. And many health-care providers aren't trained in addiction medicine. The problem is exacerbated by the push to see more patients — the seven-minute office visit. That makes it easy to prescribe opioids. A colleague of mine has a saying: It takes 30 seconds to say "yes" and 30 minutes to say "no."
Lastly, insurance companies typically do not reimburse or reimburse poorly for effective non-opioid therapies such as cognitive behavioral therapy, physical therapy, acupuncture, and non-opioid medications.
What are the risk factors for opioid use disorder?
The number-one risk factor is a previous history of an addiction or use disorder — of any kind, not just opioids.
What options do physicians have for treating patients with opioid use disorder?
Actually, opioids are not first-line therapies for the majority of pain conditions.
For instance, in fibromyalgia, a disorder with widespread pain of the muscles and bones, the first-line medications include anti-depressants and anti-epileptic drugs, which regulate brain chemistry thought to exacerbate pain. For those with chronic back pain, the first-line therapies include anti-inflammatories and anti-depressants. In addition to non-opioid medications, there are complementary interventions, such as acupuncture and chiropractic.
Other pain interventions include physical therapy or exercise. We know that exercise can promote the release of endogenous endorphins, which is the body's natural painkiller.
Many patients with pain also experience anxiety and depression, which can contribute to additional suffering and can increase body tension and pain. Increased stress is also associated with an increased risk of relapse. There is growing evidence that exercise can reduce anxiety. For help with depression, there's cognitive behavioral therapy — a type of psychotherapy that has been incredibly effective. It addresses negative, maladaptive thoughts and behaviors and provides patients basic skills to improve their coping with pain. Improving a patient's mood and anxiety — at the brain level — can reduce their perception of pain and normalize pain pathways.
Effectively treating a patient's sleep also is really helpful. We know that sleep deprivation actually increases the pain. Among other things, it lowers your pain tolerance and causes the release of the chemical that increases inflammation. There are a variety of non-habituating medications and behavioral techniques to improve sleep quality.
Pain is very complex. The overall theme is that opioids are not the first-line therapy. There are other interventions that can be just as effective. You need to use a variety of different interventions to help these individuals.
One truism I like to remember is this: Our goal in pain medicine is to alleviate suffering, not necessarily to abate pain.
A lot of things are happening. The whole area of precision medicine – getting the right treatment to the individual patient – is going to make a big difference. We're using a lot more genetic testing to maximize the response to opioids and non-opioid therapies. The concern is that people don't know if they have a genetic predisposition to developing an opioid use disorder.
There's a new emphasis on using non-opioid analgesics during and after surgery to reduce the likelihood of someone developing an opioid use disorder, particularly in someone who has had any history of a substance use disorder. We're trying to mitigate risk.
True pain care reform is desperately needed, beginning with basic pain medicine training in medical, nursing, and dental schools and residency programs. We need to overhaul the reimbursement system. Hopefully, we will not throw out the baby with the bathwater and be so focused on the opioid epidemic and become so opioid phobic that we do not relieve suffering in the appropriate patients and miss the greater opportunity to actually reform pain care.