Chronic pain and substance use disorders are common and sometimes overlap. The safe and effective use of opioid drugs to manage chronic pain can be compromised by nonadherence or frank substance abuse. Practitioners can meaningfully intervene to help patients with chronic pain and/or substance use disorders, and prevent serious complications including unintentional overdose and death. Among the key interventions is appropriate referral to specialists, when such a referral would benefit the patient or reduce the risk of an adverse outcome. When patients with chronic pain develop significant non-adherent behaviors or behaviors consistent with drug abuse or addiction at any time in their treatment, and referral is being considered, the practitioner will need to discuss with the patient the options and rationale for referral, as well as the patient’s desires and goals. They may also need to discuss the patient’s case with a pain and/or addiction specialist. In most cases, the primary care provider will remain in his or her role as the main prescriber, utilizing the guidance of the specialist. One instrument available to the practitioner to assess problems in patients receiving long term opioid therapy is the Prescribed Opioids Difficulties Scale (PODS) (see appendix A). Information obtained from collateral contacts, such as family members, with the patient’s consent, can also be helpful in assessing problems or risk.
Practitioners must be aware that the treatment of chronic pain involves a heterogeneous group of therapeutic modalities, a discussion of which is beyond the scope of this document. These modalities are individualized for each patient and include, but are not limited to, pharmacotherapy with non-opioid or opioid drugs; invasive procedures involving injections, nerve blocks or implants; physical medicine and rehabilitation approaches; psychological therapies; and complementary and alternative medicine treatments. When a referral is made to a pain specialist, in order to prepare the patient and the consultant for a meaningful consultation, the referring practitioner should attempt to clarify what types of treatments might be made available, as well as what the patient’s wishes are for treatment.
Practitioners who treat patients with chronic pain, including primary care physicians and pain specialists, should have a strong working knowledge of substance use disorders, including the disease of addiction. This knowledge will not be at the level of the specialist in addiction, but rather at a level that allows these practitioners to know when to make a referral. All practitioners managing chronic pain need to know how to monitor aberrant behaviors that may be symptomatic of addiction or misuse, and so need to have a knowledge base of substance abuse similar to that for any other disease. The timeworn saying is apt: If you don’t know about it, you can’t see it. Just as the practitioner needs to be able to recognize the possibility of, and to make appropriate referrals for heart disease, s/he needs to be able to recognize the possibility of and refer for addiction. The American Board of Addiction Medicine and the American Society of Addiction Medicine certify specialists in addiction. Practitioners are encouraged to have in place working relationships with addiction specialty care providers. It may be critical to the patient’s care that the ability to continue to manage pain not be abandoned as a substance use disorder is addressed.
When the behaviors in the following list occur, the practitioner should 1) understand that a potentially serious substance use disorder exists, 2) reassess the patient’s pain and medical/psychiatric status, 3) take actions to control the prescription (e.g., limit the amounts prescribed and increase monitoring to minimize the risk of diversion (i.e. do not prescribe if there is high index of suspicion for diversion), and 4) consider referral. These behaviors are not exhaustive and should not be used pejoratively or in a way that will compromise care:
- Aggressive demand for opioids (consider context: if the patient’s pain is severe or function is impaired, requests for more treatment may be strongly worded or repeated)
- Unsanctioned use of opioids
- Unsanctioned dose escalation (consider context: occasional extra doses for flares of pain Â may be different than increasing the regular dose, and taking more after being told that this is unacceptable may be different than doing so in the absence of clear instructions)
- Having an abnormal toxicology screen (see guidance provided on toxicology)
- Obtaining opioids from multiple prescribers (consider context: obtaining a small supply of a short acting opioid from a dentist after treatment may be different than seeking another prescription for chronic pain from another physician)
- Recurring emergency department visits for chronic pain management (consider context: information from the ED will be needed to evaluate this behavior)
- Frequently losing prescriptions
- Injecting oral/topical opioids
- Concurrent use of illicit drugs
- Forging prescriptions
- Stealing or borrowing drugs
- Selling prescription drugs
Although not all practitioners agree, there is a growing agreement within the specialty of treatment of chronic pain to define chronic pain as a disease. Chronic pain may be associated with functional decline; numerous adverse physical, psychological and social consequences; and multiple medical and psychiatric co-morbidities. While some patients adapt to pain and retain the ability to function and enjoy life, others experience role disruption and related problems best characterized as “disability.” When a patient with chronic pain is given an opioid for what is anticipated to be long-term therapy, the hope and the minimal expectation is that pain will be decreased below its baseline; flare ups will be minimized; pain-related distress, and disability all will be lessened; and that this will be sustained over time and accomplished without significant toxicity or burden, and without nonadherence or the development of drug abuse or addiction: in short, that the benefits exceed adverse effects and burdens, that treatment is used responsibly over time by the patient, and that opioid use does not prevent or distract from other treatments that may be beneficial to address residual pain or functional impairments. This challenge is easily met in some patients, but not others.
When pain treatment poses significant challenges, referral to a pain management specialist may be helpful. Physicians are certified as specialists in the treatment of pain through the American Board of Medical Specialties and the American Board of Pain Medicine. There is richness in the types of treatment pain specialists offer; not all treat pain with the same modalities. As a result, primary care practitioners should become familiar with the specialists in the area, and if possible, refer to the specialist having the skills that are most likely to be needed by the patient. If a patient with poorly controlled pain also raises concerns about opioid therapy, referral should ideally be to a pain specialist who has experience in this modality.
Primary care practitioners should consider a referral to a pain specialist knowledgeable about opioid therapy in the following situations:
- The practitioner is uncertain about the appropriateness of long-term opioid therapy; this question may arise if the patient is opioid-naïve or has been receiving an opioid for an acute pain problem that has not resolved during a period of weeks.
- The practitioner believes that opioid therapy could be useful, but perceives that his or her skills are not adequate to ensure safe and effective treatment given the complexity of the patient; based on the consultation, a decision may be made to assume responsibility for the treatment or to agree to this responsibility only if ongoing assistance from the specialist will be available.
- The practitioner believes that opioid therapy could be useful, but perceives that the practice system within which he or she works lacks the support necessary for monitoring and documentation, given the complexity of the patient; if ongoing assistance from the specialist will be available, the decision may be made to assume responsibility for the treatment.
- The practitioner is already treating the patient with long-term therapy, but needs help to assess or optimize the plan of care, as suggested by
- a dose that is at a relatively high level, such as >100 mg/day MED, without reported adequate pain relief or improved function; or
- there is a report of improvement in pain but evidence of negative outcomes such as worsening function or side effects like somnolence; or
- there is evidence that other approaches to pain management should be considered because the pain diagnosis is unusual or complex, or the pain is associated with a relatively high level of disability or comorbidity.
There can be considerable overlap between the types of issues that suggest a referral either to an addiction specialist or to a pain specialist. Some patients may need referrals to both.
Just as there is considerable variation among pain specialists in their knowledge and experience in opioid therapy, addiction medicine specialists have varying opinions about prescription of opioids for pain. Ideally, practitioners should have access to and familiarity with a number of specialists in both fields in order to make meaningful referrals and to effect coordinated care.
In addressing concerns about substance use disorders, practitioners must be careful to distinguish medical issues from the problem of drug diversion. Indicators of diversion warrant special consideration in the interest of the public health, and may require vigorous action. Measures may include discharge to alternate care and/or legal action, such as reporting to authorities, and/or other actions that the practitioner will need to define for the patient.
Various constraints can exist, such as those of insurance coverage, reimbursement, transportation access, pain or addiction specialist availability, geographic locations (e.g. urban versus rural), as well as numerous others, that may influence positively or negatively a practitioner’s ability to implement the guidance provided in this document. Notwithstanding, practitioners should understand that these issues are of critical importance and need to be addressed. Failure to address these issues undermines good care.
This guidance is offered in the spirit that patients deserve excellent treatment with referral to specialists when warranted and that patients can rightfully expect that their problems with pain and/ or addiction will be treated with respect. Further, practitioners have a role in protecting the health of their patients and the public by competently addressing these conditions and exercising informed judgment in prescribing of medications.