BG is a 47-year-old married plumber with a long history of alcohol(Drug information on alcohol) and cocaine dependence who has been abstinent and attending Alcoholics Anonymous (AA) for 3 years. While installing new bathroom fixtures, he fell from a ladder and fractured his right tibia and fibula, requiring open reduction. In the emergency department, he told the orthopedic surgeon about his addiction history and expressed a fear that the pain medication would cause him to relapse. Postoperatively, his surgeon decided to use lower doses of meperidine than usual in order to avoid any possible complications with BG's addiction recovery. However, BG was in severe pain and unable to sleep for several days.
Within hours of being discharged from the hospital with no prescription pain medication, BG began drinking heavily. His wife called the surgeon, who decided to obtain an addiction medicine consultation. BG was admitted to the hospital detoxification unit under the care of Dr J, an addiction psychiatrist, and was started on an alcohol detoxification protocol and prescribed appropriate dosages of oxycodone(Drug information on oxycodone) with acetaminophen for pain control. Dr J, with BG's permission, also contacted his AA sponsor and arranged for him to visit the patient.
After 3 days, BG was discharged from the unit with a plan for the AA group to bring meetings to his home and for his wife to hold the pain medications and administer the prescribed dose every 6 hours. By week's end, BG's pain was being managed with ibuprofen(Drug information on ibuprofen), and he reported no craving for alcohol or other drugs.
Chronic pain syndromes
Chronic pain syndromes present very different management issues in the patient who has a substance use disorder. The first step in developing a plan for safe pain management is to conduct a thorough assessment of all aspects of the patient's physical and emotional health and his recovery. This includes a comprehensive physical and psychiatric history and examination; a review of the patient's records from previous and current care providers; collateral contacts with significant persons in the patient's life, such as a spouse or significant other, parents, children, involved relatives, friends, coworkers, and current health care providers. The evaluation should also include a urine toxicology screening that tests for a range of substances, including synthetic opioids; agonist/antagonist opioids; short-acting benzodiazepines and barbiturates; and over-the-counter substances, such as diphenhydramine(Drug information on diphenhydramine), ephedrine, and phenylpropanolamine(Drug information on phenylpropanolamine).
The drug history needs to explore alcohol use patterns; use of illicit, prescription, and over-the-counter drugs; and use of herbal preparations and food supplements, including energy drinks, natural sleep aids, and other tonics.
Three drugs that are frequently prescribed for patients with chronic pain deserve special mention because of the high risk of addiction. Carisoprodol(Drug information on carisoprodol) is a muscle relaxant that is metabolized to meprobamate(Drug information on meprobamate), a tranquilizer similar to diazepam(Drug information on diazepam). Butalbital is a short-acting barbiturate that is often combined with acetaminophen or a combination of acetaminophen and caffeine(Drug information on caffeine). Tramadol(Drug information on tramadol) is a µ-receptor agonist that also appears to inhibit reuptake of serotonin and norepinephrine(Drug information on norepinephrine). Often viewed as "benign" by practitioners because they are not scheduled by the US Drug Enforcement Agency, these drugs' pharmacologic actions trigger the same receptors as other, more obvious offenders and should be avoided if possible.
For the person recovering from a substance use disorder who has a chronic or recurring pain syndrome and who is not currently taking opioids or sedatives, the safest treatment approach is for the clinician and patient to develop a pain management plan that effectively controls pain without the use of these substances. Most persons with substance use disorders who are involved in a recovery program are motivated to work with a pain treatment physician to prevent re-addiction and will have at least a vague understanding that certain drugs can be risky for them. A written treatment protocol can provide a structure and framework that will decrease the patient's anxiety and give family members and other caregivers a guideline to follow in times of crisis (Figure).
Nonopioid pain treatments vary widely in their efficacy and appropriateness, depending on the type of pain the patient is experiencing, his overall state of health, and the availability of support systems and resources.
In addition to nonspecific pain relievers including anti-inflammatory drugs, syndrome-specific drugs are available for many types of chronic pain (Table). New (and often off-label) uses for older drugs are also available, including tricyclic antidepressants9,10 and anticonvulsants.11,12Nonpharmacologic approaches are also an important part of managing chronic pain. The following are some examples:
- Physical therapy
- Massage therapy and energy work
- Group therapy
- Individual therapy
- Relaxation, meditation, and imagery techniques
- Electrostimulation, including transcutaneous electrical nerve stimulation
- Biofeedback and neurofeedback
- Expressive therapies, such as art therapy, movement therapy, and music therapy13,14
Many patients with chronic pain who are recovering from an addiction have additional psychiatric disorders that require treatment in order for the pain management strategy to be successful. Some common comorbid illnesses include depression, anxiety disorders (including posttraumatic stress disorder); somatoform disorders; personality disorders; and adjustment disorders, which may or may not be directly related to the pain syndrome itself. Commonly, the pain is found to have both physical and psychological components, and aggressive treatment of comorbid psychiatric illness can decrease the severity of the pain; improve the patient's adherence to the pain management strategy; and improve the patient's participation in, and the benefit from, his addiction recovery program.15-17
When the pain is not responsive to such approaches and opioids are required to control the patient's pain, it is essential that a structured plan of treatment be in place. In such cases, a clear written agreement such as the one that is shown in the Figure can be very helpful.18