CA is a 28-year-old single mother who is currently working as a receptionist in an attorney's office. She was actively addicted to heroin between ages 17 and 22 years, when she became pregnant. She entered a methadone(Drug information on methadone) treatment program for pregnant women and after giving birth to her daughter, spent 2 years in a drug-free therapeutic community for women with children. She has been abstinent from street drugs and alcohol(Drug information on alcohol) since that time, and she has completed her degree at a local community college.
Since her pregnancy, CA has had migraine headaches 2 or 3 times per month. Initially, she managed the headaches with over-the-counter medication, but in the past year, the headaches have become more severe. CA discussed the headaches with her family doctor but did not reveal her addiction history. Her physician prescribed hydrocodone(Drug information on hydrocodone), which was ineffective, and then oxycodone(Drug information on oxycodone) and butalbital with codeine(Drug information on codeine). CA began escalating the dosages, asking for early refills, and making frequent visits to the emergency department. She was having headaches almost daily, despite the increased dosages of medication. When a trial of fentanyl(Drug information on fentanyl) patches was not beneficial, CA admitted that she was addicted and told her physician about her addiction history.
She entered a buprenorphine(Drug information on buprenorphine) treatment program under the care of an addiction psychiatrist and was given topiramate(Drug information on topiramate) daily for migraine prophylaxis and sumatriptan(Drug information on sumatriptan) therapy for breakthrough headaches. A structured treatment protocol, including a weekly pain management group, a weekly addiction group, and 3 weekly Narcotics Anonymous meetings, was essential in managing her occasional cravings to take heroin. Her medications were not covered by insurance but were obtained through a prescription assistance program.
In general, the pain treatment regimen for a person recovering from an addiction involves the use of long-acting opioids, such as sustained-release oxycodone, methadone, or buprenorphine, administered on a fixed dosage schedule, with another person holding the medication. Unlike addiction treatment protocols, which usually employ once-daily dosing schedules, methadone and buprenorphine are divided into 2 or 3 daily doses for better pain control. For methadone, dosages can range from 60 to 200 mg or more daily; with buprenorphine, dosages of 4 to 32 mg/d are common.19 In addition, a "rescue" dose of a short-acting opioid such as oxycodone or hydromorphone(Drug information on hydromorphone) may be available, again held by the participating family member or caregiver, with clear guidelines for when it is to be used.
Other aspects of the protocol include the involvement of a single physician who writes prescriptions weekly at first with no refills, until the patient demonstrates his ability to safely adhere to the protocol. As in the nonopioid protocol, all prescriptions are filled at the same pharmacy, and no prescriptions are called in by phone; lost, stolen, or damaged prescriptions or pills are not replaced. Although controlled research to demonstrate the effectiveness of this approach in preventing substance misuse is lacking, more than 75% of pain specialists currently use some form of agreement with their patients with chronic pain.20
Urine drug screening should be done randomly but regularly to determine whether other substances are being ingested and to ensure that prescribed medications are being taken. The current use of illicit substances indicates a need for additional substance abuse treatment for the patient and may predict misuse of opioid pain medications.
When approached as a joint effort between the physician and the patient, a structured treatment plan gives the patient a strong investment in determining his own pain management strategy. Throughout the development of the protocol, it should be emphasized that the purpose of the plan is to provide maximal pain relief while protecting the recovering patient's sobriety against the insidious reactivation of his disease.
In addition to the written agreement and consistent expectations and responses on the part of the treating psychiatrist, all clinical staff need to be trained in both addiction and pain, using experiential (eg, films, group discussions) as well as didactic methods. Staff should be aware that patient behaviors arise from symptoms of their disease; despite their behavior they deserve to be treated with dignity and respect. Since clinicians ask patients to adhere to their treatment agreements, we need to keep our end of the bargain by being kind, patient, forthright, and on time.