Estimates from the 2012 National Health Interview Survey (NHIS) show that 126 million American adults experience some type of pain — 25 million suffer from daily chronic pain and another 23 million experience severe pain. With a significant section of the population battling moderate to severe pain and opioids continuing to be the “drug of choice” for pain management, opioid use disorders (OUDs) have assumed epidemic proportions. For health care professionals, identifying and providing treatment for OUDs among such patients is complex and challenging since they often exhibit drug seeking behaviors in the same way as those with untreated pain.
So far, research has not been able to accurately estimate the rate of OUDs in patients with chronic pain. According to Daniel P. Alford, professor of medicine at Boston University School of Medicine (BUSM) and assistant dean at BUSM Office of Continuing Medical Education, existing research “is limited in quality, uses ambiguous terminology, and shows conflicting results.” Alford draws reference to a systematic review of past analysis of 38 studies which suggest that for patients with chronic pain, average opioid misuse rates range between 21-29 percent while addiction rates remain between 8-12 percent.
Primary care physicians are increasingly expressing concerns regarding misuse of opioid painkillers. They are also concerned about the dangers of addiction and the limited training given to them for prescribing opioids. Although pain is the leading cause of disability in the U.S., the majority of the American population and physicians suffer from lack of knowledge or misconceptions regarding pain.
Since September is observed as the Pain Awareness Month, it is an opportunity to raise greater awareness. Untreated chronic pain can seriously impact an individual’s well-being, social life and family environment, and entail significant health care costs.
Complexities of OUDs in chronic pain patients
Alford highlights the uncertainties and complexities, including misconceptions among physicians, regarding OUDs in chronic pain patients. A key issue is that certain “aberrant behaviors” exhibited by such patients who are on long-term opioids may be misconstrued as OUDs, whereas such symptoms may actually emanate from poor pain management techniques. Sometimes these behaviors, which may be in the form of failed efforts to reduce opioid usage, can ensue due to OUDs or ineffective pain control measures. Physicians may also be reluctant to prescribe opioids to patients which may result in extra efforts being expended by affected individuals to find opioids.
According to him, patients with severe pain may exhibit a few of the 11 symptoms of OUD as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Within the restraints imposed by the DSM-5, he relies on four specific measures for identifying OUDs in chronic pain patients:
- Opioids are taken in ways not prescribed, such as voluntarily increasing dosage (loss of control)
- Focus is on getting opioid medication rather than treating the pain (compulsive behavior)
- Persistent use of opioids in spite of adverse impacts and no relief in pain (continued use)
- Constant urge to consume opioids (cravings)
He further adds that any deviation or false adaptation of any of the above behaviors indicate an addiction. Unfortunately, symptoms of addiction and withdrawal are also commonly misunderstood by both patients and physicians. When those undergoing long-term opioid therapy suddenly stop taking the medications, they will experience withdrawal symptoms. It’s a natural occurrence and cannot be termed as an addiction.
Treatment of OUDs in chronic pain patients remains a matter of concern
Long-term treatment of OUDs can be managed through the use of naltrexone, buprenorphine, methadone, alpha-2 adrenergic agonists such as clonidine, and psychosocial interventions. Using medications to treat OUDs requires long-term management and carries the risk of high relapse rates after treatment. Prior research has indicated that nearly 50 percent of patients undergoing methadone maintenance or buprenorphine maintenance treatment experience chronic pain.
Patients with OUDs who receive opioid agonist-assisted treatment (OAAT) also experience higher levels of psychiatric issues due to the severity of pain. Treatment is further complicated due to lack of standardized rules for the assessment and treatment of chronic pain in OUD patients undergoing OAAT. Moreover, prioritizing one condition over the other may lead to disparities in treatment and delayed recovery.
Given the intricacies involved, a multidisciplinary approach is necessary to simultaneously treat chronic pain and OUD. It should include the following components to deal with unmet needs:
- Training: This should emphasize the critical association between chronic pain, dependence on opioids and tolerance levels.
- Addressing pain and OUD components: If it is not possible to design a comprehensive treatment plan in a single sitting, OUD treatment professionals and pain management clinicians must coordinate closely to ensure close monitoring of both the conditions.
- Managing co-occurring psychiatric issues: Due to the association between co-occurring psychiatric conditions and severity of pain, addressing psychiatric issues will lead to optimized treatment.
Further research is required to explore unique diagnostic methods, standardized rules and superior medications to treat chronic pain in OUD patients.
Sovereign Health of San Clemente understands the plight of someone who is unable to discontinue the use of prescription opioids despite their negative impact. Our customized approach to treatment for addiction is designed to provide holistic care to the person. Call our 24/7 helpline number or chat online with a representative to know about our state-of-the-art addiction treatment centers spread across California.