The patient presenting with pain complaints who simultaneously has ongoing substance abuse or dependence (or a prior history of either) can pose significant challenges in terms of treatment options. Although effective pain management should never be withheld because of an abuse or addiction history, effective treatment might require an array of pain-reducing approaches (e.g., use of adjunctive agents, agents with low abuse potential, physical and psychological therapies, and patient participation in a concurrent substance abuse treatment program). General principles for pain management of this group are outlined in Table 9-3 (Prater et al. 2002; Savage 1998; Scimeca et al. 2000).
The patient's detoxification from the substance(s) on which he or she is dependent might be required before the initiation of treatment. An overly aggressive detoxification can be particularly distressing for patients, perhaps resulting in the inclination to abandon treatment/detoxification. In addition, during the course of detoxification, it could be imperative to undertake simultaneous measures to mitigate pain; otherwise, the distress to which the patient is subjected might be too great, and the patient may develop intense fears that his or her pain will be unrecognized and inadequately treated.
Detoxification is required for the patient who is alcohol dependent. In some cases, the substances abused might have appeal as a means of controlling one's psychological distress (e.g., cannabis and benzodiazepine abuse to address underlying anxiety or ineffective coping). Hence, psychological interventions, along with prudent psychopharmacologic interventions for underlying psychiatric disorders, might also be required to effect optimal pain control.
Patients who receive opiates over the long term for treatment of pain may become addicted to the opiates. This issue is one that raises controversy. Some authors suggest that opiate dependence does not accompany appropriate dosing in pain patients (Portenoy and Foley 1986). Nonetheless, the issue can and does arise—that patients who have been treated with analgesics can become dependent on pain medications.
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