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

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.

SELF-CARE OPTIONS FOR PATIENTS WITH CHRONIC PAIN AND ADDICTION

Consider suggesting that your patient:

Remember that chronic pain and addiction are chronic conditions, so it is important to check on self-care at each visit and revise the plan as helpful to the patient. Use selected treatments, such as targeted physical therapy, medications, procedures, or other approaches when appropriate.

Finding the best treatment approaches

Effective treatment of chronic pain may draw from 4 broad categories: psychobehavioral, physical therapeutic, and interventionalist approaches, as well as medications.

Psychobehavioral and physical therapeutic approaches can provide a foundation for recovery from chronic pain and a context in which strategic use of interventionalist procedures and medications may be more effective. Fortunately, many self-management strategies that have been shown to be effective in pain management are also effective in the treatment of addiction. Among these are: cognitive-behavioral therapy, meditation, emerging 12-step programs for pain, and physical reconditioning.

As you plan out each patient’s therapeutic regimen, consider these options:

Cognitive-behavioral therapy (CBT) aims to change behaviors and thought patterns to help patients gain control over their condition. It has been shown to be effective in improving outcomes in chronic pain and substance abuse treatment.^15,16 In the treatment of chronic pain, patients often identify negative self-talk that is impeding their recovery—”My pain is killing me. I’ll never be able to work.” They are encouraged to substitute more positive thoughts that favor recovery, eg, “My pain is hurtful but not harmful. My pain will lead me to new and more meaningful work.”

Patients also examine physical activities, stress, sleep challenges, and mood fluctuations that can increase pain and engage in approaches such as activity pacing, stretching, and relaxation that may mitigate their pain. When CBT is used in addiction treatment, patients similarly explore triggers for drug use (often people, places, and things), and they substitute alternatives that support abstinence and recovery.

For example, patients may elect social opportunities with friends who do not get high, participate in valued activities that don’t involve alcohol or drugs, and frequent places not associated with old drug use patterns. They reframe negative thinking to gain a more positive perspective that favors recovery and prevents relapse. “I can’t live without alcohol forever” becomes “I can enjoy today without alcohol.” They also apply relaxation or meditation skills to reduce stress, and they develop coping skills to address high-risk situations.¹⁷

Meditation-relaxation. Despite some scientific debate about the relative merits of different relaxation approaches, such as hypnosis, guided imagery, progressive muscle relaxation, and meditation, there is clear evidence that deep relaxation practices can play an important role in pain management. Recent studies have shown benefit for mindfulness meditation in the treatment of pain.¹⁸ Other studies suggest various forms of meditation may help patients recover from addiction.¹⁹ The physiologic basis of pain relief associated with meditation or deep relaxation has been variously attributed to muscular relaxation, reduction in sympathetic arousal, and changes in activity of different brain centers that process pain and pain inhibition. Effects on sleep enhancement and reduction in anxiety may also contribute to recovery from pain and substance abuse.

One simple approach to meditation is for the patient to sit comfortably for 10 to 20 minutes while focusing awareness on the natural flow of his or her breath going in and out. The patient is instructed to note thoughts, sounds, and sensations as they pass by and gently bring attention back to the flow of breath. A word or phrase can be silently thought on the outbreath to enhance focus.

12-step programs. Twelve-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have been a key element of self-management of recovery from addiction for at least 7 decades. AA and similar meetings engage attendees in a process of self-reflection, reframing of perspectives, interpersonal sharing, and acceptance that for many are powerful supports for substance abuse recovery.²⁰

12-step programs for pain. Recently 12-step programs for chronic pain that use the same basic strategies and paradigm to engage individuals in a process of recovery have begun to proliferate; these meetings are open to people both with pain alone and those with pain and addiction.²¹ And when pain-specific 12-step groups are not available, many patients find they can adapt the steps in an AA or NA meeting to address their pain.

The strengths of 12-step groups are that they are free and widely available. Patients may need to try different groups, however, to find one at which they feel comfortable.

Key Point

There are now 12-step programs for chronic pain that use the same basic strategies as Alcoholics Anonymous and Narcotics Anonymous to engage in the process of recovery.

Physical reconditioning. The benefits of exercise and movement therapies in chronic pain management are well documented. Exercise activates central endorphin release and descending pain inhibition. Aerobic exercise, such as cycling, using an elliptical machine, or walking, may improve circulation and tissue oxygenation, which in turn can improve healing. Stretching can relieve muscular tension and normalize joint motion; however, stretches must be tailored to the condition of the particular patient. Improved posture and proper biomechanics during movement reduce physical stress. Similarly, toning or strengthening can provide support for spinal and other joints and reduce propensity for spasm. It is usually important for a patient to initiate exercise under the guidance of a physical therapist.

Clinicians should advise patients with pain to exercise in a manner that is gentle, gradually progressive, and avoids significantly increasing the patient’s pain.²² Some studies suggest exercise can improve outcomes in addiction treatment; it is speculated that enhanced self-esteem and the increase in endogenous endorphins may contribute.²³

Key Point

Some studies suggest that exercise can improve outcomes in addiction treatment.

Adding active treatments to the platform of self-care

Selection of specific procedures and medications for different pain problems is beyond the scope of this article, but it is worth noting that engagement in a biobehavioral self-care program provides a context that supports successful use of procedures and medication. For example, improved posture, muscular support of the spine, and proper biomechanics may reduce disc stresses that can produce recurrent pain after a successful epidural injection of steroids. Similarly, muscular trigger point injections are more likely to result in protracted muscular relaxation if a patient is engaged in regular stress management and stretching.

Similarly, when withdrawal-producing medications are eliminated, when stress, anxiety, and depression are addressed, and when the patient is physically conditioned, he or she may respond better to nonopioid pain medications.

Opioids for pain in substance use disorders

Opioids are rarely first-line medications for chronic pain treatment but they can be valuable components of care for some who have not responded to self-management, interventionalist procedures, and nonopioid medications. But use of opioids in chronic pain patients with addictive disorders requires exceptional care.

As you might expect, the risk of opioid misuse is higher in individuals with a prior history of substance use when compared with a person without this history. But the relative risk for people with different types of addiction is unknown. There’s the potential to become addicted to opioids, for instance, when an individual is in recovery from addiction to alcohol or marijuana. However, observation suggests the risk of addiction to prescribed opioids is more likely in patients with a past history of opioid addiction than other addictions. Duration of recovery is generally inversely related to the risk of relapse, so longer term recovery presents less risk than recent recovery.

Whenever possible, engage any patient with a history of addiction in an active addiction recovery program and have him or her co-managed by an addiction specialist if you plan to prescribe opioids. Patients in recovery from nonopioid addiction who require opioids for pain may benefit from tightening the structure of care. This may include:

providing a smaller supply of medications at more frequent intervals;
increasing supports for recovery from pain, addiction, and co-occurring disorders;
increasing supervision including office visits, urine drug screens, and pill counts;
selecting treatments carefully to limit reward (euphoria) when possible, as reward can trigger misuse; and
assuring that the setting of care can provide optimal care coordination.²⁴

For those with a history of opioid addiction, the safest option for opioid therapy is engagement in an addiction treatment paradigm of opioid therapy. This will mean either buprenorphine/naloxone with a registered provider or methadone maintenance treatment through a licensed clinic in which medications will be tightly supervised and the patient engaged in psychosocial addiction treatment. Both types of opioid agonist therapy may provide some pain relief while providing pharmacologic treatment of opioid addiction and minimizing the risk of misuse and associated harm (such as overdose).

What’s your role?

The key roles of the primary care physician in managing chronic pain and coexisting substance use disorders are to (1) identify the variables that contribute to the patient’s experience of pain and use of substances, (2) encourage and support the patient as he or she tries to develop a self-care program, (3) strategically implement or refer for active treatment of the various contributing factors, and (4) see the patient regularly to monitor engagement in both self-care and active treatments and to revise the plan as needed.

Coexisting pain and addiction are among the most challenging scenarios encountered in primary care. Recovery is possible, but patience, time, flexibility, and consistent motivational support are critical. The process is often 2 steps forward, one step back, so clinicians and patients need to celebrate small victories.

Key Point

The process is often 2 steps forward, one step back, so clinicians and patients need to celebrate small victories.

Disclosure

The author reported no potential conflict of interest relevant to this article.

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What to do when pain and addiction coexist