Patients with substance abuse issues can be treated for pain in a variety of ways that don’t involve opioids, says Sean Mackey, MD, PhD, Chief of the Pain Management Division at Stanford University and Associate Professor of Anesthesia and Pain Management. “A multidisciplinary approach is needed to treat patients in pain who have substance abuse issues,” he says.
There are non-opioid drugs such as anti-epileptic drugs, antidepressants and anti-arrthythmic drugs, which can be effective in treating pain, Dr. Mackey says.
Patients can also be treated with psychological therapies, as well as physical and occupational therapy, he says. Many patients, however, do not receive a multidisciplinary approach to treating chronic pain because it generally requires the resources of an academic medical center. “Doctors who are treating patients without these resources need to collaborate with others who have the knowledge they don’t, either in addiction medicine or pain medicine,” Dr. Mackey advises.
If a doctor weighs all the options and determines that opioid treatment will work best for an opioid-dependent patient in pain, buprenorphine or methadone may be good options, he says. “Buprenorphine and methadone have strong analgesic benefits, and we commonly use them in this situation,” he says.
For a patient using methadone, one approach is to use a “blinded pain cocktail” in which methadone is ground up and mixed in with baclofen as a binding agent, with cherry syrup as a base. “We tell the patient what’s in it, but not how much,” Dr. Mackey says. “We closely track their quality of life measurements, and we can go up or down on the methadone accordingly. If we have a patient with clear control issues we only give out small doses at a time, or we hand it over to a trusted family member.” Mackey does acknowledge that the use of this tool is time and staff intensive and may be more than a small community practice can handle.
When treating patients with both chronic pain and a substance abuse disorder, Dr. Mackey advises making sure that they are receiving psychological counseling, either in a group or individually. “Many treatments we use in substance abuse overlap with chronic pain treatment—the psychological and behavioral skills are the same,” he says.
He also suggests an opioid contract for some patients, which establishes an understanding between patient and doctor that the patient will only receive opioids from that doctor, and from only one pharmacy. The patient may be asked to submit to urine drug screening, and is told that if their medication is lost it will not be replaced, and stolen medication will only be replaced if the person brings a police report.
“While even the most careful clinical pain management cannot eliminate risk of opioid misuse in patients with a history of addiction, good communication, knowledge of non-opioid treatment alternatives and appropriate monitoring and care in structuring opioid management can reduce risk significantly,” Dr. Mackey says.