__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use The goals of treatment include avoiding harmful use of substances and achieving physical, psycho- logical, and spiritual well-being. In patients with chronic pain with substance abuse disorders, there is a degree of overlap when substance abuse disorder treatment involves a biopsychosocial approach, as it ideally does. Effective approaches for substance abuse disorder include a combination of [178]: • Cognitive-behavioral therapy that addresses addiction recovery and chronic pain • Deep relaxation/meditation through mindfulness, progressive muscle relaxation, and/or other approaches methadone therapy or initiation of buprenorphine [177]. Methadone and buprenorphine can be used in patients with opioid use disorder during detoxi- fication. With this approach, the patient is slowly transitioned from the dose of their illicit opioid to an opioid-free state by switching the illicit opioid to the withdrawal medication and slowly decreasing the detoxification medication dose. However, in the con- text of treating the opioid use disorder, the patient is placed on methadone or buprenorphine for an extended period. Formerly termed “maintenance therapy,” this is now called “medication-assisted treatment” [180].
Treatment of opioid addiction with methadone or buprenorphine is intended to stabilize dysregulated brain pathways, thereby reducing craving and relapse risk. Persons with opioid addiction remain at very high risk of opioid relapse after successful detoxi- fication and cessation of acute opioid withdrawal symptoms. Profound changes in brain function that occur with the development and progression of opioid addiction become unmasked with cessation of opioid use. Factors contributing to relapse vulner- ability in persons attempting recovery from opioid addiction include craving for opioids, hypersensitiv- ity to emotional stress, an inability to experience pleasure or reward, and a persistent state of distress, anxiety, or malaise [181]. For many patients with opioid addiction, treatment should address these alterations in neurobiology. By targeting the same brain receptors and pathways as the abused opioid, pharmacotherapy with opioid agonists or partial agonists can effectively manage opioid withdrawal symptoms and play an essential part in the ongoing treatment plan [182]. Methadone and buprenor- phine are the two most widely used and effective pharmacotherapies for opioid use disorder, and both have regulatory approval in the United States for this indication [183]. Naltrexone is also approved for treatment of opioid use disorder [99; 182]. In 2018, the FDA approved the first non-opioid for the management of opioid withdrawal symptoms [184]. Lofexidine may be used for up to 14 days to lessen the severity of symptoms of opioid withdrawal as part of a long-term treatment plan [99].
• Working with an addiction counselor to explore substance use issues and to support recovery • 12-step program involvement, through Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or Methadone Anonymous (MA), when appropriate. Every 12-step program has sponsors who are support persons successful in their recovery through their respective 12-step program, with a desire to work with new members to help them achieve recovery success. The patient should be encouraged to find a sponsor. • Alternatives to 12-step programs for peer support in substance abuse recovery (e.g., Smart Recovery and Rational Recovery) • Chronic Pain Anonymous, the peer-support program for those with chronic pain Treatment of Opioid Use Disorder in Patients with Chronic Pain For patients on chronic opioid therapy who have minor opioid abuse relapses but quickly regain sta- bility, involving substance abuse counseling in the medical setting or through a formal addiction pro- gram may suffice. One problem is that many addic- tion treatment programs will not admit patients who require the ongoing use of opioid analgesics for pain. In patients whose frequent relapses indi- cate a serious opioid use disorder, the best option may be referral to an opioid treatment program for
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MDMS1526
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