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Thomas E. Quinn, MSN, RN, AOCN:
The responsibilities of a clinician prescribing opioids can be overwhelming especially when a patient has co-existing addiction issues. One of the most important things to recognize is there is a very wide range of patients and behaviors between “normal” and “addicted.” Complicating matters is the lack of a widely-accepted definition of addiction. The DSM-IV definition uses the term “substance dependence” (rather than addiction) and includes tolerance and withdrawal as attributes. The consensus definition of three major professional organizations emphasizes that addiction is a “primary . . . neurobiologic disease” characterized by compulsive drug seeking and continued use of the substance despite the harm it is causing the patient. It is important for a clinician to be clear about what is meant when they say a patient has an “addiction problem.” For example, a clear diagnosis of addiction cannot be made based upon an aberrant behavior that has occurred once—a so-called “one-strike rule.” Though a one-time occurrence of problematic behavior cannot be ignored, it should be considered a “yellow flag,” not a “red flag,” until a thorough reassessment is completed. Additionally, addiction is a psychiatric diagnosis that most clinicians are not qualified to make, so a psychologist or psychiatrist with expertise in addiction medicine should be consulted. Many patients with chronic pain have psychological problems. Those with addictive illness also frequently have co-occurring psychiatric diagnoses, so partnering with mental health professionals should be a regular part of the practice.
Once the treatment team has agreed that there is, in fact, a substance abuse problem (and that opioid analgesics remain an important component of the treatment plan for pain) it is essential to put in place a treatment plan to manage both pain and substance abuse. It is important for clinicians to be open and straightforward with their patients about substance abuse. Patients need to understand that substance abuse will adversely affect the outcome of their treatment. A written opioid treatment agreement can be helpful to structure treatment and lay ground rules. The agreement should be clear and understandable to the patient. It should state the patient’s pain diagnosis, outline his or her treatments and the treatment goals, articulate the responsibilities and limitations of the physician’s practice, and describe the process for assessment, monitoring, and obtaining prescriptions.
Reassessment and monitoring includes comfort level, physical and social functioning, adverse effects from the medication, and evaluation of behaviors that could be considered aberrant. These could be relatively minor, such as missed appointments or unauthorized dose increases, or more serious, such as obtaining opioids from more than one prescriber or using illicit drugs.
Regular monitoring including toxicology screens and pill counts might be necessary for some patients. If a patient continues the problematic behaviors, you may need to change his or her treatment plan to increase the frequency and tightness of surveillance. Following up with family members and other members of the treatment team is crucial in this situation. If a patient is involved in a buprenorphine or methadone maintenance program, regular contact with the staff at the clinic is important as well. Whoever is involved in the treatment of pain should also be involved with the management of the addiction.
Unfortunately, the research base for managing co-existing pain and addictive illness is weak. Nonetheless, there are a growing number of resources available for both initial screening/assessment (e.g., Screener and Opioid Assessment for Patients in Pain(SOAPP®) ) and ongoing management/monitoring (e.g., Current Opioid Misuse Measure(COMM™)). Other resources useful to clinicians include the Addiction Behaviors Checklist (ABC) and the Pain Assessment and Documentation Tool (PADT). These resources will assist the clinicians in providing individualized treatment plans for their patients in the context of multidisciplinary diagnosis and follow up, and systematic monitoring and documentation of progress.
Robert N. Jamison, PhD:
When approaching a challenging patient like this, the first step is to assess the risk for substance abuse. There are three ways to assess risk; they include structured interviews, screening tools, and toxicology screens. The structured interview can best be conducted by a mental health professional or a physician trained in pain and addiction. This clinician will ask about issues associated with pain, the kind of pain the patient is experiencing, pain duration and intensity, past treatments, and other co-morbid medical problems. Next it’s important to take a detailed family and social history. This will help the clinician understand if there are any predisposing problems that run in the family. The psychological history will tell you if the patient has a mood disorder, is seeing a therapist, if he or she has ever been hospitalized or made a suicide attempt. The interview will also consist of a substance abuse history – here is where you’ll look for red flags associated with a substance abuse disorder. For instance, does the patient smoke cigarettes or have a history of using addictive substances? Is there a DUI in the past? Did this person ever attend AA or NA.?
Second, a clinician aims to identify other risk factors through the use of validated screening tools in order to facilitate assessment and planning of patients’ opioid treatment. Various opioid risk management tools can be helpful in determining if a patient is at high risk for misuse of pain medications. Some of these self-report measures include the Screener and Opioid Assessment for Patients in Pain (SOAPP™, SOAPP-R™), the Current Opioid Misuse Measure (COMM™) , the Opioid Risk Tool (ORT), and the Pain Assessment and Documentation Tool (PADT).
Third, toxicology screens are helpful because they monitor compliance and provide objective reports. A tox screen will tell you if your patient is using the drug you prescribed, using illicit drugs, or using another prescription drug that was not prescribed. In order to conduct these tests, clinicians must have a good understanding of how prescription drugs are metabolized, what the labs test for, what type of screens are used, and the sensitivity of these screening techniques.
Ultimately these strategies aim to evaluate a patient’s compliance during treatment. Treating patients with pain and coexisting addiction issues is complicated. Substance abuse treatment professionals struggle because these patients have trouble detoxing due to their pain, the pain specialists often have a difficult time because these patients misuse their pain medication due to their substance abuse and addiction, and the mental health professionals have trouble because these patients claim that their mood disorder is a product of their pain. Therefore, it is imperative that the assessment and treatment of these patients is approached from a multidisciplinary perspective with open communication among the treatment team members.
If a patient has pain, but is at risk for using opioid medications, it is important for the patient and the treatment team to understand that the medications may place the patient at risk and that close monitoring including frequent urine screens, compliance checklists, pill counts, and motivational counseling is indicated. Although patients with pain and addiction can be treated successfully, sometimes it might be best to consider alternative treatments to opioid therapy. As clinicians – and as treatment consumers – all precautions should be taken to avoid serious problems in the future.
Having a team of healthcare professionals, such as physicians, rehabilitation therapists, and mental health specialists available to assist with treatment is best and valuable in properly diagnosing and treating these all too often “unwanted patients”.
Daniel P. Alford, MD, MPH, FACP:
This is a very challenging but not uncommon problem. It is important to start with the understanding that people with past or current addictions can also suffer from chronic pain. As with any patient suffering from chronic pain, you would want to try using non-opioid analgesics first. However, like other chronic pain populations, their chronic pain can be resistant to non-opioids yet responsive to opioids. In my primary care practice, I have treated many patients with addiction and chronic pain. Treating both the addiction and the chronic pain concurrently is crucial. Unfortunately, most primary care settings cannot provide both forms of treatment. In my practice, I tell patients that for me to treat their pain with opioids they must also be engaged in addiction treatment such as attending substance abuse counseling or 12 step meetings. I require them to bring me or my nurse documentation verifying their active engagement in addiction treatment at each primary care visit and before any medication refills. I also require a release to allow joint communication between me and their substance abuse treatment providers. Ideally I will call the substance abuse treatment provider during the primary care visit to reinforce to the patient that I take their addiction treatment seriously. This arrangement is best discussed before beginning opioid treatment. When these discussions occur after treatment as been initiated, it likely becomes confrontational, that is, the patient feels that he/she is being accused of something.
I think that a written patient controlled substances agreement is a clinically useful tool, even though its utility has never been validated. Agreements outline both your responsibilities as the health care provider as well as the patient’s responsibilities. This provides important structure to your treatment. Patients know when and how they are to obtain medication refills as well as how they will monitored such as urine drug tests and pill counts. Urine drug testing confirms that my patient is taking the opioids I prescribed as well as not taking other controlled or illicit substances not prescribed. I ideally these drug tests should be random and supervised but this is generally not possible in primary care settings. In my practice patients know that they will need to leave a urine specimen at each visit. Because by definition, addiction is associated with loss of control and compulsive use, patients who are addicted will eventually have an abnormal drug test or show some other aberrant drug taking behavior. I call this the “primary care advantage” that is, as opposed to urgent care or specialty settings, because we have a long-term relationship with these patients, we will pick up on aberrant behaviors over time. Often times I will ask my patients to tell me what I will find in their urine, that is, will I find any surprises. Sometimes they even tell me about substances that I don’t test for! I also do occasional pill counts and ask my patients to bring in their pills for every visit. I do this to monitor overuse and diversion (selling medication). Although this is tedious, it provides good information. I use a pill tray to count the pills. I will often give patients a prescription for a one month supply of medication and ask them to return in 3 weeks thus having to count only a weeks supply of medication rather than 3 to 4 weeks of pills. If a patient forgets to bring in their pills, I will ask him or her to come in the following day and have my nurse conduct the pill count.
A separate and special group is patients with chronic pain who are on methadone maintenance treatment. These patients are often on high dose methadone taken once per day. Because the analgesic properties of methadone only last 6 to 8 hours, any pain relief obtained will not last all day. In order to determine if the patients pain is opioid responsive I ask them if they get pain relief 30 to 60 minutes after their methadone dose and how long that relief lasts. If they get pain relief but it only last for 6 hours, then I believe their chronic pain is opioid responsive and the patient might benefit from additional opioids later in the day. If they get pain relief all day, I believe their pain is likely opioid withdrawal mediated pain that does not require additional opioids. If they get no relief from the methadone dose, I believe their pain is opioid resistant and would not benefit from opioid analgesics. If you prescribe opioid analgesics to a patient on methadone maintenance treatment it is important to communicate with the methadone program since your prescribed opioids may interfere with their urine drug test monitoring. Lastly it is important to remember that patients on methadone maintenance are often on methadone doses that are greater than 80 mg which creates “narcotic blockade”, that is, any potential euphoria from prescribed opioids is blocked and thus decreases the risk of opioid analgesic overuse for purposes of feeling high.
I don’t fault primary care doctors who don’t feel comfortable taking on such a challenging population. Both addiction and pain management education are limited in most medical schools and residency training. In addition, many physicians feel uncomfortable with the confrontational interactions that occur with setting limits or stopping opioid therapy. My staff knows that we do not tolerate unacceptable behavior. Unfortunately most specialty pain clinics don’t want to be responsible for long term opioid therapy and are often uncomfortable managing patients with addictions, so this is a job is often left to primary care physicians.
Lastly physicians need an exit strategy if the opioids are not improving pain or functional outcomes over time. It is okay to taper a patient off opioid analgesics if they are not benefiting the patient or are possibly causing harm. With careful patient selection, use of patient agreements and careful monitoring strategies I have had success in treating patients with concurrent addiction and chronic pain in my primary care practice.