Management of Chronic Pain in Context of a Substance Use

Disorder
 Nothing to disclose
No conflicts of interest
At the end of this presentation the participant will be
able to:
 Understand the relationship between Chronic Pain and Opioid
Use Disorder
 Know strategies for discussing realistic pharmacologic
treatment goals in this patient population
 Identify non-pharmacological options
 Identify lower-risk pain medications for use in this patient
population
45 year old female presents with chronic pain previously
diagnosed as fibromyalgia and chronic pelvic pain. Pain
from both sources has been present for more than 10
years, is described as present daily, very distressing to
her and worsened by stress. She describes a history of
using opioid analgesics, initially obtained from
acquaintances, to manage pain. Then, 4 years ago, she
began to smoke heroin as a management strategy. She
transitioned to intravenous heroin use 3 years ago.
 Patient has now been free of illicit opioid use for 6
months, denies cravings, and takes
Buprenorphine/Naloxone every morning. She reports that
buprenorphine “is helping to keep me away from heroin”
but is not helping with pain and she is seeking other
options.
 She does report depression and anxiety since childhood
that has never been treated, and is problematic daily. She
denies suicidal thinking.
 Denies use of alcohol, denies use of cannabis or other
substances.
▪ PMH: OUD, chronic pain, G2P2, two suicide attempts by
overdose in her early 20s. Never hospitalized. No
surgeries.
▪ Social History:
▪ lives with partner of 5 years
▪ feels safe in the home; denies domestic violence
▪ arrests for drug possession years ago
▪ hx of homelessness and reports sexual and physical
assaults during that time.
▪ clinic behaviorist spoke with patient and identified 6
Adverse Childhood Experiences.
▪ Physical Exam: unremarkable
▪ BP: 130/85, HR: 95, Ht: 65” Weight 180 lbs, BMI 30.0
▪ Medications:
▪ buprenorphine/naloxone 16/4mg SL QAM
▪ gabapentin 100mg TID
▪ Labs: UDS + for buprenorphine & THC only
▪ Imaging: none
▪ CSA is on file PDMP is appropriate
▪ GAD-7=15 PHQ-9=18

Review of approach to this case to follow

 Physical Pain
Emotional/Psychological Pain
Social Pain
+ Existential/Spiritual Pain

Total Pain
Image from:
Mehta A, Chan L. Understanding of the
concept of “Total Pain”.
J Hosp Palliat Nurs. 2008;10(1):26–32.
▪ Contributors can include ACEs, adult trauma, historical trauma
and current psychosocial stressors. 1
▪ Can be a driving force for Chronic Pain and Opioid Use
Disorder.
▪ Strive to approach patient from a Trauma-Informed
perspective.2
▪ Patients may unwittingly (or knowingly) seek opioids as a
remedy for all components of total pain.
1. Hassan A, The effect of PTSD on risk of developing prescription opioid use
disorder: Results from the National Epidemiologic Survey on Alcohol and Related
Conditions III. Drug Alcohol Depend. 2017 Oct 1;179: 260-266

2. Ravi A, et al. Providing Trauma-Informed Care, AAFP Journal.

May 15,2017, 95(10) 655-657
▪ Bi-directional relationship
▪ But pain often comes first
▪ N=5307 adults with Opioid Use Disorders
▪ 35.6% = no pain
▪ 9.7% OUD first, then pain
▪ 14.9% OUD and pain at presentation
▪ 39.8% Pain first, then OUD

Hser Y, et al. Chronic pain among patients with opioid

use disorder: Results from electronic health records data.
Journal of Substance Abuse Treatment. June 2017;
77(26-30)
▪ Some physiologic dependence is expected in patients
exposed to opioids for more than a few days
▪ Risk of developing OUD or aberrant drug related
behaviors after chronic opioid use is greater than 10%
▪ Patients at greater risk for overdose and developing
OUD:
▪ Patients with SUD history
▪ Patients with depression or other psychiatric conditions
▪ Patients with a history of overdose
▪ Patients taking >50 MME per day
Salsitz E. Chronic Pain, Chronic Opioid Addiction: A Complex
Nexus. Journal of Medical Toxicology. 2016: 12; 54-57.
 Vowles et al. [2015]: meta-analysis; 38 studies included
◦ Average rates of problematic use 21-29%
◦ Average rates of addiction 8-12%
 Minozzi et el. [2013]:
◦ median incidence of opioid dependence (DSM-IV) 0.5% (range
0%–24%)
◦ median prevalence was 4.5% (range 0%–32%)
 CDC [2016]:
◦ rates of opioid abuse or dependence diagnoses (DSM-IV) were
0.7% with a low daily dose of opioids
◦ 6.1% with a higher daily dose
 17 studies of 2,466 chronic pain patients found rate of 11.5%
for aberrant behavior.
 For patients without SUD, rate was 0.59%.
 5 studies (15,542 patients) by urine toxicology: 20.4% had no
Rx opioid or an opioid not prescribed.
 5 studies (1,965 patients): 14.5% had illicit drugs.
 About 20% of primary care population on long term
opioid treatment
 High pain interference
 Aberrant behaviors
 High opioid doses
 Psychiatric co-morbidity
 Unwilling/unable to taper opioids despite functional
deterioration
 OUD like behaviors emerge with taper/cessation
 [Manhapra, Becker 2018]
Pain catastrophizing: the tendency to magnify the
threat value of pain stimulus and to feel helpless in the
context of pain. 1

Pain catastrophizing and associated disability are

associated with greater tendency for substance use
disorder. 2
1. Van Damme S, et al. A confirmatory factor analysis of the Pain
Catastrophizing Scale: invariant factor structure across clinical and non-
clinical populations. International Association for the Study of Pain. 96 (3):
319-324.

2. Tetsunga T, et al. Drug dependence in patients with chronic pain.

Medicine: October 2018: 97(40)
Associated with an increase in all-cause mortality
(hazard ratio of 1.64):
Long-acting opioids- Morphine SR, Oxycodone CR,
Transdermal Fentanyl, Methadone

Compared with non-opioid treatments:

Gabapentin, Pregabalin, Carbamazepine,
Amitriptyline, Doxepin, Nortriptyline

Wayne R, et al. Prescription of Long-Acting Opioids and

Mortality in Patients with Chronic Noncancer Pain JAMA 2016;
315(22), 2415-2423
 Set Realistic Goals

▪ Collaborate with patient to determine functional goals

▪ Re-iterate that pain will not likely be completely
eliminated
▪ Discuss that successful management usually involves
more than one treatment modality – there’s no panacea
▪ Collaborative discussion: what would occur if there is an
opioid or alcohol relapse?
▪ Low-impact aerobic exercise for fibromyalgia
▪ Exercise for weight loss, physical therapy and patient
education for Osteoarthritis
▪ Exercise, cognitive behavioral therapy (CBT), TENS unit
interdisciplinary rehab for Low Back Pain
▪ CBT, relaxation, exercise, biofeedback for Migraines
▪ Psychotherapy for PTSD

Chang KL, et al. Chronic pain management: non-

pharmacological therapies for chronic pain. FP Essentials
May 2015; 432:21-26.
 Non-Pharmacologic Treatments Endorsed by American College of
Physicians

For patients with chronic low back pain, clinicians and

patients should initially select non-pharmacologic
treatments:
• Exercise • Relaxation (progressive)
• Multidisciplinary rehab • Biofeedback
• Acupuncture • Tai chi
• Yoga
• Mindfulness-Based
Stress Reduction • Spinal manipulation
• Laser Therapy
• Traditional healing
modalities
 What is Self-Management?

The individual’s ability to manage the symptoms,

treatment, physical and social consequences and
lifestyle changes inherent in living with a chronic
condition
The active participation of individuals in achieving their
own best health & wellness
Involves gaining confidence, knowledge and skills to
manage physical, social and emotional aspects of life, in
partnership with health care teams and community
supports
Pain Self-management Toolbox

Physical
Problem-Solving
Activity/Exercise
Managing Fatigue Using your Mind
Pacing & Planning Healthy Eating
Relaxation & Better
Communication
Breathing
Understanding
Medications
Emotions
Working with Health
Finding Resources
Professionals
Psychological Therapies for Management of
Chronic Pain in Adults
Absence of evidence for behavioral therapy, except for pain
immediately following treatment
CBT = small, positive effects on pain, disability, and mood
CBT and behavioral therapies effective at improving mood
outcomes, and benefits may be maintained at 6 months

Cochrane Review, 2009

Mindfulness-Based Stress Reduction (MBSR)
MBSR attempts to teach
participants how to harness
their own abilities to
diminish stress and pain, and
improve overall physical and
mental health.
MBSR was developed by Jon
Kabat-Zinn in 1979, and is
used in hundreds of schools,
hospitals and other
institutional facilities
worldwide.
 Acceptance Based Interventions
Mindfulness Based Cognitive Therapy [MBCT]
Acceptance and Commitment Therapy [ACT]
Targets ineffective control strategies and experiential avoidance
[such as kinesiophobia]
Learn to stay in contact with unpleasant emotions, thoughts, and
sensations
Value clarification and committing to those values in daily life
How to use risk assessment tools:
▪ Should not be used to deprive patients of pain
management or opioid therapy, but to identify those who
are at risk for addiction
▪ Should be used to help guide us to determine the
frequency and intensity of monitoring during the course of
treatment
▪ Should be used to develop the most efficacious and safest
treatment strategy
▪ Use only with informed consent and with advisement that
refusal may, for safety reasons, alter the treatment plan
▪ Ask about alcohol and drug use.
▪ Single screening questions can be used: “How many times in
the past year have you used an illegal drug or used a
prescription medication for non-medical reasons?” An answer
of one or more is considered positive.
▪ Other validated tests include the Drug Abuse Screening Test
(DAST), the Alcohol Use Disorders Identification Test (AUDIT),
and the Screener and Opioid Assessment for Patients with Pain
Version 1 (SOAPP-R)
▪ Remember-
▪ The psychosocial history is the most important part of exam
▪ Screening tests do not take the place of clinician/patient
interactions
 “I’m worried about your safety.” People with opioid use
disorder are at higher risk of dying from a drug overdose. Also,
dependence on opioids can affect your mood, your ability to work
and function, and your relationships.
 “I’m worried about the safety of other people around
you.” If you are driving under the influence of alcohol and/or
drugs, you put other peoples’ lives at risk. You may not be able to
safely care for children or others who depend on you.
 “We are going to look for safer ways to manage you pain.”
As we discussed before, your safety is my paramount concern.
 “Let’s find you some additional treatment options.” Opioid
use disorder can be treated safely and effectively. Are you willing
to consider treatment?
 Watch for “red flags” (higher risk predictors):
▪ Patient sees more than one provider (check PDMP)
▪ Hx. of diverting from family members
▪ Hx. of obtaining controlled meds from non-medical sources
▪ Concurrent use of other substances (check UDS)
▪ Presence of substance-related deterioration @ work or
socially
▪ Frequent reporting of lost or stolen prescriptions
▪ Any Hx. of Rx forgery or Rx alteration

Solis K, “Ethical, Legal and Professional Challenges Posed by

“Controlled Medication Seekers” to Healthcare Providers, Part 2,
American Journal of Clinical Medicine, Spring 2010 7(2)
 Also consider the following “yellow flags”
▪ Stated allergy to or intolerance of all other classes of
relevant medication
▪ Early refill requests / unsanctioned dose escalation
▪ Patient has little interest in Dx. or alternative Tx.
▪ Patient fails to keep appts. with other providers who are
necessary for referral or continuity of care
▪ History of abuse of alcohol or other substances with
respiratory depressant effects

Solis K, “Ethical, Legal and Professional Challenges Posed by

“Controlled Medication Seekers” to Healthcare Providers, Part
2, American Journal of Clinical Medicine, Spring 2010 7(2)
▪ Avoid opioids + benzodiazepines (lorazepam, diazepam,
alprazolam, clonazepam, chlordiazepoxide, oxazepam)
whenever possible.
▪ Avoid opioids + barbiturates (Fioricet, Primidone) whenever
possible.
▪ Use caution with muscle relaxants + opioids
▪ Avoid Carisoprodol (Soma) + other CNS depressants
▪ If concurrent prescribing must be done, always use lowest
possible doses of both medications.

https://www.cdc.gov/drugoverdose/prescribing/guidelin
e.html
Gudieline #11
▪ If patient has a history of OUD, expect the emergence of
craving and withdrawal.
▪ Taper opioid slowly to reduce withdrawal symptoms, which
will reduce likelihood of seeking opioids from other sources
▪ Reduce dose by 10% - 25% per month
▪ Initiate appropriate non-opioid analgesics before or during
taper
▪ If craving or withdrawal becomes apparent, consider
Medications for opioid Use Disorder [MOUD]
Kral LA. Opioid tapering: Safely discontinuing opioid analgesics.
http://paincommunity.org/blog/wp-
content/uploads/Safely_Tapering_Opioids.pdf (Accessed on April 28, 2016).
 Appropriate Not Appropriate
Do the benefits of this Is the patient good or
treatment outweigh any bad?
side effects and risks of Does the patient deserve
harm to the patient or pain meds?
society?
Should I trust the patient?
Should he/she be
punished or rewarded?

Adapted from Alford

▪ Consider the use of Buprenorphine (mu receptor partial
agonist) for both Opioid Use Disorder and Chronic Pain
▪ Sublingual, subcutaneous (Sublocade) or transdermal
(Butrans) formulations
▪ It has a better safety profile than other opioids
▪ Anti-craving effect can last for 24 hours.
▪ Analgesic effect will usually last 6-8 hours
▪ So split dose to TID or QID for optimize analgesia
▪ Must dissolve and absorb sublingually - buprenorphine
(tablet or film) has a lower bioavailability when swallowed
and absorbed from the GI tract.

https://www.samhsa.gov/medication-assisted-
treatment/treatment/buprenorphine
▪ If Buprenorphine is not successful at preventing
relapse, consider referral for Methadone clinic
treatment (better evidence for treatment retention)
▪ Methadone is effective for both OUD treatment and
Chronic Pain
▪ If patient is not taking an opioid and is worried about
relapse, consider long-acting naltrexone (Vivitrol
monthly IM).
Hser Y. et al. Treatment Retention among Patients
Randomized to Buprenorphine/Naloxone Compared to
Methadone in a Multi-site Trial. Addiction.
Jan 2014; 109 (1): 79-87.
▪ Concurrent alcohol and opioid use increases risk for
respiratory depression and accidental overdose
▪ Treatments to consider for AUD:
▪ Naltrexone
▪ FDA approved for AUD
▪ cannot be used if patient is taking an opiate
▪ also a treatment for fibromyalgia
▪ Acamprosate - FDA approved for AUD
▪ Disulfram - FDA approved for AUD
▪ Topiramate - off label treatment for AUD
- FDA-approved treatment for migraines
Witkiewitz K, Vowles K. Alcohol and Opioid Use,
Co-Use, and Chronic Pain in the Context of Opioid Epidemic: A Critical
Review. Alcoholism Clinical and Experimental Research. Jan 2018.
▪ Clear, up-front discussion of expectations
▪ Controlled Substance Agreement at time of first Rx
▪ PDMP checks at time of each Opioid Rx
▪ UDS regularly (screening for diversion and other
substance co-administration)
▪ Pill Counts (inform patient up-front that this will
happen periodically, this will help maintain
treatment alliance)
Clark, T., Eadie, J., Kreiner, P., & Strickler, G. (2012). Prescription drug
monitoring programs: An assessment of the evidence for best
practices. Waltham, MA: Brandeis University, Heller School for Social
Policy and Management
▪ Naloxone (Narcan) Rx to all patients who are
treated with opioids
▪ Encourage or require substance counseling or
engagement in 12-step program
▪ Counsel on the importance of keeping opioid
medications (including Buprenorphine) locked
up for the safety of others in the household!
▪ A 45 year-old female with pain from multiple
etiologies and history of OUD.
▪ Taking medium-dose (16mg), once daily
Buprenorphine
▪ Also taking low-dose Gabapentin.
Non-pharmacological:
Referral for psychotherapy if possible (CBT, ACT, biofeedback)
Encourage or require 12-step or substance use counseling
Encourage low-impact exercise

Pharmacological:
Optimize Gabapentin dose
Consider adding SNRI or TCA
Split Buprenorphine dose TID or QID to address pain

Safety Measures:
Yearly controlled substance agreement
Routine PDMP checks
Regular UDS (point-of-care UTOX)
Consider pill counts
Prescribe naloxone