Pain is the most common symptom that brings patients to our office and chronic pain is a co-existing disease state in more than 50% of the patients we see on a regular basis. A disproportionate share of the chronic pain patients we treat have been discharged from other practices because of alleged misuse of medicine, alleged aberrant behavior, or simply because a prior treating physician became concerned that they would be investigated for prescribing pain medications.
In my opinion, pain and addiction often exist on a continuum and can occur co-morbidly. Any chronic pain patient treated with opioids for an extended period of time will become opioid dependent. Many of these patients demonstrate aberrant behavior but do not fit the definition of addiction. Some patients have histories consistent with a substance use disorder but when involved in a recovery program their addictive disorder can become a secondary diagnosis. The American Society of Addiction Medicine (ASAM) recognizes that addiction is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Chronic pain patients with opioid dependency that present to our practice are screened and treated for substance use disorder if it is a concurrent diagnosis. Patients that continue to be treated with an opioid for pain management may or may not have previously met the criteria for a substance use disorder. In either case, compliance with our program requires that behaviors associated with addiction cease.
The strongest and most effective pain relievers are opioids, derived from the opium poppy or synthetic versions of its active compounds. In the past, opioids have been associated with addiction, moral weakness and crime but recent research and clinical experience have led to breakthroughs in the understanding of pain and addiction, and how to effectively manage these conditions with a vast array of medications, many of which are commonly used off label. Federal law or regulations do not restrict the prescribing, dispensing, or administering of a narcotic medication to a narcotic-addicted patient for the purpose of alleviating pain if such prescribing is medically appropriate within standards set by the medical community (21 CRF 1306.07).
The primary opioid used in our practice to treat chronic pain is buprenorphine. Acute pain superimposed on chronic pain is sometimes treated with hydrocodone or Percocet but the ongoing use of short acting opioids in our patient population is discouraged. Of note, buprenorphine in the form of Buprenex® has been indicated for the treatment of pain in the United State since 1985. In 2002, the FDA approved two buprenorphine products (Suboxone® and Subutex®) for the treatment of narcotic addiction. Its unique pharmacological profile and the special amendment allowing it to be used in the treatment of narcotic addiction have propelled it into the awareness of the medical community and the general public but it was first marketed in the US as a schedule V narcotic analgesic.
