Pain Management in the Chemically Dependent

Substance abusers who have chronic pain present a difficult challenge for the physician. A recent journal of American Medical Association study indicated that in 50% of serious accidents, there was a coexisting history of substance abuse in the individuals involved. When one included past history, the incidence rose as high as 70-80%. Obviously accidents lead to severe trauma and resulting pain. How then does the physician treat the patient with chemical dependency and pain. The answer is very carefully.

The particular difficulty with this type of patient is not knowing why they “need the medication”. Are they taking it for the pain or for their emotional suffering. If it is truly the former, you may be successful, if the latter, then it becomes a “slippery slope”. Although initially opiates will quell emotional pain, tolerance will quickly develop and escalating doses are required. This patient will ultimately get into trouble. Their history will be marked with obvious unmanageability occurring in their daily life and relationships. They are set up for drug overdose.

Certain steps can be taken as safeguards. A thorough initial psychiatric evaluation to establish a dual diagnosis. Identifying psychiatric disorders such as depression, anxiety, bipolar disorders and psychosis that may be triggering the addiction disorder and then appropriate treatment. This will decrease the likelihood of future relapse. Involving the family and significant others in the treatment, for support as well as collateral information and feedback. Attempting to simultaneously involve the pain patient in a 12-step program such as AA or NA. So that, they can constructively handle everyday anxieties, frustrations and disappointments in an appropriate fashion. “Life on life’s terms”. Involving their sponsors from such programs. They should be seen frequently, at a minimum monthly, to assess their condition, making appropriate adjustments in their treatment plan. Giving them enough medication for only one month. The use of medication should be strictly monitored. It should come from only one pharmacy. If they run out of medication early, because they have been taking more than the correct amount, they will need to wait until their next month’s prescription. Extra medication should not be given to them if they run out early. They must agree to random drug screens. If they develop a new injury or pain problem and are given a new narcotic medication, then the prescribing doctor must confirm this with the primary physician. Altered or forged prescriptions, attempts to sell or purchase medication from someone else will not be tolerated.  If this were to occur, the medication should be slowly reduced and stopped. Opiates are controlled substances, prescriptions will not be automatically replaced if lost or stolen.

By establishing these ground rules and putting them into a contractual form, having a tight rein and a short feedback loop with such a patient minimizes the chance of that patient running into problems. I put the stipulations into a contractual form, have the patient sign an informed consent, we both receive a copy of the contract and if there are any aberrations, medication is withdrawn in a responsible way. If the patient at that point in time is in trouble and needs help with withdrawing from the opiate medication, then arrangements are made to have him admitted into a rehab facility where the process can occur in a more controlled environment.