SAN DIEGO – Pain patients with a history of substance abuse who are otherwise appropriate candidates for opioid medications should receive the same consideration from their physicians as patients without the disease of addiction, Dr. Howard A. Heit said the annual meeting of the American Academy of Pain Medicine.
“Patients should have their pain appropriately treated. But there are barriers to pain management, including the fear of addiction or misuse of controlled substances–especially opioids–in the treatment of this population,” he said. “These patients should be treated with dignity using medications approved by the Food and Drug Administration consistent with state and federal regulations, and we should never withhold these valuable medicines for the fear of the disease of addiction.”
Stress is a major cause of substance abuse relapse, and pain is probably the most severe of all life stressors, he said. “Undertreatment or nontreatment of pain can predispose those in recovery to relapse, and it stands to reason that if a patient is in recovery and the pain is undertreated, that patient may turn to the street for diverted prescription medications or listed meds, or he'll use legal drugs such as alcohol to anesthetize himself against the pain,” said Dr. Heit, a pain specialist in Fairfax, Va.
The disease of addiction, he said, strikes between 8% and 10% of the general population, but there are no good data on the incidence of addiction in chronic pain patients, though he believes it exceeds 10%. In addition, the prevalence of chronic pain appears to be higher among those who are addicted to opiates and alcohol.
To minimize situations in which opioids become the problem rather than the solution, Dr. Heit uses a patient assessment model that includes a possible history of aberrant behavior and the application of careful and reasonable limits based on mutual trust and honesty in the doctor-patient relationship.
“When a new patient comes into my office, I say, 'Please tell me everything that has happened in your life that is pertinent in relation to sexual and physical abuse, depression, addiction. … It will not be held against you, but I need that information in order to formulate a valid treatment program.' Then, using universal precautions, it's possible to treat chronic pain patients with histories of substance abuse with opioid agonist therapy,” he said.
The pain therapy process involves 10 key steps:
1. Make a diagnosis with an appropriate differential that elicits any chronic condition that the patient is dealing with.
2. Make a psychological assessment.
3. Obtain informed consent.
4. Make a treatment agreement placing responsibility on both parties.
5. Have a pre- and postintervention assessment of pain level and functioning.
6. Have an appropriate trial of opioid therapy (opioids might not be needed, indicated, or efficacious in a given patient).
7. Periodically reassess pain score and level of function.
8. Regularly assess the “four A's” of pain medicine: analgesia, activity, adverse reactions, aberrant behavior.
9. Periodically review pain diagnosis and comorbid conditions, including addictive disorders.
10. Create and maintain documentation.
This last step is no less important than the first nine, Dr. Heit stressed. “If you don't put it in your chart, legally it's a figment of your imagination and you may be open to investigation. I'm sure a patient of mine has diverted a prescription without my knowledge, but the key is, Did I do my due diligence after getting the information by changing the treatment plan to prevent that from happening again?” he said, adding that firing the wayward patient would be the wrong thing to do because he or she would then circulate to another doctor or another community. Instead, urged Dr. Heit, increase communication with the patient to solve the problem.
'Undertreatmentor nontreatmentof pain can predispose those in recovery to relapse.' DR. HEIT