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Treatment of Chronic Pain, SUD Requires Balance

September 11, 2020

Even as opioid prescribing has tapered in recent years, opioid-involved deaths in the United States remain high thanks in large part to the availability of illicit substances. In patients with comorbid chronic pain and substance use disorders, developing protocols for continuing opioid therapy are key for patient safety, W. Clay Jackson, MD, and Arwen Podesta, MD, DFASAM, DFAPA, ABIHM, told Psych Congress 2020 attendees on Friday.

Dr. Jackson is director of palliative care at West Cancer Center in Memphis and assistant professor of clinical psychiatry and family medicine at the University of Tennessee College of Medicine. Dr. Podesta is assistant professor of psychiatry at Tulane University, ACER LLC medical director, and owner/psychiatrist for Podesta Wellness in New Orleans.

Dr. Jackson and Dr. Podesta charted the three waves of the opioid epidemic in the United States over the past 20 years: A steady rise in the prescription of opioid medications from 1999 to 2010, an increase in heroin use once practitioners began to prescribe fewer opioid medications, and most recently starting in 2013, a continuing escalation in the use of synthetic opioids, such as illicit fentanyl. Whereas opioid overdose-related deaths from prescriptions and heroin use have plateaued in recent years, deaths associated with synthetic opioid misuse have continued to climb, Dr. Jackson said.

Currently, about 1.9 million U.S. adults are actively addicted to prescription opioids. Data suggests that the longer for which a patient is prescribed an opioid painkiller, the more likely they are to develop an addiction. Just 6% of patients given a one-day prescription remained on an opioid one year later, whereas nearly 30% of those prescribed an opioid pain medication for more than 31 days engaged in chronic use.

Efforts are underway to regulate opioid prescribing and develop alternative forms of chronic pain management. In Tennessee, for example, the legislature in 2012 implemented a requirement for pain clinics to register with the state. Board of Health Commission for Chronic Pain Guidelines were published in 2013, Dr. Jackson said. The number of registered pain clinics in the state dropped from more than 350 to less than 150 and opioid prescriptions dropped by 21% from 2013 to 2016. (Of note, however, opioid overdose deaths in the state still increased by 57% over the same period, a rise attributed to heroin and synthetic opioids).

Rational prescribing

For patients who have engaged in chronic use of opioids—either illicit or licit as prescribed—having the opioid taken away and leaving the patient’s opioid receptors empty can create problems in treatment, Dr. Podesta said.

“If someone is sitting in front of me and they have a history of opioid use disorder, I’m not letting them be my patient if they’re not covering their opioid receptor,” Dr. Podesta said. “That can be with naltrexone, buprenorphine or methadone. [If the opioid receptor is not covered], there is such a high risk of suicidal ideation with relapse or even those in regular chronic pain treatment with a doctor and then they stop, and then they’ll go find [substances] from the street if their opioid receptors are not covered.

“We want to use pharmacological and non-pharmacological treatments.”

Dr. Jackson reviewed interventions beyond opioids that can be used to treat pain, from non-opioid pharmacologic treatments such as anti-inflammatory agents and SNRIs, to interventional treatments such as nerve blocks, implantable devices and surgery, to non-pharmacologic treatments, such as cognitive behavioral therapy (CBT), mindfulness-based cognitive therapy, and various forms of physical therapy.

Dr. Podesta explained the use of pacing—activity modulation for pain management that allows patients to consistently be active without causing extra pain.

“A lot of people who are in pain want to mow the whole lawn, and if they don’t mow the lawn, they feel like they’re going to be judged,” Dr. Podesta said. “Pacing is a learned skill to mow half the lawn—spend just enough time on an activity to get the most out of it, but don’t push too far. It’s like fitness in general. You don’t run a marathon without building and slowly training up.”

Who is at risk?

Lastly, Dr. Podesta and Dr. Jackson stressed the importance for all prescribers of conducting a thorough clinical work-up on patients to determine their level of risk for substance misuse and addiction. Dr. Podesta said a good work-up should include discussion of:

  • Family history, which will lend information about the patient’s genes and epigenetics
  • Patient history of psychiatric disorders and potential childhood trauma
  • Patient history of immune inflammatory disorders
  • Nutrition
  • Past drug use
  • Current stress experiences
  • Multiple pharmacy and doctor uses

Lastly, multi-modal treatment is essential, Dr. Podesta said. Treatment should address the multiple needs of the individual and not just the patient’s pain or addiction. Multiple courses of treatment may be required, and an adequate timeframe is needed—more than three months to produce a stable behavior change in the patient.

“That’s so important,” Dr. Jackson added. “We get a three-minute conversation with patients and expect them to make three changes that day. From a receptor standpoint, just biologically, we have to give patients more time and more grace to make their changes as they are responding to our interventions.”

— Tom Valentino


“Chronic Pain and SUD: When Worlds Collide.” Presented at Psych Congress 2020: Virtual; September 11, 2020.

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