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Managing Patients With Opioid Use Disorder and Chronic Pain

October 03, 2019

SAN DIEGO—Mental health clinicians will likely be taking on many more patients with opioid use disorder (OUD), as 40% of primary care providers will not accept any new patients who take opioids, an addiction expert told attendees at Psych Congress 2019.

“If you haven't gotten any patients like this yet, well, you will,” said Thomas R. Kosten, MD, the JH Waggoner Chair and professor of psychiatry, pharmacology, immunology and neuroscience at Baylor College of Medicine, Houston, Texas.

See the session slides here

According to 2018 data from the US Centers for Disease Control and Prevention, 20% of people in the country have chronic pain and for 8%, daily living and work activity is impaired by that pain. That represents “many millions of people,” Dr. Kosten said.

“There are many more of them than all the psychiatric patients you see,” he added. “You could in fact be overwhelmed from just this population alone.”

Also at Psych Congress: Supportive Care Essential to Maximize Effectiveness of Buprenorphine for Opioid Addiction

Dr. Kosten, who is also director of the Division of Addictions at Baylor College of Medicine, presented an overview of how mental health clinicians should handle patients who have chronic pain and are taking opioids, from withdrawal techniques to alternative approaches for treating pain.

When seeing a new patient with chronic opioid use, the first order of business is discontinuing the opioids, Dr. Kosten said. Over time, opioids stop relieving pain and may actually result in more pain, he said.

“You don’t get anywhere until you stop the opiates,” he added.

Opioid withdrawal feels like a bad case of the flu that lasts about 1 week, Dr. Kosten told attendees.

“Nobody dies from opioid withdrawal. They may tell you they want to die. They may tell you ‘I feel like I’m going to die,” but they not going to die unless they have some other major significant medical complication,” he said. “It’s basically just unpleasant.”

The Triple Threat of Substance Abuse, Chronic Pain, and Psychiatric Disorders

Dr. Kosten reviewed medications which can be used to help patients during withdrawal. Lofexidine, approved by the US Food and Drug Administration in 2018, is safe and effective, with a very low risk of abuse or diversion, he said. It lessens opioid withdrawal symptoms and makes it more likely that a patient will fully withdraw from opioids, according to the presentation.

Other medications that can be used in withdrawal are naltrexone and buprenorphine. Dr. Kosten recommended to attendees that the acquire the waiver needed to prescribe buprenorphine, saying it is a simple process.

The speaker also reviewed how clinicians can help patients manage chronic pain after withdrawal from opioids. Options discussed included a small dose of naltrexone, hypnosis, acupuncture near the pain site, antidepressants (particularly tricyclics), ketamine (which he thinks will be used more frequently for pain management in the future), and cannabis and its byproducts.

—Terri Airov


“Innovative non-opioids for chronic pain: lofexidine, ketamine, and cannabidiol.” Presented at Psych Congress 2019: San Diego, CA; October 3, 2019.

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