Medication and the Substance Abuse Patient

Click the tabs below to see responses from different professionals.

On the issue of medication management, what would you recommend? 

A patient with a history of substance abuse who has been sober for 3 years is referred to you. He reports a severe level of constant pain that is not being relieved by his methadone, and a reluctance on the part of his primary care provider to prescribe additional pain medication, especially opioids. The patient believes he is being discriminated against because of his substance abuse history.

Maripat Welz-Bosna, M.S.N.:

After a comprehensive history and based on the type of pain this patient is experiencing I would begin to prescribe and titrate this patient on some of the adjuvant medications, such as neurontin, topamax, or keppra which are used for neuropathic pain. I would see if he has ever tried any of the new Cox-2 inhibitors for pain and I would asses for secondary depression and decide if an antidepressant may be beneficial both for depression and help with pain. These medications [nortriptylene, amitriptylene, effexor] can help with neuropathic pain or sleep disturbance. Also the use of Lido-derm 5% patches, to help with pain relief, may be tried.

This patient may also benefit with an increase of his Methadone dosage. If he is tolerating the medication and it has provided some pain relief he just may not be on a sufficient dosage to help with his pain control. If after titration to additional medications and an increase of his Methadone this patient still stated there was no significant pain relief we may consider a trial of another opioid to see how this patient would respond.

Also this patient, again depending on the type and location of his pain, may benefit from a consultation from an interventionalist who may be able to provide pain relief via ESI, select nerve root block, or sellate block just to mention a few.

This is why we are advocates for comprehensive pain programs, where a group of pain specialists from all disciplines can work together and manage a patient, have team meetings and discuss care options, unfortunately many of these do not exist for patients.

On the issue of medication management, what would you recommend? 

A patient with a history of substance abuse who has been sober for 3 years is referred to you. He reports a severe level of constant pain that is not being relieved by his methadone, and a reluctance on the part of his primary care provider to prescribe additional pain medication, especially opioids. The patient believes he is being discriminated against because of his substance abuse history.

Knox Todd, M.D.:

The first question I would consider is whether the referring clinician possesses the expertise and skill to treat a patient with chronic pain and a history of substance abuse. Given the referral I would assume this is not the case. Unfortunately, access to physicians with such clinical skills is not widespread and most patients receive inadequate and less than comprehensive care. The patient's concerns about being discriminated against more often than not reflect a real bias on the part of his primary care provider. We know that those with addictive disorders and chronic pain are at particular risk for inadequate treatment, largely due to lack of knowledge about addiction, widespread societal bias against the addicted, and physicians' fear of regulatory and criminal sanctions.

Although the patient reports being sober for three years, pain treatment for this patient can be challenging. As with all patients, care begins with a careful history. In particular, I would want to clarify the relationship between pain and addiction. Does the patient's distress result from pain or does it represent opioid craving? Chronic pain itself may have been a factor in development of the addictive disorder and although opioids can be very helpful in controlling pain, this patient is likely at higher risk for aberrant drug behaviors. Inadequately treated pain itself increases the risk of relapse, as does access to opioids.

In the acute setting, inadequate pain treatment presents a real risk of relapse for this patient, and a history of addiction should not interfere with rapid relief of pain using efficacious analgesics, including opioids. When acute pain appears to become chronic, one should consider other undetected causes for pain, including neuropathic disorders and treat them specifically if identified. In addition, screening the patient for anxiety or depressive disorders is indicated, as the patient may be using analgesics to treat symptoms of these disorders, rather than pain. Finally, one must consider whether the patient's behaviors are consistent with addiction. Here one must distinguish between dependence and addiction. Addicted patients will commonly experience negative consequences of opioid use, including decreases in social and work function and episodic intoxication. Loss of control over opioid use may result in reports of lost or stolen prescriptions. Interviews with family members will be particularly important.

Should the final diagnosis be chronic pain affecting a patient in recovery from an addictive disorder, their management becomes more straightforward. The goals of therapy for his patient are similar to those for other patients with chronic pain: pain reduction, the amelioration of pain-related symptoms, such as anxiety, depression, and sleep disturbances, and improved function.

Assuming that non-opioid therapies, including multidisciplinary pharmacologic and nonpharmacologic interventions, have been maximized, chronic opioid therapy may well be indicated. Although the history of addiction likely increases the risk of relapse, chronic opioid therapy can represent the optimal choice. Some clinicians may choose to utilize written "contracts" with such a patient; however, this is perhaps better considered a formalized informed consent process, rather than a "contract" as such. Routine drug screening is advisable to document that prescribed medications are actually being used by the patient and careful documentation of the goals of therapy and the patient's responses to therapy are mandatory. Should evidence of addictive behaviors become apparent, the therapeutic focus must shift to active treatment of the addictive disorder.

On the issue of medication management, what would you recommend? 

A patient with a history of substance abuse who has been sober for 3 years is referred to you. He reports a severe level of constant pain that is not being relieved by his methadone, and a reluctance on the part of his primary care provider to prescribe additional pain medication, especially opioids. The patient believes he is being discriminated against because of his substance abuse history.

Bob Kerns, Ph.D.:

There is no question that there are many challenges associated with the management of pain among persons with concurrent alcohol and substance abuse or dependence, or even a history of these problems. Research suggests that persons with these problems are particularly vulnerable to poor management of pain, even in the acute post-operative setting. Unfortunately, little research has been published that can help guide effective pain management in this population, particularly with regard to the use of opioids. The following recommendations are, therefore, largely based on the collective wisdom of clinicians in the field of pain management.

There is no substitution for a comprehensive pain assessment that includes a focused consideration of psychosocial problems and disorders such as substance abuse. In the specific case presented, there is apparently evidence that the patient has maintained sobriety for a lengthy period of time, although concerns about relapse remain. It is inferred that the patient’s experience of persistent pain previously responded to methadone (thus the decision to employ chronic opioid therapy) but that the medication is no longer particularly effective.

If the patient is agreeable, I would develop a plan for continued use of methadone, but with a planned escalation of dose. Increasingly, providers are employing an “opioid agreement” that spells out both provider and patient responsibilities with regard to chronic opioid therapy, including contingencies if problems with adherence to the plan for treatment are observed. Routine and random toxicology screens may be appropriate as a strategy for protecting both the patient and provider. A detailed plan should be developed and implemented for an upward titration of the methadone dose, linking dosing to ongoing assessment of pain severity and some index of functioning (including sleep, work, social activities, and so forth).

Evidence that pain can be reduced and functioning can be improved with an increased dose of this medication should encourage confidence in this decision. If positive changes are not observed with reasonable dose increases, alternatives should be considered. Adjuvant pain medications should also be considered. Simultaneously, I would encourage the consideration of alternative pain management approaches, particularly non-pharmacological approaches, such as rehabilitation medicine and psychological treatment. Referral to a multidisciplinary pain program may be appropriate if one is accessible and feasible.

On the issue of medication management, what would you recommend? 

A patient with a history of substance abuse who has been sober for 3 years is referred to you. He reports a severe level of constant pain that is not being relieved by his methadone, and a reluctance on the part of his primary care provider to prescribe additional pain medication, especially opioids. The patient believes he is being discriminated against because of his substance abuse history.

Jayne Pawasuaskas, Pharm.D.:

It is important to remember that patients with substance abuse histories also feel pain. The presence of pain can negatively impact a patient like this in the same ways that it could affect a non-abuser (i.e. decreased healing response, decreased quality of life, depression, etc). Sometimes they will require higher doses (compared to non-abusers) of analgesic medications to achieve a therapeutic effect.

For patients who are receiving methadone as part of a maintenance program, who then develop a painful condition, there are a couple of options for managing the pain. The first step that should be taken is verification of the methadone maintenance dose with the patient’s maintenance program. Then, one option is to increase the methadone dose and split that total dose into 3 or 4 daily doses. (Typically methadone is used every 6 to 12 hours for pain.) Another option is to continue the once daily methadone and add a different opioid for pain relief. In this case, the maintenance program may have specific recommendations about which opioid(s) to use or avoid. This will be determined by the type of urine testing that a particular program uses to check if their patients are using illicit drugs while in the maintenance program. A third option would be to avoid use of opioids altogether for managing the pain, and opt for another class of medications. The appropriateness of this option would depend on the type and severity of the pain that the person is having.