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In ThIs chApTer
• Overview of Pain
• The Treatment Team
• Treating Patients in
• Treating Psychiatric
• Opioid Therapy
• Treating Patients in Medication-Assisted Recovery
• Treating Pain in Patients
With Active Addiction
• Acute Pain Episodes
• Assessing Treatment
• Key Points
overview of pain management
Chronic noncancer pain (CNCP) is a major challenge for clinicians as well as for the patients who suffer from it. The complete elimina tion of pain is rarely obtainable for any substantial period. Therefore, patients and clinicians should discuss treatment goals that include reducing pain, maximizing function, and improving quality of life. The best outcomes can be achieved when chronic pain management addresses co-occurring mental disorders (e.g., depression, anxiety)
and when it incorporates suitable nonpharmacologic and comple mentary therapies for symptom management. Exhibit 3-1 presents the consensus panel’s recommended strategy for treating CNCP in adults who have or are in recovery from a substance use disorder (SUD).
The Treatment Team
Chronic pain management is often complex and time consuming. It can be particularly challenging and stressful for clinicians working without input from other clinicians. The effectiveness of multiple interventions is augmented when all medical and behavioral health care professionals involved collaborate as a team (Sanders, Harden,
& Vicente, 2005). A multidisciplinary team approach provides a breadth of perspectives and skills that can enhance outcomes and reduce stress on individual providers. Although it is ideal when all relevant providers work within the same system and under the same roof, often a collaborative team must be coordinated across a com munity. This combined effort requires identification of a designated lead care coordinator and a good system of communication among team members and the patient. A treatment team can include the following professionals:
• Primary care provider
• Addiction specialist
• Pain clinician
exhibit 3-1 Algorithm for managing chronic pain in patients With sUD
• Other behavioral health treatment spe cialists (e.g., social worker, marriage and family therapist, counselor)
• Physical or occupational therapists
Addiction specialists, in particular, can make
significant contributions to the management of chronic pain in patients who have SUDs. They can:
• Put safeguards in place to help patients take opioids appropriately.
• Reinforce behavioral and self-care com
ponents of pain management.
3—Chronic Pain Management
• Work with patients to reduce stress.
• Assess patients’ recovery support system.
• Identify relapse.
When the addiction specialist is the prescriber of analgesics, medical responsibilities (e.g., prescribing of analgesics, physical therapy, orthotics) should be coordinated with the clinician responsible for other components of pain treatment. In some States, consultation with an addiction specialist is required before scheduled medications can be prescribed on
a long-term basis to patients who have SUD histories. State laws, regulations, and policies are available at http://www.painpolicy.wisc. edu/.
The more complicated the case, the more beneficial a team approach becomes. However, many clinicians will have to treat complex patients who have little or no outside
Treating patients in recovery
A thorough patient assessment (see Chapter
2) provides information that allows the clini cian to judge the stability of a patient’s recov ery from an SUD. Goals for treating CNCP in patients who are in long-term recovery
or whose SUD is in the distant past are as follows:
• Treat CNCP with non-opioid analgesics
as determined by pathophysiology.
• Recommend or prescribe nonpharmaco logical therapies (e.g., cognitive–behavioral therapy [CBT], exercises to decrease pain and improve function).
• Treat comorbidities.
• Assess treatment outcomes.
• Initiate opioid therapy only if the poten
tial benefits outweigh risk and only for
as long as it is unequivocally beneficial to the patient.
Non-opioid pharmacological options include acetaminophen and nonsteroidal anti- inflammatory drugs (NSAIDs), as well as adjuvant medications—so called because they originally were developed for other purposes but have analgesic properties for certain con ditions. The primary adjuvant analgesics are antidepressants and anticonvulsants. Exhibit
3-2 presents a summary of these analgesics as they pertain to patients who have SUDs.
Researchers disagree on the beneficial and harmful effects of benzodiazepines and ben zodiazepine receptor agonists on chronic pain. Several studies demonstrate increased pain
exhibit 3-2 summary of non-opioid Analgesics
exhibit 3-2 summary of non-opioid Analgesics (continued)
with benzodiazepines or reduced pain follow
ing benzodiazepine antagonist use (Ciccone et al., 2000; Gear et al., 1997; Nemmani & Mogil, 2003; Pakulska & Czarnecka, 2001). All benzodiazepines have side effects, includ ing impaired coordination, reduced memory, and addiction liability. For the following rea sons, the consensus panel concludes that ben zodiazepines have no role in the treatment of CNCP in patients who have comorbid SUD, beyond very short-term, closely supervised treatment of acute anxiety states:
• Guidelines from the American Psychiatric Association (2006) and the United Kingdom’s National Institute for Health and Clinical Excellence (Hughes et al., 2004) caution that benzodiazepines are not first-line medications.
• Excellent options to benzodiazepines
for treating anxiety exist (see Treating Psychiatric Comorbidities, below).
• Anxiolytic use in adults with CNCP is often protracted.
• Benzodiazepines pose significant risk for addiction relapse and functional impairment.
The consensus panel recommends that clinicians treat comorbid anxiety and insomnia with antidepressants or anticonvulsants. Some antidepressants (e.g., trazodone, mirtazapine, amitriptyline, doxepin) may be useful sleep aids. Benzodiazepine weaning can be done
in consultation with a psychiatrist or SUD treatment provider (see Center for Substance Abuse Treatment [CSAT], 2006).
3—Chronic Pain Management
At least two types of cannabinoid receptors are present in the human nervous system, and they interact with systems relevant to pain percep tion, including the serotonergic and dopami nergic systems. Cannabinoids are anti-inflam matory and increase levels of endogenous opi oids. They inhibit glutamatergic transmission and antagonize the N-methyl-D-aspartate (NMDA) glutamate receptor, both of which actions would be expected to inhibit pain (Burns & Ineck, 2006; McCarberg, 2006).
The primary psychoactive chemical in marijuana responsible for its abuse potential
is Δ9 tetrahydrocannabinol (THC). Synthetic THC (Marinol) is approved in the United States for chemotherapy-induced nausea and AIDS-induced anorexia. Sativex, a mixture of THC and cannabidiol, is an oromucosal spray that spares the lungs the toxicity of drugs and smoke. It is analgesic in neuropathic pain and is approved in Canada for the pain of multiple sclerosis. Nabilone is a synthetic drug similar to THC. Its reported analgesic effects were determined to be weaker than codeine in a controlled study of neuropathic pain (Frank, Serpell, Hughes, Matthews, & Kapur, 2008).
Although it is reasonable to conclude that modulating the human cannabinoid system shows promise for treating pain, there is no reason to believe that inhaled smoke is an acceptable delivery mode. The consensus panel does not recommend smoked marijuana for treating CNCP.
An approach to pain management that inte grates evidence-based pharmacological and nonpharmacological treatments can ease pain and reduce reliance on medication.
Nonpharmacological treatments for CNCP (Hart, 2008; Simpson, 2006):
• Pose no risk of relapse.
• May be more consistent with the recover ing patient’s values and preferences than pharmacological treatments, especially opioid interventions.
• May reduce pain and improve quality
of life in some patients who have CNCP.
• Should be included in most pain treat
Common nonpharmacological therapies for
• Therapeutic exercise.
• Physical therapy (PT).
• Cognitive–behavioral therapy (CBT).
• Complementary and alternative medicine (CAM; e.g., chiropractic therapy, massage therapy, acupuncture, mind–body therapies, relaxation strategies).
Appendix D provides information on how to find qualified practitioners who provide CAM.
A number of practitioners, including physicians, chiropractors, and physical therapists, frequent ly include exercise instruction and supervised exercise components in CNCP treatment. Therapeutic exercise can increase strength, aerobic capacity, balance, and flexibility; improve posture; and enhance general well being. Fitness can be an antidote to the sense
of helplessness and personal fragility experi enced by many people with CNCP. Moderate evidence shows that exercise alleviates low back pain, neck pain, fibromyalgia, and other
conditions. Furthermore, exercise reduces anxi ety and depression. Limited evidence suggests that exercise benefits individuals undergoing SUD treatment (Weinstock, Barry, & Petry,
PT facilitates recovery from a large variety of medical conditions, including cardiopul monary, geriatric, pediatric, integumentary, neurologic, and orthopedic. Neurologic PT and orthopedic PT are most likely to be used to treat chronic pain. Physical therapists use various hands-on approaches to help patients increase their range of motion, strength, and functioning. They also offer training in move ment and exercises that help patients feel and function better.
Many widely used interventions by physical therapists lack definitive evidence. For example, several Cochrane Collaboration reviews of a commonly used PT modality—transcutaneous electrical nerve stimulation—found inconsis tent evidence of effectiveness in a variety of chronic and acute pain conditions. Despite
this lack of an evidence base, PT interventions have the advantages of being nonsurgical, bringing low risk of injury or dependence,
and encouraging patients’ involvement in their own recovery.
Several studies have shown that CBT can help patients who have CNCP reduce pain and associated distress, disability, depression, anxiety, and catastrophizing, as well as improve coping, functioning, and sleep (McCracken,
MacKichan, & Eccleston, 2007; Thorn et al.,
2007; Turner, Mancl, & Aaron, 2006; Vitiello, Rybarczyk, Von Korff, & Stepanski, 2009). In addition to its salutary effects on pain syn dromes, CBT also benefits people who have SUDs. In a meta-analysis of 53 controlled trials of CBT for alcohol or illicit drug disor ders, CBT was found to produce a small but significant benefit (Magill & Ray, 2009).
Complementary and Alternative
CAM includes health systems, practices, and products that are not necessarily considered part of conventional medicine (National Center for Complementary and Alternative Medicine, 2007). Surveys show that 27–60 percent of chronic pain patients use CAM (Fleming, Rabago, Mundt, & Fleming, 2007; McEachrane-Gross, Liebschutz, & Berlowitz,
2006; Nayak, Matheis, Agostinelli, & Shifleft,
2001). Clinicians are urged to learn about these approaches to pain treatment not only because of their therapeutic promise, but also because many patients use CAM, raising the possibility of interactions with conventional treatments (Simpson, 2006). Exhibit 3-3 presents one way to ask patients about their use of CAM.
The evidence supporting CAM interventions for adults with comorbid CNCP and SUD is