Treatment of Pain and Substance Abuse

Review of Critical Issues Related to the Treatment of Substance Abuse and of Chronic Pain; Alexander DeLuca; War on Doctors/Pain Crisis blog of the Pain Relief Network; 2007-11-15. (Note: one of the most popular articles here, originally published one year ago.)

Permalink: http://doctordeluca.com/wordpress/archive/rx-pain-subab/

See also:
Why Chronic Pain is a Medical Emergency
Alex DeLuca, Pain Relief Network, 2008-02-28

Pain must be treated aggressively because it is harmful to the patient and to society.

Unrelieved pain has a devastating impact on the physical, emotional, social, and economic well being of patients and their families. According to the Amazing Vanishing DEA FAQ, diagnosing and treating pain is, therefore, fundamental to the public health. ¹

When specialists and academics and researchers come together to discuss common barriers to optimal pain management, they have found opioid therapy complicated, in both the pain medicine and addiction medicine fields, by misapprehensions and myths.

Portenoy and Payne identified “Four types of phenomena that exemplify the accommodations that must be made to further [the goal of dissemination of accurate and up to date information to the fields].” ²

Briefly, excerpting from “Pain Specialists and Addiction Medicine Specialists Unite to Address Critical Issues.” ³

Non-analgesic Opioid Effects
Uninformed expectations about these effects can contribute to stigma and negatively influence attitudes about therapeutic potential. For inexperienced clinicians and the public at large… the expected response to an opioid is impaired consciousness… and euphoric mood… [Specialists] in addiction medicine and pain specialists have an entirely different expectation for opioid therapy, derived from experience in methadone maintenance or long-term opioid therapy for pain, respectively.

Specifically, it is expected that the non-analgesic CNS effects during chronic dosing will be clinically unapparent. If the therapy is working as it should, the patient appears normal. Those who work in pain and those who work in addiction must emphasize this reality.

Physical Dependence
Physical dependence is a pharmacological effect of a drug defined by the occurrence of an abstinence syndrome following administration of an antagonist drug or abrupt dose reduction or discontinuation… Many clinicians who treat pain patients perceive physical dependence to be a problem [assuming] it could contribute to aberrant drug-related behavior or could possibly sustain pain or disability. [However the] perspective of pain specialists and addiction specialists [is that physical] dependence is usually clinically unimportant as long as abstinence is avoided and, in fact, the major problem with this phenomenon is its mislabeling by clinicians.

The term addiction should never be applied solely to the perceived capacity for abstinence. This serious error stigmatizes the patient and the therapy. The capacity for withdrawal should always be labeled physical dependence. Pain specialists and addictionists alike must work to clarify this nomenclature.

Tolerance
Tolerance is the diminution of drug effect over time [and] can refer to any drug effect and may be related to any number of diverse processes, including learning (so-called associative tolerance), changes in drug concentration (pharmacokinetic or dispositional tolerance), or changes in receptors and post-receptor processing (pharmacodynamic tolerance)… To clarify the nature of the phenomenon, pain specialists and addictionists must begin to describe tolerance as a complex process that may or may not be clinically desirable.

During opioid therapy for pain, tolerance to side effects is beneficial and is presumably for the reason that patients can function normally. Tolerance to analgesia would be a problem, but fortunately this seldom appears to be the driving force for dose escalation. In stable disease, opioid doses typically plateau for prolonged periods. Moreover, there is no evidence in pain populations that the occurrence of tolerance drives the development of addiction. [The] dangers associated with it have been overstated.

Addiction, Aberrant Drug-Related Behaviors, and Pseudoaddiction
The definition and description of the term addiction must be carefully considered. This is one of the most significant challenges for specialists in pain or chemical dependency. Published definitions of the term are inadequate when applied to populations with pain.

Addiction is best defined as a behavioral pattern characterized as loss of control over drug use, compulsive drug use, and continued use of a drug despite harm… It is clear that aberrant drug-related behaviors exist on a spectrum ranging from egregious behavior (e.g., injecting an oral formulation) to behavior that is more difficult to interpret in a clinical context (e.g., aggressive complaining about the need for higher doses or unsanctioned dose escalation once or twice in the setting of uncontrolled pain).

In pain management, aberrant drug-related behavior has an important differential diagnosis, which certainly includes not only addiction, but also so-called Pseudoaddiction,⁴ other psychiatric conditions, family problems, criminal intent, and other events. Given the existence of this differential diagnosis, addiction may not be easily diagnosed in patients with or without histories of chemical dependency when unrelieved pain interacts with clinical decision making during therapeutic administration of an opioid. Pain specialists and addictionists must coalesce around a practical and clinically appropriate definition of addiction and must help promulgate it to clinicians and non-clinicians alike…

Reynolds, Fisher, Libby, and Szalavitz - circa 2004

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