Author: By Seddon R. Savage, MD, MS
The role of opioids in chronic pain treatment has become increasingly controversial and includes important questions about who may benefit from long-term opioid therapy. While much chronic pain can be managed with nonopioid approaches, it is clear that some patients and providers find opioids a helpful component of ongoing pain treatment.
Others on opioid therapy, however, may experience loss of analgesia, declining function, persistent side effects, mood changes, increasing pain, escalating dose requirements, and/or diverse types of opioid misuse that can result in adverse consequences, including addiction or death. And across the US, misuse and diversion of prescribed opioids have contributed to a major public health crisis.
In order to support positive pain outcomes and reduce opioid-associated harm, it is critical that prescribers are prepared to identify and intervene appropriately when opioid misuse occurs, and at the same time be prepared to offer robust nonopioid approaches to pain management.
This issue of Practical Pain Management focuses on the challenges of managing chronic pain in patients who have developed opioid use disorders (OUDs). Dr. Daniel Alford describes different presentations of opioid misuse, discusses the difficulty of determining causes for the misuse with certainty, and provides guidance on the pharmacologic treatment of OUDs in the context of chronic pain. Dr. Jordan L. Newmark identifies important tools for monitoring opioid therapy that can help track the benefits and risks of opioid therapy and discusses alignment of provider and patient goals with respect to continuing or discontinuing opioids. Dr. Robert Rich Jr. provides a primary care perspective on decisions to continue or taper opioids and describes a patient-centered approach to discontinuing opioids when indicated.
Common threads in these articles include an appreciation of the multidimensional nature of pain and the complex challenges of managing chronic pain in the context of co-occurring OUDs. The authors also note the importance of continuing to care for patients when opioids are discontinued and to engage them in alternative approaches to pain treatment. If there is anything positive in our current opioid challenges, it may be the renewed emphasis on the importance of multidimensional care in addressing complex chronic pain, including pain associated with co-occurring OUDs.
Recognition of chronic pain and addiction as chronic conditions with complex biopsychosocial dimensions has the promise to improve the care of patients with these co-occurring conditions. To successfully treat other chronic illnesses, such as diabetes and heart disease, we address both biological and psychobehavioral factors and aim to manage, not cure the condition: We educate patients about diet; encourage exercise and weight loss; provide medications; treat secondary problems; and, importantly, motivate patients to be active in self-care. Such multidimensional management has been demonstrated to similarly improve outcomes for patients with pain,1 addiction,2 and co-occurring pain and addiction.3
Addiction has long been viewed as a chronic, potentially relapsing disorder from which patients may recover but are not generally cured. Patients with chronic pain and their care providers, however, often continue to search for a cure for pain indefinitely, understandably hoping to find a definitive injection, medication, or surgery that will end their suffering.
However, while some chronic pain is due to ongoing tissue injury (eg, degenerative arthritis, inflammatory conditions, etc), pain also can be sustained by non-nociceptive factors in the absence of ongoing identifiable tissue damage. If a remediable cause is not found, transition to a primary goal of managing the pain may be both more realistic and more helpful than an exclusive focus on a cure. Although active treatments such as interventional procedures and medications may have important roles in ongoing treatment, engaging in active self-care can help patients thrive with improved function and quality of life. This can be especially important when chronic pain and opioid or other substance use disorders co-occur.
A number of self-management skills can empower patients to effectively address both pain and OUD, among them cognitive behavioral therapy (CBT), meditation, group support, and exercise. CBT aims to reduce physical and psychosocial triggers or reinforcers of pain or drug use, and helps patients adapt thoughts, feelings, and behaviors to reduce symptoms and improve quality of life. Patients with chronic pain and/or OUD often feel overwhelmed, so CBT breaks problems into small, manageable pieces to achieve targeted goals, supporting a sense of mastery and improved self-esteem.4,5
Meditation/deep relaxation approaches, often components of CBT, deserve special consideration. Growing evidence suggests meditation can alter neural processing to reduce pain and reduce addiction-related craving.6,7 Whereas scientists debate the nuances of different approaches (eg, mindfulness, mantra-based meditation, progressive muscle relaxation, autogenic training, hypnosis), evidence indicates even limited practice can significantly affect pain and recovery from OUD. Simple-to-learn, daily meditation practice can have profound effects on pain and OUD recovery and well-being.
Self-help groups such as Alcoholics Anonymous (AA) and Narcotic Anonymous (NA) are among the most established approaches to addiction recovery.8 The use of the 12 steps and traditions has evolved to address chronic pain as well,9 and Chronic Pain Anonymous (CPA) groups are spreading across the country.10 Other positive support groups can be accessed online through organizations such as the American Chronic Pain Association (https://theacpa.org).11 Both CPA and the American Chronic Pain Association offer access to groups (in person, online, and by telephone) in different regions of the country.
Exercise is an important component of self-care for most people with chronic pain. Pain often leads to deconditioning, muscle restrictions, loss of tone, changes in posture and joint motion, and loss of aerobic capacity and circulation, all of which can increase pain. Gentle, progressive exercise that does not increase pain can gradually restore fitness, function, and self-esteem.12 Recent evidence suggests regular exercise may reduce drug craving and increase recovery in people with addiction.13
Outcomes studies from intensive residential treatment programs support the effectiveness of such integrated, bio-behavioral models in improving pain, reducing pain interference on activity and enjoyment of life, and reducing reliance on opioids when they have proven unhelpful or harmful. One study found that 63% of patients using opioids on admission to an interdisciplinary program were able to taper off and elected to stay off opioids at discharge, 18% required transition to opioid agonist therapy for treatment of OUD using either buprenorphine/naloxone or methadone, and 19% had improved pain and function on a lower dose of opioid (average >75% reduction in MMEs).14 Another study of interdisciplinary treatment of patients with co-occurring chronic pain and OUD found that of patients who were tapered completely off opioids and were available for follow-up, 77.5% remained off opioids 1 year later.15
There are significant challenges, however, to providing such integrated approaches on an outpatient basis in the community. Patients may receive serial, less-effective treatments rather than integrated care due to difficulty coordinating care across provider systems. Insurers often decline support for prolonged physical therapy or psychobehavioral treatments. Adherence to the tapering of opioids may be harder to achieve in a less controlled environment, and access to pharmacologic as well as psychosocial therapies for OUD are sometimes limited. Transportation and childcare can be barriers to attendance at frequent appointments. And the challenges of continuing recovery and self-management practices on a long-term basis once formal treatment is concluded are legion—who does not struggle with following a consistently healthy diet, getting to the gym, or practicing meditation or other stress reduction techniques on a regular basis?
Health care systems can enhance or confound care of chronic conditions. In the US, fee-for-service medicine has incentivized shorter medical visits and procedures rather than longer time spent educating and motivating patients. The Affordable Care Act, however, has put a higher priority on chronic illness management, provides support for care coordination, has expanded access to treatment of mental health and substance disorders, and created revisions in codes and payment structures that could ultimately improve care of both chronic pain and OUD.16 However, it is not clear how these changes will fare in coming years. Emerging online and telephonic technologies promise expanded access to multidimensional care for pain, OUD, and other chronic conditions, but implementation of these in diverse health care settings is challenging.17,18
To reduce the clinical and public health challenges of chronic pain treatment that is complicated by opioid or other substance misuse, health care providers would do well to support policies that improve care of chronic illnesses and encourage engagement of patients in self-care. Recent changes in health care systems and the expanded use of technologies have increased opportunities for patients to engage effectively in this model of care, but strong advocacy is needed to maintain and advance such gains.
- Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions.Psychol Bull. 2007;133(4):581-624.
- Kim TW, Saitz R, Cheng DM, Winter MR, Witas J, Samet JH. Effect of quality chronic disease management for alcohol and drug dependence on addiction outcomes.J Subst Abuse Treat. 2012;43(4):389-396.
- Morasco BJ, Gritzner S, Lewis L, Oldham R, Turk DC, Dobscha SK. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder.Pain. 2011;152(3):488-497.
- Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. 1999;80:1-13.
- McHugh RK, Hearon BA, Otto MW. Cognitive behavioral therapy for substance use disorders.Psychiatr Clin North Am. 2010;33(3):511-525.
- Zeidan F, Grant JA, Brown CA, McHaffie JG, Coghill RC. Mindfulness meditation-related pain relief: evidence for unique brain mechanisms in the regulation of pain.Neurosci Lett. 2012;520(2):165-173.
- Dakwar E, Levin FR. The emerging role of meditation in addressing psychiatric illness, with a focus on substance use disorders.Harv Rev Psychiatry. 2009;17(4):254-267.
- Kaskutas LA. Alcoholics Anonymous effectiveness: faith meets science.J Addict Dis. 2009;28(2):145-157.
- Colameco S.12 Steps for Those Afflicted with Chronic Pain: A Guide to Recovery From Spiritual and Emotional Suffering. 2nd ed. CreateSpace Independent Publishing Platform; 2013.
- Chronic Pain Anonymous. Available at: http://www.chronicpainanonymous.org. Accessed March 1, 2017.
- The American Chronic Pain Association. Available at: http://theacpa.org. Accessed February 27, 2017.
- Nijs J, Kosek E, Van Oosterwijck J, Meeus M. Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise?Pain Physician. 2012;15(3 Suppl):ES205-13.
- Brown RA, Abrantes AM, Read JP, et al. A pilot study of aerobic exercise as an adjunctive treatment for drug dependence.Ment Health Phys Act. 2010;3(1):27-34.
- Savage SR, Moore B, Singer B, et al. Opioid pathways in chronic pain recovery. Poster presented at: International Conference on Opioids; June 7-9, 2015; Boston, MA.
- Huffman KL, Sweis GW, Scheman J, Covington Opioid use 12 months following interdisciplinary pain rehabilitation with weaning.Pain Med. 2013;14(12):1908-1917.
- Savage SR. Affordable Care Act offers opportunity to combat pain and drug abuse. Congressional Quarterly Roll Call, April 5, 2013. Available at: http://www.rollcall.com/news/savage_affordable_care_act_offers_opportunity_to_combat_pain_and_drug_abuse-223628-1.html. Accessed March 2, 2017.
- Molfenter T, Boyle M, Holloway D, Zwick J. Trends in telemedicine use in addiction treatment.Addict Sci Clin Pract. 2015;10:14.
- Eckard C, Asbury C, Bolduc B, et al. The integration of technology into treatment programs to aid in the reduction of chronic pain.J Pain Manag Med. 2016;2(3).
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