○ Declining activity. ○ Increasing pain complaints. ○ Increasing relationship dysfunction. ○ Increasing anxiety, mood lability, or depression. ● Clinician-patient visit factors : ○ Reports of lost or stolen prescription slips. ○ Urgent calls or unscheduled visits. ○ Inability to produce medications on request. ○ Frequent early prescription renewal requests. ○ Frequently missed appointments unless prescription is expected. ● Signs of opioid withdrawal : ○ Anxiety. ○ Excessive tearfulness. (Psychology Today, 2019) Even though most patients do not become addicted to opioids, chronic use of opioids is potentially counterproductive. Research indicates that chronic opioid use causes increased pain – a phenomenon referred to as opioid-induced hyperalgesia which usually occurs among patients who use high doses of opioids for an extended duration (Dave, 2018). The use of dietary supplements, herbal supplements and nutraceuticals for the prevention and/or the treatment of chronic diseases is a popular component of CAM. However, these products can vary in their consistency and dosage and can have adverse side effects and can have adverse interactions with prescribed medications. Patients must be wary of claims made about these products and their capacity to prevent or treat any chronic disease especially when the internet is their source. Supplements such as chondroitin, glucosamine and alpha-lipoic acid, acetyl-L-carnitine and Vitamin E have not been approved for medicinal use by the Food and Drug Administration (FDA) (Drugs.com, 2020a; Drugs.com2020b; Tennant, 2016). Patients cannot assume that over-the-counter products such as these have an absolute margin of safety and should discuss the use of any supplement with their physician especially if they are taking any prescription medication. What advice can be given to individuals with chronic pain regarding CAM use? First, many patients may describe trying a variety of CAM approaches, and it is important to maintain an open and nonjudgmental stance when discussing them. This openness is essential for two reasons. First, good relationships with healthcare providers are associated with better pain control. Second, it is important from a safety perspective that healthcare providers have a complete understanding of the treatments their patients are trying, since there is always the possibility of a counterproductive result or, in the case of some supplements, a biological interaction. ○ Yawning. ○ Insomnia. ○ Goosebumps (gooseflesh). ○ Runny nose/watery eyes. ○ Restlessness. ○ Anxiety. One productive approach when working with patients who express interest in CAM is to emphasize the complementary rather than alternative nature of such treatments. A provider might explain that the research is mixed on the use of most CAM approaches, but that the vast majority of interventions do no harm and might be helpful when used in conjunction with established medical care. Although several examples exist of dangerous medication interactions with CAM treatments (e.g., the combination of certain antidepressants and St. John’s wort, kava kava, SAMe, and valerian), the greatest risk from CAM approaches comes when patients place trust in alternative approaches to the exclusion of more general lifestyle changes that are known to help with chronic pain (e.g., exercise, weight loss, sleep
Among individuals who are prescribed opioids for chronic pain, between 8 and 12 percent will develop an opioid use disorder and approximately 21-29% of patients who take these medications misuse them (National Institute on Drug Abuse, 2021). Even so, a number of studies have attempted to identify risk factors for problematic drug behavior among individuals on opioid therapy. The following factors have been shown to be associated with opioid addiction and should be considered part of the client assessment and the development of a pain management plan: ● Age (younger individuals being more likely to abuse). ● Current or past legal problems. ● Previous reported history of drug abuse. ● Current use of other illicit drugs. ● Heavy use of tobacco. ● History of personality disorder. ● Mood factors, such as depression and anxiety. ● Current use of other psychotropic medications for mood or sleep. ● Chronic and unresolved psychosocial stressors (e.g., a chaotic lifestyle). (Webster, 2017; Burcher et al, 2018) Additionally, the following behavioral patterns and physical signs may suggest opioid addiction and opioid withdrawal in persons with chronic pain. These patterns should be assessed and, when present, openly discussed with the patient: ● Adverse clinical consequences : ○ Being intoxicated, somnolent, or sedated. Complementary and alternative medicine approaches Complementary and alternative medicine (CAM) is difficult to define because the field of Western pain medicine is constantly changing, and what is labeled alternative now may be considered mainstream in (National Center for Complimentary and Integrative Health, 2018). Complementary and alternative medicine approaches are frequently employed by people with chronic pain and may hold special appeal to pain sufferers for several reasons. First, many patients feel that their physicians treat pain using only single modalities and without attempting to track effectiveness over time. Second, as a part of their philosophy of care, many CAM practitioners manifest a welcoming, less reserved attitude toward people with pain, have fewer time constraints than medical specialists, and may be more willing to hear a patient’s full pain story (Agarwal, 2020). It is estimated that 38% of adults and 12% of children have used CAM at some point in their lives (Millstine, 2018). The use of CAM techniques appeal to patients because they offer a patient-centered approach and can assist patients in meeting physical, neurological, psychological, social and spiritual challenges (Agarwal, 2020). Because CAM treatments are generally outside the traditional medical model, research on their effectiveness is somewhat incomplete and prone to methodological concerns. Acupuncture is a CAM treatment modality which stimulates the production of endorphins, serotonin and central nervous system (CNS) and is the best known treatment modality among the armamentarium of traditional Chinese Medicine. Johansson and colleagues conducted a study in which they found that 90% of chronic patients who received acupuncture treatment had significant improvement in their symptoms compared to those patients who did not receive acupuncture treatment. A study by Raustia and colleagues that TMD patients treated with acupuncture had an increase in the opening axis of their mouths (Krishna, et al., 2018). However, in addition to the relatively small number of patients included in the analysis, the treatment duration ranged from just 1 to 3 weeks, with the assessments made immediately after treatment in 6 of the 7 studies. A more recent meta-analysis of nine studies found that acupuncture seemed to reduce the pain of temporomandibular disorders. However, once again, the researchers caution that their sample was fairly limited (Wu et al., 2017).
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