Special Topics in Pain: Opioids

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Managing Opioid Use Disorders and Chronic Pain.

Author(s): Alford D P, et al.
Journal: Practical Pain Management. 2017;17(2): 24-28. 13 references.
Reprint: Daniel P Alford, MD, MPH, Professor of Medicine, Assistant Dean of Continuing Medical Education, Director of the Safe and Competent Opioid Prescribing Education (SCOPE of pain) program at Boston University School of Medicine (BUSM) and Boston Medical Center.
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Legal considerations; Review and evaluate the latest advances and newest information in the area of Opioids


Editor’s Note: Patients with opioid use disorder may still have chronic pain and still need treatment. This is an excellent discussion of the management of this most difficult group.

Class: Opioid use disorder; pharmacology: Suboxone

Recognizing and treating opioid use disorders (OUDs) among patients with chronic pain on long-term opioid therapy is challenging. A key issue is that certain aberrant behaviors in patients with chronic pain managed on opioids may be misinterpreted as signs of an OUD, when in fact the behaviors may be a result of poorly controlled severe pain and suffering.

Some of the 11 symptoms of an OUD could apply to a patient in pain so Dr. Alford often falls back to the 4 C's. Loss of Control is present when patients with an OUD cannot take the opioid as prescribed. Compulsive use is present when patients exhibit preoccupation with obtaining the opioid, as opposed to focusing on obtaining pain relief, and are opposed to trying other treatments despite continued severe pain. Continued use despite the risk of harm is present if patients recognize that the opioid is causing adverse events and is not helping the pain, but they still want more. Craving-- if the patient wakes up and all he/she thinks about is having more opioids, this is worrisome. Making a definitive OUD diagnosis may not be as critical as making a treatment change for patients with the 4 C's.

For patients with both chronic pain and OUD, Dr. Alford prefers  buprenorphine/naloxone (Suboxone) over methadone because he has a waiver to prescribe buprenorphine and can treat both conditions simultaneously. Use of methadone is restricted to being dispensed at licensed methadone treatment programs. It is illegal to write a prescription for methadone for the treatment of an OUD. In terms of treating pain, it is important to understand the pharmacology and mechanism of action of the various medications used to treat OUD.

Methadone is dosed daily for OUD but its analgesic properties last only about eight hours. There are three possible outcomes from methadone treatment for an OUD in a patient also suffering with chronic pain. (1) If a single methadone dose relieved pain all day, this suggests that the patient had withdrawal-mediated pain. (2) If pain is relieved for eight hours following a dose, with resumption of severe pain thereafter, the pain is probably opioid responsive. This patient may benefit from an additional nonopioid treatment (e.g., nonsteroidal anti-inflammatory drug or gabapentin) or an opioid given later in the day when methadone's analgesic effect wears off. This can be challenging as it may interfere with urine drug testing so synthetic opioids such as fentanyl may be helpful in that case. (3) If no pain relief occurs with methadone, the patient may be among the 50% of patient with chronic pain whose pain is not or is only minimally responsive to opioids.

Buprenorphine like methadone has analgesic properties that last about eight hours and its OUD-treating properties last > 24 hours. For OUD, buprenorphine is given once a day and for OUD and chronic pain, three times per day (every eight hours) to give 24 hours of coverage for both pain and addiction. Naltrexone is an extended-release formulation for OUD treatment that is a full-opioid antagonist. Thus, it is impossible to treat a patient on naltrexone with an opioid for chronic pain. These patients require pain treatment with nonopioid medications and nonpharmacologic treatments (e.g., cognitive behavioral therapy).

Patients with a history of OUD seem to experience pain in a more intense way than do people without an addiction history. It is important people with a history of addiction not feel stigmatized and they know that their pain will be aggressively managed despite their addiction history. The low number of individuals with OUD seeking treatment is more of a problem having to do with patients' perception of whether or not they need treatment, lack of geographic access to treatment centers, and lack of financial access/health care coverage. Negative attitudes toward medications used to treat addiction are also an issue.

Boston University's Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program has been developed to improve primary care physicians' knowledge and confidence in safe opioid prescribing. It is a free two-hour, online case-based program designed to help assess whether opioids are appropriate for any given patient and how to safely and competently initiate, modify, continue or discontinue opioids when managing patients with severe chronic pain.

Important Points:
Certain aberrant behaviors in patients with chronic pain managed on opioids may be misinterpreted as signs of an OUD, when in fact the behaviors may be a result of poorly controlled severe pain and suffering. For patients with both chronic pain and OUD, Dr. Alford prefers buprenorphine/naloxone (Suboxone) over methadone to treat both conditions simultaneously. The SCOPE of Pain program has been developed to improve primary care physicians' ability to assess whether opioids are appropriate for any given patient and how to safely and competently initiate, modify, continue or discontinue opioids when managing patients with severe chronic pain.

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