© Springer International Publishing Switzerland 2017
Alexios Carayannopoulos DO, MPH (ed.)Comprehensive Pain Management in the Rehabilitation Patient10.1007/978-3-319-16784-8_1616. Pain in the Addiction Rehabilitation Patient
(1)
Calmar Pain Relief, Salve Regina University, Graduate Program in Rehabilitation Counseling West Warwick, Newport, RI, USA
Keywords
AddictionChronic painOpioidsDrug dependenceIntroduction
The death rate from drug overdose in the United States more than doubled during the period from 1999 to 2013. It is estimated that the death rate was 6.0 per 100,000 population in 1999, and has risen to 13.8 per 100,000 by 2013 [1]. These overdoses are attributable mainly to the misuse of prescription controlled substances , especially opioid analgesics, anxiolytics, and sedative hypnotics [2, 3]. A corresponding increase in morbidity, as measured by visits to the Emergency Department (ED) , has also occurred because of the use/abuse of prescription drugs, which has increased 153% for opioid analgesics and 124% for anxiolytics and sedative hypnotics [4, 5].
In view of these alarming statistics, many states have developed initiatives to reduce prescriptions of opioid analgesics in general, and in particular to people experiencing chronic pain. Numerous individuals who have developed tolerance are unable to get an increase in their opioid analgesic medication dose, or they are being slowly titrated down. These public health policy changes are creating problems for the population of chronic pain patients who have relied on opiate analgesic medications for many years. It is not uncommon to see a patient with a history of chronic pain to be on the same dose of medication for 1 or 2 years. These patients describe a “subclinical” withdrawal state, which is characterized by general feelings of malaise, excessive irritability, generally feeling “sick”, but never in full withdrawal. These patients are often seen by their family, and sometimes their physician, as complaining, depressed, or catastrophizing. A subgroup of patients supplement their prescriptions with illicit opiate analgesics and sometimes even heroin.
Definitions
It is important when treating patients with chronic pain and addiction to define these conditions, as follows:
Pain
Pain is defined by the International Association for the Study of Pain (IASP) as a “psychological state” characterized by “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” [6].
Addiction
Addiction is defined by the American Society of Addiction Medicine (ASAM) as a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations . This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors [7].
It is interesting how both definitions infer significant brain-based perspectives , which implies a need to understand the individual with either affliction from a neurobehavioral perspective. The influence of genetics is an integral part of various aspects of both conditions. Gene expression is influenced by the presence or absence of polymorphisms, which alter the brain’s neurotransmitter system. Reward-deficiency syndrome is a good example of the presence of excessive polymorphisms in the expression of dopaminergic genes [8, 9]. An individual with altered gene expression in the dopaminergic system is highly vulnerable to the development of opioid addiction. That individual may also have an altered perception of the severity of pain and its implications (reduced joyfulness). Such an individual is likely to be prescribed an analgesic opioid, which will then initiate the rapid formation of addiction to opiates.
The Pain and Addiction Paradigm
Assessment of Addiction in the Chronic Pain Patient
The most common drug of addiction in the chronic pain patient is obviously opioids followed by benzodiazepines . It is often the case that clinicians treating chronic pain patients conceptualize the addiction disorder as either a “pseudo addict” or an addict. The distinction is made on the basis of the presence of drug-seeking behavior. Addicts typically present with obvious drug-seeking behavior, often fail toxicology screens, and frequently run out of their medications. Pseudo addicts with chronic pain are troubled by their prescription dependence and engage in more subtle drug-seeking behavior, which disappears with adequate dosing. These patients are often irritable and demanding and often feel that they are not being treated properly by their healthcare team .
There is a natural progression through characteristic phases of pseudo addiction, which include the following:
- 1.
There is an inadequate prescription of analgesics to relieve or to reduce pain in the patient.
- 2.
There is escalation of analgesic demands by the patient, associated with behavioral changes to convince others of the pain severity.
- 3.
There is a crisis of mistrust between the patient and the healthcare team in providing appropriate and timely analgesics to control the patient’s level of pain [10].
The distinction between the pseudo addict and the addict is sometimes difficult to make, but an adequate diagnostic assessment will be helpful to determine the proper diagnosis. It is often the case that a pseudo addict is so frustrated that they may engage in increasingly bizarre drug-seeking behavior in an attempt to convince the physician or other clinician for the need of additional pain medication. The physician is likely to view this behavior as an indication that the patient is an “addict” and then try to avoid the patient. Eventually, the physician will refer the patient to a mental health professional for the treatment of addiction. Once this occurs, it is not likely that this patient, who is now labeled as an addict, will have any chance of receiving sufficient analgesia; thereby, the patient will be expected to continue to suffer in pain, with pain flare-ups likely.
A psychologist , with a specialty in pain management, should be able to provide an adequate assessment of the drug use component of the patient’s presentation. The use of standardized psychological tests, as well as the administration of a comprehensive history that includes corroboration from family members is necessary. This author has had great success in treating patients who were pseudo addicts through the use of Suboxone.
Treating Pseudo Addiction and Chronic Pain
The treatment of non-malignant chronic pain with opioid analgesics has resulted in massive increases in the amount, duration, and expense of pharmacotherapy. Opioid availability has increased substantially and prescription drug dependence is the fastest growing epidemic in this century. The number of opioid overdose deaths has now exceeded all accidental deaths, including alcohol fatalities. Many of these patients became addicted to opioids because of painful conditions, such as back problems, failed surgery, arthritis, headaches, fibromyalgia, and neuropathies.
When buprenorphine/Suboxone was first being prescribed for office-based opioid treatment, two categories of patients emerged: (1) those who were prescribed opioids for pain and had difficulty reducing their dosage; (2) those who, when exposed to opioids, became addicted and started using more than prescribed. Buprenorphine resulted in rapid withdrawal suppression and excellent pain relief, such that many of the patient’s symptoms stabilized and they were able to taper down dosage without return of pain. Others got acceptable pain relief initially, until during dose reduction, the pain complaints returned and persisted.
The treatment needs of these populations are distinct, as most patients with chronic pain, who have never abused medications, do not perceive themselves as an addict. Having these patients engage in traditional substance abuse treatment requires a pain management approach focusing upon the emotional and behavioral consequences of pain, suffering, and functional disability, as well as a clear understanding of the implications of their addiction.
After initial stabilization of withdrawal symptoms, and titration of medications for pain control, it is useful to engage the patient in a pain group as a long-term weekly group therapy service. The format can be a combination of process and education group, which this author has found to be helpful, but not sufficient to meet the more comprehensive needs of this population. Ultimately, a comprehensive program that addresses medication issues, addiction, and pain management is necessary to treat these complicated patients successfully.
Referral Sources and Initial Patient Evaluation
Patients who have become physically dependent upon opioids for pain are referred from their primary care physician, surgeon, or other pain specialists for evaluation. Self-referrals should be encouraged, with the expectation that ongoing treatment involvement with their prescribing physician is required for participation. Most patients have already been on opioids for years and have failed multiple medical and surgical interventions. Referring physicians are concerned about the dosage and duration of opioids complicating evaluation and management, often secondary to concurrent but occult physical dependence symptoms. Many patients have already been tried on long-acting opioids or have attempted opioid tapering or substitution without benefit.
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Manual Therapy and Pain in the Rehabilitation Patient
Peripheral Nerve Stimulation for the Treatment of Pain in the Rehabilitation Patient
Opioids for the Treatment of Pain in the Rehabilitation Patient
Trigeminal Neuralgia in the Rehabilitation Patient
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