__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use Some personality traits common in patients with addiction, such as external locus of control and catastrophization, are predictors of poor outcome in pain therapy. Intoxication and withdrawal activate the sympathetic nervous system to augment pain perception and increase muscle tension, irritabil- ity, and anxiety. The depletion of brain dopamine associated with withdrawal exacerbates discomfort in addicted patients. Many patients with addiction have lost their network of social support, another fac- tor associated with poor pain therapy outcome [20]. In susceptible persons with chronic pain, use of opioid analgesics for pain relief can lead to a cyclical relationship between pain symptoms, opioid use, and drug effect that is driven by positive and nega- tive reinforcement. The positive reinforcement from opioids comes from induction of a pleasurable state such as euphoria or relaxation, with negative rein- forcement coming from elimination of an unpleas- ant state such as pain or distress. In some patients with chronic pain and biopsychosocial risk factors for addiction, the reinforcing effects they experience from opioids are sufficiently powerful to compel compulsive efforts to replicate the drug experience. Chronic pain adds a layer of complexity to the devel- opment and management of opioid addiction. The positive and negative effects of opioids become more elusive over time, and tolerance develops to the anal- gesic effect. Attempts to cut back or quit can induce opioid withdrawal or the unmasking of severe pain. The patient becomes increasingly preoccupied with obtaining and using opioid analgesics to alleviate his or her intense physical and emotional distress. This preoccupation can be severe, to the point of involving the entirety of motivational resources. Although patients with chronic pain and opioid use disorder represent a complex and challenging population, these chronic co-occurring conditions can be effectively managed [177]. developing an opioid use disorder in the context of pain treatment. It is important to note that among patients in recovery from a substance abuse disorder, risk of developing problematic opioid analgesic use is inversely proportional to their duration of recov- ery. While many patients with a previously active substance use disorder are forthcoming during the comprehensive assessment, some may not be; oth- ers may lack an appreciation of either the gravity of their former substance abuse disorder or the clinical importance in disclosing this history to their health- care provider. Family members can be a valuable resource in providing this information [177]. It is important for the prescriber to determine the recovery status of the patient in order to appropri- ately tailor the treatment plan. For patients who have achieved stable remission, corroborate and sup- port them in their recovery. If a patient is receiving buprenorphine or methadone maintenance therapy for an opioid use disorder, verify and continue buprenorphine or methadone. If a patient has an active substance abuse disorder, refer him or her to a substance abuse specialist, if possible, for further evaluation [127; 177].
An important point is that clinicians often find patients with chronic pain to be difficult to treat, due to the pain condition often eluding diagnosis and the effects unrelenting pain can have on patient ability to interact calmly and civilly. A comorbid substance abuse disorder amplifies the likelihood of difficult behavior from the patient. Such patients can provoke strong negative responses from treatment providers, often based on either frustration from attempting to treat difficult or intractable problems or clinicians feeling they are working harder for the well-being of the patient than the patient is. It may be helpful for clinicians to remind themselves that, despite the apparent lack of patient motivation, no one would wish the experience of comorbid pain and addiction on anyone [177]. These patients have complex and intense needs, best served by a treatment team approach involving a team of professionals, including [179]:
Some people have achieved durable recovery from their substance use disorder and also require medical care for long-standing pain or pain that developed and became chronic during their recovery. Although the former drug of choice is the agent most likely to lead to cravings and relapse, those with a history of addiction to any drug (or alcohol) are susceptible to
• Primary care provider • Addiction specialist
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MDMS1526
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