Michael McGee, MD
Chief medical officer, The Haven at Pismo, Avila Beach, CA. Author of The Joy of Recovery: A Comprehensive Guide to Healing from Addiction (Union Square Publishing)
Dr. McGee has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
It can be challenging to manage chronic pain, even more so when our patients suffer from addiction. We can find ourselves walking a tightrope between the risk of relapse due to the inadequate treatment of pain, and the risk of relapse due to the use of opioid analgesics.
Since our mission is to minimize suffering and optimize functioning while helping our patients stay in recovery, this article will outline the general principles for achieving these goals in a pain management setting.
Nature of chronic pain There are three types of pain: nociceptive, neuropathic, and mixed. In acute pain, nociceptors send pain signals upon tissue injury. Neuropathic pain arises from dysfunction of the sensory nervous system, often due to sensory nerve injury. Mixed pain is a combination of nociceptive and neuropathic pain.
Chronic nociceptive pain can persist long after the healing of tissues. This appears to be due to autonomous neural signaling of sensitized nerve fibers. Alteration of inhibitory pain signaling may also play a role. For example, after suffering severe burns, some patients develop complex neuropathic pain syndromes.
Pain signals can be altered in the peripheral nerves, the spinal cord, the thalamus, and the cerebral cortex (Compton P et al. Principles of Addiction Medicine, 5th ed. Chevy Chase, MD: American Society of Addiction Medicine; 2014). This makes an accurate diagnosis of the chronic pain’s source potentially important for treatment. For example, pain originating in peripheral nerves may respond best to electrical stimulation or acupuncture, while post-stroke pain that originates in the cerebral cortex will respond better to cortical interventions and cortex stimulation (Zaghi S et al, J Pain Manag 2009;2(3):339–352).
Psychosocial factors influence the perception and impact of chronic pain. For example, a positive outlook and family support can reduce both pain and disability (Flor H and Turk DC, J Behav Med 1988;11(3):251–265). Low self-efficacy is associated with greater depression, pain, and disability (Turk DC and Okifuji A, J Consult Clin Psychol 2002;70(3):678–690). Reinforcing pain behaviors—providing secondary gain—can also worsen a patient’s symptoms and functioning. The benefits of pain (eg, relief from family obligations, medico-legal rewards) can both perpetuate disability and impede recovery (Dersh J et al, J Occup Rehabil 2004;14(4):267–279).
Preexisting psychiatric illnesses, including depression, anxiety, and PTSD, increase suffering due to pain and impair coping ability. (See https://bit.ly/2FUxIVu for a pain treatment improvement protocol.) Conversely, chronic pain often worsens psychiatric illness, creating a vicious cycle.
Additionally, chronic pain often causes depression, anxiety, insomnia, or impaired functioning. Like any stressor, chronic pain can also trigger relapse to addiction (Gourlay GL et al, Pain Medicine 2005;6(2):107–112). The interplay of addiction, other psychiatric illnesses, and chronic pain can make it challenging to assess and treat these conditions.
Assessment of patients with chronic pain Since chronic pain is multifaceted, its assessment should be too. Be sure to obtain consent to speak to collateral providers and supports. You’ll want to gather the findings of other clinicians and the observations and concerns of loved ones. Be sure to also check your state electronic prescription monitoring program to see whether the patient is being prescribed controlled substances. Ideally, you should try to obtain medical, psychiatric, and addiction treatment records from other clinicians.
After doing these things, you should assess the following:
Assess the nature of the pain. Ask questions about onset, what the pain feels like, its severity, and what makes the pain worse (see box on page 3).
Assess how the pain impacts functioning. Ask how the patient copes with it. How does the pain affect daily activities, including work, household responsibilities, socializing with friends, sex, and having fun?
Further explore how the pain makes the patient feel. Does the patient feel irritable, frustrated, or hopeless? Be sure to ask how the pain is affecting sleep and mood. Listen for underlying negative beliefs about the pain, such as the idea that life is not worth living or that there is nothing that can be done about the situation. Is the patient willing to accept the pain and pursue a fulfilling life? Is there a sense that the pain can be addressed through the help of others? Degrees of acceptance and self-efficacy will inform and impact the treatment.
Ask about the impact of pain on a patient’s recovery. Is the patient sober? Having cravings? Is the patient adhering to a recovery program, or is pain getting in the way? Is the patient continuing to reach out to recovery supports, or retreating into isolation? If the patient is new to you, conduct a thorough substance use assessment, including details of current and past use, treatment history, and recovery history. Pay attention to factors that have sustained the patient’s recovery and examine relapse history, taking note of factors that triggered relapse to addiction.
Assess all other co-occurring conditions and disorders. Include other psychiatric illnesses, medical conditions, and neuropsychiatric impairments.
Assess environmental contingencies. Does the family reinforce wellness behavior or illness behavior? Are there vocational, financial, or insurance/legal incentives or disincentives for being in pain? What will be the consequences of resuming healthy functioning? These factors can significantly impact pain severity and associated disability. Is the family concerned about the medication, opioids or otherwise, being prescribed to the patient?
In addition, conduct or obtain a physical exam. Look for relevant associated signs of a pain disorder and for signs of a substance use disorder, such as track marks, hepatomegaly, residuals of skin infections, and nasal and oropharyngeal pathology.
In your mental status exam, take note of whether the patient is focused on medications, particularly opioids. Look for somatic preoccupation. Assess both mood and the presence of suicidal ideation, intent, plans, and behaviors. Assess cognition, as impairments will affect the treatment.
Just as we assess our patients’ “recovery capital” (social, cultural, emotional, financial, and occupational resources and supports), assess the patient’s pain recovery capital. What environmental and social resources are available to promote wellness? Conversely, what are the patient’s life stresses that impede healing from chronic pain?
After completing a thorough assessment, develop a formulation, or clinical understanding of the patient’s difficulties. What are the patient’s and family’s overt and covert agendas? What are their impairments, and what factors contribute to those impairments? What are the patient’s strengths and vulnerabilities? What resources can be brought to bear for the patient’s healing? What stressors or other negative factors stand in the way of a successful outcome? A good formulation will make for a good treatment plan.
Assessing the Nature of Pain When assessing the nature of a patient’s pain, Michael McGee, MD, recommends that you use the mnemonic “OPQRST,” which stands for the following:
“O” stands for onset: Was the pain gradual or sudden? What was the patient doing when it started?
“P” stands for provokes or palliates: Ask, “What situations cause the pain to get better or worse?”
“Q” stands for quality: Ask, “What does the pain feel like?” Let the patient attempt to describe the pain before giving options such as sharp, dull, or shooting.
“R” stands for radiates: Ask the patient to point to where the pain hurts the most, then ask, “Where does the pain go from there?”
“S” stands for severity: Ask how severe the pain is on a scale of 1–10, both when the pain is at its least severe and when it is at its worst. Ask whether the pain is constant or intermittent, and what the variation in severity is during a 24-hour cycle.
“T” stands for time: How long ago did the pain start? You also want to know the location(s) of the pain. If the patient claims to hurt “all over,” ask the patient to point to where it hurts the most. Ask about prior pain assessments and the response to prior treatments, including complementary and alternative treatments.
Starting treatment Treatment begins with an empathic connection. Try to make the patient feel understood and cared for. Since chronic pain can rarely be eliminated, it is important to communicate that you will be an ally throughout the patient’s distress.
Begin treatment with education and negotiation of realistic treatment goals. Such goals include reduction of pain, maximization of functioning, and improvement in quality of life. I like to explain that there is a difference between suffering and distress. While the distress of pain can be reduced but not generally eliminated, suffering can be alleviated with a comprehensive, multimodal, biopsycho/social/spiritual approach.
Explain that pain is as much a psychological as a physical experience, and that it can be reduced by psychological and behavioral interventions. Patients need to understand that treating chronic pain is much more than taking a pill. They should also know that treating chronic pain generally takes a team: primary care providers, addiction specialists, pain clinicians, nurses, pharmacists, behavioral health clinicians, physical and occupational therapists, and alternative and complementary caregivers such as massage therapists and acupuncturists.
Reducing pain You can frequently reduce pain using non-opioid analgesics. Acetaminophen should not exceed 4 g/day. With NSAIDs, be mindful of the risk of gastrointestinal bleeding and renal insufficiency. Combining or alternating acetaminophen with an NSAID and using them on a standing basis (not PRN) over a period of greater than 48 hours can optimize pain reduction (Altman RD, Clin Exp Rheumatol 2004;22(1):110–117). Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and tricyclic antidepressants (TCAs) raise the pain threshold in the dorsal root ganglia and thus reduce pain levels.
Watch for anticholinergic side effects and orthostatic hypotension with TCAs (eg, confusion, constipation, and fall risk in the elderly). Due to the risk of cardiac conduction abnormalities, check an ECG when prescribing a TCA to someone over the age of 50. Antidepressants offer the obvious benefit of also treating co-occurring depression. Some anticonvulsants are indicated for treating fibromyalgia, migraine prophylaxis, and neuropathic pain.
Be mindful that gabapentin and pregabalin (a Schedule V controlled substance) can be misused and that discontinuation can cause withdrawal symptoms. Carefully monitor the use of these medications. Topical analgesics, including topical NSAIDs, capsaicin, and lidocaine, provide treatment of localized superficial pain with minimal systemic side effects.
Muscle relaxants, benzodiazepines, and THC are generally not recommended for treating chronic pain, especially in patients with a vulnerability to addiction. Cannabidiol, which is non-psychoactive, may be helpful for some patients, particularly for central neuropathic pain, inflammatory, and cancer pain (Russo EB, Ther Clin Risk Manag 2008;4(1):245–259); however, more research is required and it lacks FDA approval.
Non-pharmacological approaches Cognitive behavioral therapy (CBT) addresses negative cognitions and unhelpful pain behaviors, including avoidance and isolation. CBT can reduce pain and associated distress, disability, depression, anxiety, and catastrophizing. It can also improve functioning, sleep, and coping (Vitiello MV et al, J Clin Sleep Medicine 2009;5(4):255–362).
Mindfulness approaches, especially mindfulness-based stress reduction, enhance distress tolerance through acceptance and nonjudgment. They diminish the anxiety and depression that can arise as distress-avoidant responses to pain. Practicing the acceptance of pain can help reduce the suffering associated with it.
A word about opioid treatment Research suggests that chronic opioid treatment fares no better than long-term non-opioid treatment of moderate to severe chronic pain due to osteoarthritis (Krebs E et al, JAMA 2018;319(9):872–882). Pain specialists should only initiate opioid pharmacotherapy as a last resort, when other interventions have failed, and only after a careful consideration of the potential risks and benefits.
Opioid treatment rarely shows more than a one-third reduction in pain beyond 18 months and poses the risk of triggering relapse in patients with opioid use disorder and other addictions (Reid MC et al, J Gen Internal Medicine 2002;17(3):173–179). Opioids may be necessary in extreme cases, however, and they should not be totally ruled out simply because your patient has an addiction. Buprenorphine can be considered for patients with both chronic pain and moderate to severe opioid use disorders. Any patient with addiction to opioids will require careful monitoring, and many patients will not benefit from prolonged opioid therapy.
CATR Verdict: In treating chronic pain and addiction, work to improve functioning, reduce pain, and ease psychological suffering. Integrate the treatment of pain and other comorbidities, including addictions and other psychiatric illnesses. Combine non-opioid pharmacological and nonpharmacological therapies, collaborating as part of a team with other caregivers. As always, be wary of the risk of relapse, and consider the potential role of buprenorphine.