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What to do when pain and addiction coexist

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A multidimensional approach to pain treatment will serve all patients with chronic pain well and is especially important for those who misuse alcohol, street drugs, or prescribed medications.


 

Chronic pain and addictive disorders are each distinct clinical conditions that can be expressed in unique ways in different individuals. Similar to other chronic conditions such as diabetes, hypertension, or asthma, both pain and addictive disease often have biological as well psychobehavioral contributors that may shape clinical expression.1

As with these other illnesses, it is helpful for clinicians to engage the patient in a consistent process of self-care and to provide long-term clinical care while at the same time coordinating the care of other providers and specialists.2,3 In some cases a definitive cure for pain may be possible, but more often, chronic pain, like addiction, is a persistent condition requiring treatment over many years.

It will come as no surprise to learn that the convergence of pain and addiction can complicate recovery from both problems.4 Pain or its associated symptoms may prompt continuing use of substances that provide transient relief, but which sometimes perpetuate distress and reduce quality of life. And addiction may drive the experience of pain and seem to justify use of an addictive substance that the patient craves.

It is also important to recognize that pain and addiction frequently share a number of similar clinical features—including sleep and mood disturbances, substance use, deconditioning, functional losses, and high levels of stress—such that the conditions can reinforce one another. Full evaluation and comprehensive treatment of the biopsychosocial components of both conditions can improve outcomes.

The purpose of this article is to explore a model of multidimensional care that will serve all patients with chronic pain well, including those with addiction disorders.

What drives substance use? How common is it?

Patients with chronic pain may use alcohol, street drugs, or prescribed medications for diverse reasons. Many are self-medicating pain, sleep difficulties, mood fluctuations, or painful, intrusive memories. Others use these psychoactive agents as a form of recreation, as a compulsive act due to addiction, or to avoid withdrawal symptoms when physically dependent. And still others use these agents for diversion and profit.

Sometimes only one motive drives their behavior, but often several are present. As a physician, your goal is to identify the substances being used and the motivators of use (when possible) to better address the underlying causes.

The lifetime prevalence of addictive disorders among US adults is about 12.5% for alcohol dependence, 17.8% for alcohol abuse, 2.6% for drug dependence, and 7.7% for drug abuse.5,6

Research also suggests that there is a relatively high rate of chronic pain among individuals with addiction disorders.7 Many factors may contribute to pain in people with addictions, including injuries8 and traumatic childhood experiences. The latter appears to increase the risk of developing addiction and/or chronic pain later in life.9,10

Key Point

Research suggests that there is a relatively high rate of chronic pain among individuals with addiction disorders.

Conducting a thorough assessment

In addition to a careful assessment of pain and its consequences for the patient, it is important to conduct a thorough assessment of current and past use of alcohol, street drugs, tobacco, and controlled prescription drugs in a nonjudgmental manner. A number of validated screening tools are available that may help identify substance abuse.

Consider using NIDA-Modified ASSIST (http://www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf), an excellent assessment tool for primary care providers that inventories substance use and helps monitor it on an ongoing basis. If the patient does not misuse substances, the screen is very brief. If he or she misuses them and acknowledges it, NIDA-Modified ASSIST will provide a comprehensive picture of the nature of the problem. Other assessment tools—including those specifically geared to opioid misuse11—are listed in the TABLE.

TABLE

Screens for addictive disorders

Instrument Screening target What’s involved
Addiction Behaviors Checklist
http://dsibmeetings.westat.com/SBIRT/Wu%20addiction%20behaviors%20checklist.pdf
Tracks behaviors of patients who have been prescribed opioids 20 observations
CAGE-AID
http://www.ncdhhs.gov/mhddsas/providers/DWI/dualdiagnosis/CAGE-AID.pdf
Alcohol, drugs 4 questions
Cyr Wartman screen
http://www.ama-cmeonline.com/pain_mgmt/tables/table_cage.htm
Alcohol, drugs 2 questions
DAST (Drug Abuse Screening Test)
http://www.emcdda.europa.eu/attachements.cfm/att_61480_EN_DAST%202008.pdf
Drugs 20 questions
DIRE (Diagnosis, Intractability, Risk, Efficacy)
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CEEQFjAA&url=http%3A%2F%2Fwww.fmdrl.org%2Findex.cfm%3Fevent%3Dc.getAttachment%26riid%3D6613&ei=FJz2UbkNuMfgA_2IgBg&usg=AFQjCNECSYFnam9UATA-Xm_JQ0cjm6Xdiw&sig2=aXAOK1vtEqTYxeREDsBOiw&bvm=bv.49784469,d.dmg
Opioid risk specific Scoring of 4 factors
NIDA-Modified ASSIST
http://www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf
Alcohol, tobacco, drugs Short to comprehensive, depending on use
ORT (Opioid Risk Tool)
http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf
Opioid risk specific 5 questions
PMQ (Pain Medication Questionnaire)
http://download.journals.elsevierhealth.com/pdfs/journals/0885-3924/PIIS0885392404001010.pdf
Opioid risk specific 26 questions
SOAPP (Screener and Opioid Assessment for Patients with Pain)
http://www.painedu.org/soapp.asp
Opioid risk specific 3 versions: 24,14, and 5 questions
Urine drug screening Objective information on drug/medication use Objective lab test

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