ATLANTA – A biopsychosocial approach may offer the most effective way to manage chronic pain in patients with a comorbid mood or substance use disorder without compromising recovery processes, Martin D. Cheatle, Ph.D., said at the Southeastern conference on alcohol and drug addiction.
The key is treating the whole patient, and treating the disorders concurrently rather than sequentially. A patient who goes through detox but goes home in pain is at high risk for returning to narcotics abuse, and the effects of depression and anxiety on pain and treatment outcomes, and vice versa, also have to be considered, said Dr. Cheatle of the Behavioral Medicine Center, Reading (Pa.) Hospital and Medical Center.
The biopsychosocial model involves the use of evidence-based medication management along with cognitive-behavioral therapy and an exercise/physical therapy program with a goal of empowering the patient to take charge of the pain. Relaxation and thought focus techniques, and development of adaptive resources such as coping skills, strength, and stamina can help in providing that empowerment.
Also key to success is community support via a network of specially trained primary care doctors and specialists working together in the patient's interest.
Programs incorporating this approach have been shown to improve treatment outcomes, promote return to gainful employment, reduce pain, and increase functionality. For example, a study of 123 patients at the Behavioral Medicine Center showed that from admission to 1.5 years following completion of a 3-week residential behaviorally based pain program including rehabilitation and group cognitive-behavioral therapy, the use of opioids, benzodiazepines, nonsteroidal anti-inflammatories, and antidepressants dropped dramatically, and the use of over-the-counter treatments for pain increased.
The frequency of walking and cycling significantly increased, and depression scores dramatically decreased. Pain scores were reduced by half, Dr. Cheatle said.
Further, employment increased from 5% to 74%, and health care utilization dropped by 78%.
It is important to note that the population which completed the treatment program was a motivated population–nonmotivated patients dropped out early–thus the findings are somewhat skewed, but the approach does appear to be of benefit, he said.
As for the use of opioids for the treatment of pain in patients with a substance use disorder or substance abuse history, these drugs aren't necessarily contraindicated. Data are lacking, but noncompliance with prescription nonopioid drugs, insistence on rapid release formulations of pain medication, complaints of pain at varying body sites (initial treatment for back pain and a later call with tooth pain), and numerous phone calls or clinic/emergency department visits requesting pain medication are among the signs of an increased risk for substance abuse.
History of substance abuse, smoking, or psychiatric disorders also should be considered when deciding the best approach for treating pain.
A patient who goes through detox but goes home in pain is at high risk for returning to narcotics abuse. DR. CHEATLE