What to do when pain and addiction coexist

If you are considering the use of opioids to treat a patient’s chronic pain, urine drug testing can provide objective information regarding current substance use and is especially important in patients with known addictive disorders or substance misuse.

A 24-hour inventory of substance and medications use, identifying exactly when and for what symptoms each was used, can reveal important clinical information. It is not unusual, for instance, to identify a pain patient using alcohol at bedtime to induce sleep (although alcohol actually disrupts sleep architecture) or using opioids for stress or anxiety even when pain is not anticipated or present.

Multidimensional treatment approach

Your goals in treating chronic pain include reduction in pain and associated symptoms, enhanced functioning, and a return to a high quality of life with meaning and purpose. The goals of addiction or substance misuse recovery usually include avoiding harmful use of substances and similarly achieving physical, psychological, and spiritual well-being. These goals are entirely compatible.

Unless specific surgeries, procedures, or other interventions are able to eliminate a patient’s pain, treatment usually must address not only the pain, but also coexisting mental health or medical issues, as well as pain sequelae that may increase pain. An interdisciplinary approach often offers the best opportunity for success.¹²

To effectively address substance misuse in the context of chronic pain requires an understanding of what is driving the misuse and again must address coexisting mental health or other medical issues, as well as the sequelae of the substance problem. A biopsychosocial approach to treatment of both pain and addiction that actively engages the patient in self-management is critical to recovery from both chronic conditions.¹³ (See “Self-care options for patients with chronic pain and addiction," below.)

Such treatment ideally involves the primary care physician, psychologist or counselor, and physical or occupational therapist—with support from pain or addiction providers. The medical home can play important roles in coordination of care, facilitation of self-management, and promotion of recovery from both conditions.¹⁴

The structure of our health care system, however, favors payment for short clinic visits and procedures and may limit access to mental health and substance services. It may be more expedient to prescribe a medication or refer for a pain block than to explore things like stress, diet, exercise, sleep, mood, substance use, and the ability to function at work and home. The “quick solution” approach often omits the development of a foundation of self-care that is important to long-term success.

While patients without co-occurring substance use disorders may get by with this approach, patients with co-occurring addiction-related disorders can be hurt by reliance on medications and other passive therapies.