Tailor-made Chronic Pain Management and Reducing the Risk of Opioid Addiction

By Kim Kristiansen, M.D and Henriette Poulsen, M.D.

You can find previous blogposts about this subject at the Picture of Pain Blog and listen to a conversation between the authors as a Picture of Pain Podcast

It is challenging to navigate between effect of treatment and risk of aberrant drug behaviour when treating chronic pain with opioids. In this blog post we will describe methods to navigate in this difficult field from a clinical point of view.

If a person, who is prescribed opioids for chronic pain takes more than the dose prescribed or uses more extra “as needed” medication, is she or he then addicted? Or developing tolerance? Or pseudo-addicted? Is the medication taken for something more or other than the pain? …  And how do we – we being both healthcare professionals and patients – act responsibly in respect to both the pain condition and the risk of aberrant drug behaviour?

Well let’s face it; opioids have been part of pain treatment for millennia and for a very good reason: they actually do relieve pain. So no doubt opioids have some kind of role in chronic pain management, but there seems to be two extremes of seeing this either very liberal “my patients are getting what they need to relieve pain” or very restrictive “don’t use opioids, patients get addicted”. Unfortunately both these extremes entail a great risk of not providing optimal treatment for chronic pain. The fact is that chronic pain is more than the pain alone, chronic pain is not just acute pain taking longer time. Intensive research in this field has brought us knowledge about these conditions, and today we see it as a disease in its own right. A disease composed of an individual mixture of components with physical, mental and social components leading to alterations in the nervous system which are finally perceived as pain by the sufferer.

Opioids are very effective for relieving acute pain and they can also – but to a lesser degree – ease the pain in some chronic pain conditions, an effect that often will change over time. Opioids also reduce the burden of the emotional components in chronic pain conditions But that is not the right way to use opioids and dramatically increases the risk of aberrant drug behaviour and it is not the right way to treat these problems. The patient might want extra opioids to relax, sleep, and just reduce the emotional burden, which is better treated otherwise. In a recent published study more than one third of veterans reported aberrant drug behaviour where the most frequent was using alcohol, using street drugs and sharing prescriptions all with the purpose of getting better treatment [1].

Furthermore chronic pain most often have some degree of sensitization of the nervous system leading to increased pain experience, and this is better treated with other drugs than opioids, but often in combination with opioids. In the very common syndrome fibromyalgia both opioids and NSAIDs have been shown to have no or close to no effect on the pain. This might lead to increasing doses resulting in small improvements in the condition again leading to increased doses …. and so on. It might be better treated in combination with or only with drugs targeted at neuropathic pain and at sensitization.

So when a patient takes more opioids by increasing the daily dose or taking more “as needed” it will most often be to improve the condition. It might be reducing the pain, but can also be a question of relaxation, sleep, mood and so on. Taking extra opioids to achieve a better effect of treatment some call “pseudo-addiction”  – the person behaves like persons addicted but the reason for their dispositions are other than for addicts. In these situations it is extremely important to make a comprehensive assessment of the involving factors and have on-going conversations with the patient, and together facing the problem and search for responsible solutions. DoloTest^® is a communication- and assessment tool quantifying the influence of the pain condition on the quality of life (Fig.1) It takes less than 2 minutes for an average patient to complete and due to the visual presentation of the test result it can be used for communication, goal setting and evaluation of response to treatment by both the patient and the healthcare provider. If there is a small or no response on “pain” when treating with an opioid, but perhaps an improvement on mood, it might be worth reconsidering the treatment strategy and focus more on mood issues and perhaps treat these problems by treatment targeted for this. Otherwise the dose of opioids can be titrated to the optimal dose for effect on “pain” in a balance with adverse effects. Similarly different treatment modalities can be considered, tried and evaluated such as acupuncture, cognitive behavioural therapy, mindfulness, exercise, physical therapy alone or in combination.

The patient must be informed about the risk of aberrant drug behaviour and it must be made clear, that both the patient and the healthcare provider have a common responsibility in this field that is the basis for the pain management process. Many patients are afraid of addiction problems when treated with opioids and this might contribute to under treatment Therefore the patient must be informed about the comprehensive and on-going assessment, as the condition is dynamic and not static, and that this actually also is a way to individualize the treatment to achieve the best possible quality of life as well as a way to reduce the risk of addiction. The patient must be informed that “tolerance” is a normal and physiological mechanism leading to a need for an increased dose of a drug to get the same effect and that physical withdrawal symptoms are to be expected if the treatment is stopped abrupt – and that this is not the same as addiction.

The numbers of persons suffering from chronic pain are enormous and each individual has his or her own mixture of the different components in chronic pain, and the treatment must be tailor-made.

We can find the optimal balance for each individual in the treatment of chronic pain, but it requires awareness and cooperation from all involved.

Reference:

1: Goebel, Joy R, Peggy Compton, Lisa Zubkoff, Andy Lanto, Steven M Asch, Cathy D Sherbourne, Lisa Shugarman, and Karl A Lorenz. “Prescription Sharing, Alcohol Use, and Street Drug Use to Manage Pain Among Veterans.” Journal of pain and symptom management 41, no. 5 (2011):

Kim Kristiansen, M.D and Henriette Poulsen, M.D. (2012). Tailor-made Chronic Pain Management and Reducing the Risk of Opioid Addiction Picture of Pain Blog