Balancing Pain Treatment With Potential Addiction

July 27, 2017
Arwen Podesta

It’s a conundrum for modern-day clinicians: The country is dealing with an epidemic of people addicted to opioids, yet patients in pain still need medication for relief. Among patients prescribed pain pills for more than a week, 1 in 7 will become dependent and will still be taking them a year later—through no fault of their own, according to Arwen Podesta, MD, ABPN, FASAM, ABIHM, author of Hooked: A Concise Guide to the Underlying Mechanics of Addiction and Treatment for Patients, Families, and Providers.

“There are so many examples of patients who start their opioid addiction with pain medications as prescribed by their doctors. And there are also examples of those in recovery who suffer from true pain and receive an opioid after maybe a surgery, relapse, and even die of overdose,” said Dr. Podesta.

The news, however, isn’t all bleak.

“These issues are mostly preventable,” she said, “as we have rational treatment and ways to contain this disease, even in the light of pain treatment.”

Dr. Podesta, who has subspecializations in addiction medicine, forensic psychiatry, and integrative and holistic medicine, will discuss evidence-based ways to assess and treat patients with opioid addiction and pain, during a session at Psych Congress. The talk will cover the basic etiology and epidemiology of both addiction (see Figure 1) and pain, and will provide the rationale for various types of treatment based on individual patient needs.

Session info“This will be a jam-packed session with tons of information on treatment of addiction and pain,” she said. “Attendees will leave with tangible evaluation and treatment ideas, which will change lives.”

The subject matter is relevant to mental health clinicians of all kinds, she said, since at least half of patients seeking mental health treatment have or previously had an issue with substance misuse. Even if a patient is not seeking treatment for a substance-related issue (stigma and fear may render some silent on opioid misuse), providers should still be equipped to treat the whole patient.



I have several concerns about the information provided in this summary:

1. It appears to indicate that the only pain medications are opioids.  In fact, there are many types of chronic pain such as neuropathic pain for which non-opioids such as the SNRIs and anti-convulsants are far more efficacious than opioids.

2.  It appears to indicate that we have an extensive knowledge about the underlying mechanisms of opioid addiction.  This may be true for non-medical users of opioids but with regard to patients started on opioids for legitimate pain complaints who abuse the opioids we have virtually no research on the mechanisms. We also have no research on the best treatment approaches for these patients.

3.  I am very concerned that it suggests that the only role psychiatrists have to play in treating patients with pain is treating opioid abuse.  I have spent over 25 years arguing that psychiatrists have an important role to play in treating pain and that more need training in the field.  Dr. Podesta's suggestion that psychiatrists seek out training in addiction medicine will not do anything to help them provide treatment for the pain as addiction medicine fellowships do not teach pain management.  I have written multiple Psychiatric Times columns on this subject.