Chronic Pain

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Chronic pain, as has been agreed arbitrarily, is pain which persists for more than 3 months or which persists past the time of healing (Merskey and Bogduk 1994). After severe trauma, major surgery, or painful diseases such as pancreatitis, severe acute pain can persist more than 10-14 days and become essentially chronic (Bonica 1985). Chronic pain progressively leads to limitation of physical, mental, and social activities, and it is not uncommon for it to cause anger, depression, and family and socioeconomic perturbation (Siddall and Cousins 1998). In chronic pain, sympathoadrenal responses are not apparent and are seemingly habituated or exhausted, and vegetative responses such as irritability, loss of appetite, sleep disruption, depression, or attenuation of motor activity emerge. Patients may be sad, subdued, or sleepy secondary to excessive consumption of medications. Such affect may mask the presence of pain. Psychological disturbances may result from severe refractory chronic pain. Such various components of chronic pain syndromes must be recognized and addressed when treating this type ofpain.

About one-third of the American population experiences chronic pain. Billions of dollars are lost yearly due to health care expenses and missed workdays for chronic pain. Addictive illness has been rapidly evolving in the social, medical, and legal/regulatory environment. Like that of acute pain, there is a consensus that patients involved with substance abuse are generally undertreated by clinicians for their chronic pain due to biases, misconceptions, and systems issues.

The goal of management in chronic pain is to increase function and decrease pain while monitoring for side effects of the prescribed medication.

A history of substance abuse has been previously considered a contraindication to opioid therapy for chronic pain. It appears that individuals with a prior history of recent substance abuse are more likely to have abuse recurrence than individuals with a distant polysub-stance abuse or isolated alcohol abuse. Currently, opioid therapy in patients with a recent history of substance abuse is controversial. Existing studies report mixed results. Preventing or detecting addiction recurrence is key.

Although patients with chronic pain may be at increased risk for addiction, clinical research shows that the general population has demonstrated similar addiction rates. Indeed, it has been noted that addiction does not occur in the majority of chronic pain patients who are properly evaluated and treated with opioids. Individuals receiving opioids, whether it is for appropriate reasons or for the disease of addiction, are expected to experience physical dependence and tolerance when taking opioids regularly (Nestler et al. 2001). One must always ask if the patient is being undertreated for the pain syndrome. Constant reevaluation of pain treatment is key to prevent undertreatment. A variety of assessment and treatment approaches have been formulated to make managing pain abusers more effective.

There has been an unequivocal support for the notion that pain medication should not be withheld from pain patients, even in the presence of addiction. Individuals with substance abuse or dependence can be effectively treated for pain provided their substance abuse disorder is addressed immediately and treatment of substance dependence be included in the management plan (Passik and Kirsh 2005, Weaver and Schnoll 2002, Coluzzi and Pappagallo 2005, Savage 2002, Compton and Athanasos 2003). It is recommended that monitoring should be increased, more frequent visits initiated, and the amount of medication available at one time limited. To detect the presence of illicit drugs or substances not prescribed for pain management and to verify that the patient is taking the prescribed opioid instead of selling it, random urine drug tests are utilized. Certified substance abuse treatment provider should be consulted, appropriate medication-assisted treatment initiated, and participation in 12-step programs encouraged. With the patient's permission, it is prudent to consult and coordinate with the designated substance abuse treatment provider on an ongoing basis. When warranted, opioid treatment must be discontinued (e.g., prescription forgery, opioid diversion, continued inappropriate opioid use). Providing opioid analgesia to patients who are psychologically dependent does not necessarily worsen their dependence, nor will withholding opioids increase their likelihood of recovery; however, unrelieved pain can trigger relapse (Compton and Athanasos 2003, Alford 2006, Gourlay 2005). Below are some of the recommended strategies to have higher chances of successful outcome when dealing with this patient population.

How to talk to patients with pain about substance use problems (Weaver and Schnoll 2002):

1. Be nonjudgmental - patients are more likely to be forthcoming.

2. Avoid yes/no questions that do not allow patients to express their feelings.

3. Start with sweeping questions (e.g., "How helpful have your medications been for you?") rather than begin with questions about medication misuse.

4. Listen to what patients say about how and why they take their medications.

5. Use existing tools for screening.

6. Ask questions about warning signs (e.g., "Have you ever taken your pain medication for other reasons?").

7. Inquire about their willingness to try alternative, nonopioid forms of therapy.

In Table 31.2, guidelines for prescribing drug with abuse liability in pain patients with history of addiction are outlined. Physicians should set clear rules and expectations for them and the patient and have both sign an agreement. Based on current evidence, physicians assume that patients adhering to controlled substance agreements and without obvious dependency behavior do not abuse either illicit or licit drugs. The dose of the medication should be set at the appropriate level to treat the condition and titrate as necessary. Using feedback from patient to set dose is often helpful. To prevent undertreatment of pain or treatment gaps, physician should give enough medication plus rescue doses. Patients should be asked to bring in all original medication bottles with or without medication including the date they are filled, the prescribing physician and the dispensing pharmacy, the number of pills dispensed, and the number of remaining pills. Physicians should monitor for lost or stolen prescriptions and obtain random urine screens, as well as, obtaining knowledge of

Table 31.2 Guidelines for prescribing drug with abuse liability in pain patients with history of addiction.

1. Set clear rules and expectations for you and the patient, have both sign an agreement

2. Set the dose of the medication at the appropriate level to treat the condition, and titrate as necessary

3. Use feedback from patient to set dose

4. Give enough medication plus rescue doses

5. Ask patient to bring in all original medication bottles with or without medication: date filled, pharmacy, prescribing physician, number of pills dispensed, and number of remaining pills

6. Monitor for lost or stolen prescriptions

7. Obtain random urine screens

8. Know the drugs for which the laboratory screens

9. Use adjunctive medications as necessary

10. Document, document, document

11. See the patient as frequently as needed

12. Work with significant others or closed family members

13. Know how to withdraw the patient from the medication

14. Know the pharmacology, duration of action, and parenteral to oral conversion ratio of the drugs being prescribed

15. Bring patient in for unscheduled visits

16. Obtain release to contact other health care providers

17. Limit p.r.n. medications since this promotes drug-seeking behavior

18. Adequately treat the condition and trust the patient to avoid problems of pseudoaddiction

Adapted from: Schnoll and Weaver (2003).

the drugs for which the laboratory screens. Adjunctive medications are often prudent to use as necessary to avoid unnecessary escalation of opiate doses. Documentation is key to prevent confusion and overprescription. Good practice dictates seeing the patient as frequently as needed, working with significant others or any closed family member. Knowing how to withdraw the patient from the medication is important, as well as, bringing patient in for unscheduled visits. PRN medications need to be limited to prevent drug-seeking behavior. And last, to avoid problems of pseudoaddiction, trust the patient and adequately treat the condition.

No known modality is appropriate as a single intervention for all types of pain. Multimodality, multidisciplinary approaches appear to hold the most promise. Constant reassessment and adjustment to the treatment plan are essential. Opioid analgesics may be an integral part of the treatment plan for many patients, but long-term efficacy, i.e., improved analgesia, improved functional levels and quality of life, and minimized side effects is essential. Few pain specialists have cross-training in managing addictive illness and, similarly, few addiction specialists have cross-training in pain management. Developing collaborative treatment and monitoring plans between the specialties is essential to successful outcomes. The medical and social complexity of treating pain patients with addictive behavior certainly calls for a systematic, structured, and multidisciplinary approach to achieve better outcome, but to date such strategies, however, have not been tested through research.

Considerable experience exists with the use of non-opiate pain medications for chronic pain. There has been widespread success with the use of anti-inflammatory medications, antidepressants, and antiepileptics.

Opioids have long been used to treat moderate to severe chronic pain. When opioids are used to treat moderate to severe pain, physical dependence and tolerance occur, but the disease of addiction occurs only in some patients. The clinician can use either a short-acting opioid such as morphine, hydromorphone, or oxycodone; a short-acting opioid in a controlled-release delivery system such as Oxycontin® (Purdue Pharma, Cranberry, NJ) or Duragesic® TTS patch (Ortho-McNeil-Janssen, Titusville, NJ); or a long-acting opioid such as methadone or levorphanol. While physical dependence is inevitable with opioid therapy, clinicians should work to minimize tolerance and abuse. By definition, an increased opioid requirement is considered "tolerance" only when all other conditions are stable, i.e., there is no disease progression, new disease, excessive physical activity that exacerbates pain, skipped analgesic doses, drug interaction, etc., that would lower analgesic effectiveness. Evidence suggests that the use of a long-acting opioid medication such as methadone and controlled-release opioids are less likely to induce tolerance and abuse than that of a short-acting opioid (Garrido and Troconiz 1999, Brookoff 1993). The short-acting opioids usually should be reserved for breakthrough or incidental pain. Dose increase and opioid rotation are rational responses to inadequate pain relief, but again, reasons for a diminution in analgesic effect must be investigated to rule out other reasons, i.e., progression of the disease or psychosocial factors that may aggravate the pain experience. For most mu-receptor agonists, there is no pharmacological ceiling dose - the dose beyond which no additional analgesic effect will be achieved in an opioid-responsive condition (Chang et al. 2007, Rich 2007).

During pregnancy, the clinician has several options recommended for managing opioid abuse. One is methadone maintenance, which has been the standard of care since the early 1970s. Another is the use of buprenorphine and naltrexone. Although not yet established, buprenorphine and naltrexone appear equally safe. While limited clinical trials exist, opioid detoxification preferably during the second trimester is considered another option. When used for maintenance in pregnancy, the dose of methadone should be adjusted according to their current withdrawal signs and symptoms caused by methadone's increased metabolism (via the effect of increased progesterone on liver cytochrome P450 enzymes) and decreased plasma protein binding (Wolff et al. 2005). Patients already on methadone maintenance should be continued on their outpatient dose (McCarthy et al. 2005). To have fewer withdrawal cycles, heroin and fentanyl users are converted to using methadone during pregnancy. Conversion has been associated with fewer spontaneous abortions and a reduced risk of intravenously transmitted infections (McCarthy et al. 2005). The rate of spontaneous abortion with methadone (3-4%) has been found to be lower (Kashiwagi et al. 2005) compared with that of pregnant individuals who continue to use heroin (10-20%). This was attributed to fetal stress secondary to fluctuating levels of opiates. The recommended starting dose of methadone for conversion often ranges from 1 to 20 mg; patients are then dosed on an as needed basis every 6 h depending upon signs and symptoms of opiate withdrawal including subjective cravings. Most patients reach a stable dose after 48-72 h (Kashiwagi et al. 2005).

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