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A TreATmenT ImprovemenT proTocol Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

TIP 54
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment
1 Choke Cherry Road

Rockville, MD 20857


1

In ThIs chApTer
• Chronic Pain Impact

• Audience

• Purpose

• Definitions

• Pain and Addiction

Basics

• Summary of TIP

• Key Points

Introduction


chronic pain Impact

Chronic noncancer pain (CNCP) is common in the general population as well as in people who have a substance use disorder (SUD) (Exhibit

1-1). Chronic pain is not harmless; it has physiological, social, and psychological dimensions that can seriously harm health, functioning, and well-being. As a multidimensional condition with both objective and subjective aspects, CNCP is difficult to assess and treat. Although CNCP can be managed, it usually cannot be completely eliminated. When patients with CNCP have comorbid SUD or are recovering from SUD, a complex condition becomes even more difficult to manage.
exhibit 1-1 statistics on substance Use and chronic pain in the United states




category

statistic

Chronic pain patients who may have addictive disorders

32% (Chelminski et al., 2005)

People ages 20 and older who report pain that lasted more than

3 months

56% (National Center for Health

Statistics, 2006)

People experiencing disabling pain in the previous year

36% (Portenoy, Ugarte, Fuller, & Haas, 2004)

People ages 65 and older who experience pain that has lasted more than 12 months

57% (National Center for Health

Statistics, 2006)

Civilian, noninstitutionalized U.S. residents ages 12 and older who report nonmedical use* of pain relievers in past year

5% (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007)

People ages 12 and older who report that they initiated illegal drug use with pain relievers

19% (SAMHSA, 2008)

People with opioid addiction who report chronic pain

29–60% (Peles, Schreiber, Gordon, & Adelson, 2005; Potter, Shiffman, & Weiss, 2008; Rosenblum et al., 2003; Sheu et al., 2008)

*Nonmedical use is use for purposes other than that for which the medication was 1

prescribed.

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders



Audience

This Treatment Improvement Protocol (TIP) is for primary care providers who treat or are likely to treat adult patients with or in recovery from SUDs who present with CNCP. Given the prevalence of CNCP in the population,

this audience includes virtually all primary care providers. Addiction specialists, psychiatrists, nurses, and other clinicians may find infor­ mation here that will help them ensure that their patients with CNCP receive adequate pain treatment. By providing a shared basic understanding of and a common language for these two chronic conditions, this TIP facili­ tates cooperation and communication between healthcare professionals treating pain and

those treating addiction.

purpose

This TIP equips clinicians with practical guidance and tools for treating CNCP in adults with histories of SUDs. It does not describe how to treat SUDs or other behav­ ioral health disorders in patients with CNCP; however, it provides readers with information about SUD assessments and referrals for fur­ ther evaluation. For patients with histories

of SUDs, the most controversial and possibly hazardous pain treatment in widespread use

is opioid treatment. For this reason, this topic receives significant attention in Chapters 3 and 4.

Definitions

Many terms important to the treatment of CNCP in people with SUDs are used incon­ sistently. Clinicians should not assume that their definitions of addiction, CNCP, physical dependence, recovery, tolerance, or other terms are shared by others, especially by patients

and their families.

It is especially important that clinicians clarify with their patients terms related to substance use. For example, patients with histories of SUDs who are no longer using substances

may or may not consider themselves to be in recovery. Likewise, some mutual-help groups may not regard patients as abstinent if they are treated for SUDs with medications such as naltrexone, buprenorphine, or methadone. Many people equate physical dependence or

tolerance with addiction. However, if clinicians prescribing opioids for CNCP equate these terms, they may misdiagnose their patients on opioids as having an addiction, when in fact they do not.
In 2001, the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine formed a Liaison Committee on Pain and

Addiction to standardize the use of the terms addiction, physical dependence, and tolerance among pain professionals. Shared under­ standings of these and other terms facilitate research, advance dialog among professionals in the fields of addiction and pain, and help patients make informed decisions about their treatment.
Definitions used in this TIP are presented below.
addiction. A primary, chronic, neurobio­ logic disease, with genetic, psychosocial, and environmental factors influencing

its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use or compulsive use, continued use despite harm, and craving (Savage et al., 2003); clinicians commonly refer to these behaviors as the “3Cs.”

addictive substance. The phrase addictive substance is controversial. The phrase draws attention to the properties of the sub­ stance; however, some experts prefer to



2

1—Introduction



emphasize the importance of individual

variability, environment, and situational factors in addiction. Evidence suggests that animals will self-administer all drugs commonly sought by humans (with the

exception of hallucinogens). Evidence also suggests that, if animals are exposed to a sufficient dose for a sufficient time, a sub­ stantial percentage will develop behaviors remarkably similar to those that suggest addiction in humans (e.g., “drug seeking” despite electrical shocks). Nonrewarding drugs (see Neurobiology of Addiction, below) do not elicit these behaviors in animals or humans. In this TIP, drugs

or medications that elicit “drug seeking”

behaviors are referred to as addictive.

behavioral health. The term comprises substance use issues, mental health issues, and the prevention of both.

chronic noncancer pain (CNCP).

Pain that is (1) unassociated with an imminently terminal condition, and (2) unlikely to abate as a result of tissue healing, thus requiring long-term man­ agement. The term often refers to pain not caused by ongoing tissue pathology (e.g., backache, fibromyalgia). The term is

problematic because it includes pain asso­ ciated with sickle cell disease or recurrent pancreatitis, in which both neurological sensitization and tissue damage, at least

in part, are likely. Inflammatory arthritis, connective tissue diseases, ischemia, and other conditions cause pain that persists for years yet are not, at least initially, life threatening.

chronic pain syndrome. Intractable pain of 6 months or longer, with marked alter­ ation of behavior; depression or anxiety; marked restriction in daily activities; frequent use of medication and medical services; no clear relationship to organic disorder; and a history of multiple, non­

productive tests, treatment, and surgeries

(U.S. Commission on the Evaluation of Pain, 1987). This term is used casually and imprecisely to refer to pain, distress, and dysfunction that are not fully attributable to an identifiable medical condition.

hyperalgesia. An abnormally intense response to a normally noxious stimulus.

narcotic. Substance used to induce narco­ sis or stupor. Narcotic is not a synonym for the opioid class of medications.

opioid-induced hyperalgesia.

Hyperalgesia that results from the effects of opioids on the central nervous system (CNS).

pain. An unpleasant sensory or emotional experience associated with actual or poten­ tial tissue damage or described in terms

of such damage (International Association for the Study of Pain, 1986). Pain is subjec­ tive and may not always be corroborated by objective data.

physical dependence. A state of adaptation that is manifested by a drug-class-specific withdrawal syndrome that can be pro­ duced by abrupt cessation, rapid dose reduction, decreasing the level of the

drug in the blood, or administration of an antagonist (a substance that opposes the action of the drug) (Savage et al.,

2003).

pseudoaddiction. A controversial term coined to describe aberrant drug-related behaviors (e.g., clock watching, drug seek­ ing), that resemble those of patients with addiction but that actually result from inadequate treatment of pain (Weissman

& Haddox, 1989).

recovery. A process of change through which an individual with an SUD achieves abstinence, wellness, and improved health and quality of life (Center for Substance Abuse Treatment [CSAT], 2007).


3

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders



relapse. A return to substance abuse after

a period of abstinence.

substance use disorder (SUD). A condition that includes alcohol and drug problems. SAMHSA recognizes that several term­ inologies (e.g., substance abuse and addic­ tion) can be applied and respects that some individuals and communities may choose to use different terminologies (CSAT, 2007).

tolerance. A state of adaptation in which exposure to a substance induces changes that result in a diminution of one or

more of the substance’s effects over time

(Savage et al., 2003).
pain and Addiction Basics

Studies indicate that CNCP and addiction frequently co-occur (Chelminski et al., 2005; Rosenblum et al., 2003; Savage, Kirsh, & Passik, 2008). Chronic pain and addiction have many shared neurophysiological patterns. Most chronic pain involves abnormal neural processing, which can occur at various levels

of the peripheral and CNS. Similarly, the dis­ ease of addiction results when normal neural processes, primarily in the brain’s memory, reward, and stress systems, are altered into dysfunctional patterns. A full understanding

of each condition is still emerging, and there is much to be learned regarding neurobiologic interactions between the conditions when they co-exist.
Chronic pain and addiction are not static conditions. Both fluctuate in intensity over time and under different circumstances and require ongoing management. Treatment for one condition can support or conflict with treatment for the other; a medication that may be appropriately prescribed for a particular chronic pain condition may be inappropriate

given the patient’s substance use history. Other

commonalities include the following:
• Both are neurobiological conditions with evidence of disordered CNS function.

• Both are mediated by genetics and

environment.

• Both may have significant behavioral

components.

• Both may have serious harmful conse­

quences if untreated.

• Both often require multifaceted

treatment.
Chronic pain and SUDs have similar physical, social, emotional, and economic effects on health and well-being (Green, Baker, Smith,

& Sato, 2003). Patients with one or both of these conditions may report insomnia, depression, impaired functioning, and other symptoms. Effective CNCP management

in patients with or in recovery from SUDs must address both conditions simultaneously (Trafton, Oliva, Horst, Minkel, & Humphreys,

2004).

neurobiology of pain

Both pain and responses to pain are shaped by culture, temperament, psychological state, memory, cognition, beliefs and expectations, co-occurring health conditions, gender, age,

and other biopsychosocial factors. Because pain is both a sensory and an emotional experience, it is by nature subjective.
When nociceptors are excited, the stimulus

is converted through transduction into action potentials that travel to the dorsal horn of the spinal cord. Signals then continue from the dorsal horn to the brain along multiple path­ ways in the cord: to the somatosensory cortex, where pain is evaluated; to the limbic system,



4

1—Introduction



where emotional reactions are mediated; to

the autonomic centers that control such auto­

matic functions as breathing, perspiration,

and heart rate; and to other parts of the brain, where a behavioral response to the stimuli

is determined. Nociceptive impulses are also transmitted to nearby terminals of the same nerve, where they may lead to diffuse pain and release of inflammatory substances that pro­ duce the flare and swelling that is a protective response to tissue injury (Exhibit 1-2).
Nociceptive input triggers a pain-inhibiting response. Signals traveling the ascending pathways are met by descending signals that emerge at various points along the spinal cord and brain. This antinociceptive response involves a panoply of chemicals, including

endorphins, enkephalins, gamma-aminobutyric

acid, norepinephrine, serotonin, oxytocin, and relaxin. Inhibitory signaling serves to attenuate nociceptive input, dampening the formation

of pain sensation and providing pain relief

(Brookoff, 2005).
Pain may be acute (e.g., postoperative pain), acute intermittent (e.g., migraine headache, pain caused by sickle cell disease), or chronic (persistent pain that may or may not have

a known etiology). These categories are not mutually exclusive; for example, acute pain may be superimposed on chronic pain. Acute nociceptive or neuropathic pain can transform into chronic neuropathic pain in which the

original sensations are extended and amplified.


exhibit 1-2 The pain pathways

5

Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders


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