Learn how health care providers are using new tools to help patients manage chronic pain while limiting long-term health risks and without misusing addicting medications. Click here to view the full article featured in SAMHSA News.
Managing Chronic Pain & Medication Misuse
David Loffert was a success. He was two years into a Ph.D. program. He ran his own consulting firm. He’d published papers and developed a patent. He had just one problem: migraine headaches.
He consulted a doctor, who gave him pills for pain. He also gave him pills to sleep, pills to stay awake, and pills to manage anxiety. In just eight months, the doctor prescribed almost 7,000 pills to him, all of which were “controlled substances”– medications with abuse liabilities. These medications require that a practitioner have a Drug Enforcement Act (DEA) registration to prescribe them. “I knew about addiction, but I thought I was too intelligent to become addicted,” said Mr. Loffert. He was wrong. While the doctor lost his medical license, Mr. Loffert lost almost a decade of his life.
After being arrested for forging a prescription, he spent nine years “doctor shopping” for pills, losing jobs, and suffering overdoses and suicide attempts. After nine years, he made it through rehab and he has been sober since 2007.
Mr. Loffert’s trajectory is a common one. According to SAMHSA’s Treatment Improvement Protocol (TIP) 54, “Managing Chronic Pain in Adults with or in Recovery from Substance Use Disorders,” almost one third of chronic pain patients may have substance use disorders.
Treating pain in patients who have substance use disorders or are in recovery can be challenging, said Elinore F. McCance-Katz, M.D., Ph.D., SAMHSA’s Chief Medical Officer.
Opioids used for pain relief can prompt a relapse, for example. They can also interact with both illegal drugs and medications used to treat opioid addiction. Dangerous interactions can also occur with medications used to treat mental illnesses such as depression, which is common among pain patients.
That doesn’t mean pain patients with behavioral health conditions should never use opioid pain medications, according to Dr. McCance-Katz. “It does mean that they will require extra care, support, and monitoring to help prevent relapse. It also means that opioids should not be a first consideration for the treatment of pain in those with substance use disorders. There are many alternatives to opioids for pain relief and these should be considered first for patients with substance use disorders who are at risk for relapse,” she said.
When patients with chronic pain are evaluated, she said, health care providers should ask about the pain and underlying medical conditions that are contributing to the pain, and should conduct any needed examinations and testing to determine a diagnosis, previous response to treatment, history of substance use and mental health concerns, and family history of substance use disorders. Non-opioid pain treatments or other services, such as physical therapy or acupuncture, are better options for those who may need ongoing treatment for pain, particularly since there is little evidence for effectiveness of opioids in the long-term treatment of chronic pain. If other treatments have been unsuccessful, a trial of an opioid pain medication may be needed. Providers must closely monitor anyone prescribed opioid therapies for response to the medication and pay attention to signs of misuse. Patients must also be monitored for other drug use or dangerous medication interactions. For those with a history of substance use disorder, it is important to have a monitoring plan in place before starting opioid therapy.
Unfortunately, said Dr. McCance-Katz, most health care providers don’t get the training they need to care for patients facing both pain and substance use disorders. “In medical school, there’s not a lot of time devoted to either the recognition and treatment of substance use disorders or the appropriate management of pain,” she said, adding that dentists, pharmacists, and other health care professionals also lack training.
That’s why SAMHSA has developed resources, including a manual, training, and clinical tools, to help clinicians and others manage this high-risk patient population.