Managing chronic pain and opioid addiction
Continued opioid prescribing for people who may have an addiction
Studies have shown that prescribing opioids to patients with an opioid addiction and chronic pain can be effective, as long as careful controls and monitoring are in place (Chelminski et al., 2005; Currie et al., 2003; Jamison et al., 2010; Manchikanti et al., 2006a, 2006b; Wiedemer et al., 2007).
However, there are limitations to the evidence supporting continued opioid prescribing. The interventions were conducted not in primary care settings, but in multidisciplinary clinics with nurses, internists and pharmacists. The studies also had high drop-out rates.
Opioid prescribing should be viewed as a time-limited therapeutic trial (e.g., three to four months).
If the patient is non-compliant or the aberrant behaviours continue, the prescriber should discontinue prescribing if appropriate, or begin tapering and refer the patient for methadone or buprenorphine therapy. Methadone and buprenorphine are effective treatments for chronic pain and addiction, and are easier in terms of monitoring and intervention.
Deciding whether to continue prescribing opioids
Only continue prescribing if the patient:
- is well known to you, and you are reasonably confident that the patient is reliable in reporting misuse
- has a definite nociceptive or neuropathic pain condition that often or usually requires opioid therapy
- is not accessing opioids from the street, friends or other doctors
- is not injecting or crushing oral tablets
- is not currently addicted to cocaine, alcohol or other drugs.
Safeguards for prescribing to patients with chronic pain and addiction
Opioid prescribing to patients with chronic pain and addiction to opioids should have the following safeguards in place:
- Use a written treatment agreement.
- Dispense small amounts of medication frequently (e.g., daily, every two days, twice per week).
- Perform frequent clinical assessments, regular urine drug testing and pill or patch counts.
- Switch the patient to sustained-release preparations.
- Switch to a different opioid than the one the patient is currently misusing or addicted to.
- Taper if the dose is above 200 mg/day morphine equivalent.
- Refer the patient for opioid agonist treatment if aberrant drug-related behaviours persist despite safeguards.
Supports for managing patients with chronic pain and addiction
Comprehensive pain clinics have pain experts, mental health professionals and sometimes addiction experts. They use various strategies, including cognitive therapy, pharmacotherapy and physical modalities. Unfortunately, access to comprehensive pain clinics is limited in Ontario.
Addiction medicine physicians can provide assessment, advice, follow-up and referral for pain patients who may be addicted to opioids. They will initiate treatment with methadone or buprenorphine when indicated.