Chronic Pain and Addiction Advances in Psychosomatic Medicine Vol. 30 Series Editor T.N. Wise Falls Church, Va. Editors G.A. Fava Bologna I. Fukunishi Tokyo M.B. Rosenthal Cleveland, Ohio Chronic Pain and Addiction Volume Editors M.R. Clark Baltimore, Md. G.J. Treisman Baltimore, Md. 10 figures and 14 tables, 2011 Basel · Freiburg · Paris · London · New York · New Delhi · Bangkok · Beijing · Tokyo · Kuala Lumpur · Singapore · Sydney Advances in Psychosomatic Medicine Founded 1960 by F. Deutsch (Cambridge, Mass.) A. Jores (Hamburg) B. Stockvis (Leiden) Continued 1972–1982 by F. Reichsman (Brooklyn, N.Y.) Library of Congress Cataloging-in-Publication Data Chronic pain and addiction / volume editors, M.R. Clark, G.J. Treisman. p. ; cm. -- (Advances in psychosomatic medicine, ISSN 0065-3268 ; v. 30) Includes bibliographical references and index. ISBN 978-3-8055-9725-8 (hard cover : alk. paper) -- ISBN 978-3-8055-9726-5 (e-ISBN) 1. Chronic pain--Treatment--Complications. 2. Analgesics--Effectiveness. I. Clark, M. R. (Michael R.) II. Treisman, Glenn J., 1956- III. Series: Advances in psychosomatic medicine ; v. 30. 0065-3268 [DNLM: 1. Chronic Disease. 2. Pain--drug therapy. 3. Analgesics -- therapeutic use. 4. Opioid-Related Disorders--etiology. 5. Substance-Related Disorders--complications. 6. Substance-Related Disorders--etiology. W1 AD81 v.30 2011 / WL 704] RB127.C4824 2011 616' .0472 -- dc22 2011006954 Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents® and Index Medicus. Disclaimer. The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publisher and the editor(s). The appearance of advertisements in the book is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements. Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, reproduced or u tilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. © Copyright 2011 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland) www.karger.com Printed in Switzerland on acid-free paper by Reinhardt Druck, Basel ISSN 0065–3268 ISBN 978–3–8055–9725–8 e-ISBN 978–3–8055–9726–5 Section Title Contents 1 From Stigmatized Neglect to Active Engagement Clark, M.R.; Treisman, G.J. (Baltimore, Md.) 8 A Behaviorist Perspective Treisman, G.J.; Clark, M.R. (Baltimore, Md.) 22 Addiction and Brain Reward and Antireward Pathways Gardner, E.L. (Baltimore, Md.) 61 Opioid Therapy in Patients with Chronic Noncancer Pain: Diagnostic and Clinical Challenges Cheatle, M.D.; O’Brien, C.P. (Philadelphia, Pa.) 92 Optimizing Treatment with Opioids and Beyond Clark, M.R.; Treisman, G.J. (Baltimore, Md.) 113 Screening for Abuse Risk in Pain Patients Bohn, T.M.; Levy, L.B.; Celin, S.; Starr, T.D.; Passik, S.D. (New York, N.Y.) 125 Cannabinoids for Pain Management Thaler, A.; Gupta, A. (Philadelphia, Pa.); Cohen, S.P. (Baltimore, Md./Washington, D.C.) 139 Ketamine in Pain Management Cohen, S.P. (Baltimore, Md./Washington, D.C.); Liao, W. (Baltimore, Md.); Gupta, A. (Philadelphia, Pa.); Plunkett, A. (Washington, D.C.) 162 Subject Index V Clark MR, Treisman GJ (eds): Chronic Pain and Addiction. Adv Psychosom Med. Basel, Karger, 2011, vol 30, pp 1–7 From Stigmatized Neglect to Active Engagement Michael R. Clarka,c (cid:2) Glenn J. Treismana–d Departments of aPsychiatry and Behavioral Sciences and bMedicine, The Johns Hopkins University School of Medicine, and cChronic Pain Treatment Program and dAIDS Psychiatry Service, The Johns Hopkins Medical Institutions, Baltimore, Md., USA Abstract Chronic pain and substance abuse are common problems. Each entity represents a significant and independent burden to the patients affected by them, the healthcare system caring for them, and society at large supporting them. If the two problems occur together, all of these burdens and their consequences are magnified. Traditional treatments fail a substantial percentage of even the most straightforward cases. Clearly, new approaches are required for the most complex of cases. Success is possible only if multiple disciplines provide integrated care that incorporates all of the principles of substance abuse and chronic pain rehabilitation treatment into one package. While experience provides the foundation for implementing these programs, research that documents the methods behind successful outcomes will be needed to sustain support for them. Copyright © 2011 S. Karger AG, Basel Chronic pain and substance abuse are independently recognized as complex problems growing in both scope and severity. Each has its own unique difficulties that contrib- ute to poor outcomes and partial response to treatment. Unfortunately, a substantial number of patients suffer from both of these devastating problems. These patients represent a highly stigmatized and uniquely underserved population that would easily benefit from clinical and research enterprises. Practical and longitudinal exper- tise is needed for the assessment, formulation and treatment of patients who suffer with chronic pain and substance dependence disorder. Identifying opportunities and directions for translational research are important elements in advancing our under- standing of these problems and their critically important interrelationships. In this volume, we have compiled papers related to the topic of chronic pain and addiction. The epidemic increase in the use of prescription opiates and the increasing use of opiates for the purpose of euphoria has led to great concern. There has been an epidemic increase in prescription opiate addiction as well as a dramatic upsurge in opiate use by adolescents. The increased appreciation of the large number of patients who suffer from chronic pain that diminishes their function is one of the drivers of the increased use of opiates. Unfortunately, many of the medications that are effective at reducing pain are reinforcing and create the potential for addiction. Refractory Chronic Pain Does Not Equal Addiction Patients with a poor response to typical treatments for chronic pain are at increased risk of being labeled a ‘drug addict’ when they request more aggressive pain ther- apy. Whether they specifically ask for opioid analgesics or not, practitioners will often assume the worst. In patients with known substance use disorder, continuing complaints of pain are routinely regarded simply as drug-s eeking behavior that is undermining or counterproductive for their ‘recovery’ plan. The usual approach to evaluating this complex set of problems devolves to determining whether the patient has a ‘real pain’ problem or is simply an ‘addict’. This dichotomy ends in unsophisti- cated diagnoses and cookie- cutter treatments. In contrast, patients with unquestionable chronic pain can and do develop inde- pendent substance use disorders that emerge despite the most sincere efforts to seek understandable relief from their pain. Once again, the rush to judgment reflected in the evaluation phase of this problem can lead to the emphasis on only one dimension of the presentation (e.g. substance abuse or pain), which minimizes the other dimen- sion (pain or substance abuse). An essential element in the successful treatment of these patients that present with features of both problems is tolerating the ambigu- ity that can dominate the initial evaluation and accepting that the question can be resolved with sufficient time in active treatment. Enhancing Treatment with Integrated Approaches The common interactions between chronic pain, opioids, and other medical and psychiatric problems including substance use disorders makes treatment-s eeking, opioid-d ependent patients a critically important subgroup of patients with a compel- ling need for enhanced evaluation and treatment services [1–3 ]. Regrettably, patients with chronic pain combined with substance use disorder (especially opioid depen- dence) remain a stigmatized, maligned and often neglected population [4–6 ]. Our inability to transmit the public health needs to the individual patient increases the risk for drug-s eeking behavior, including self-m edication with illicit drugs and the serious hazards associated with this practice. While the benefits of substance abuse treatment are widely touted, there is lit- tle discussion about how routine substance abuse treatment can accommodate the needs of a patient with a comorbid chronic pain syndrome. In addition to patients’ 2 Clark · Treisman inaccurate and underreported use of prescription medications and illicit drugs, the level of difficulty associated with the management of these patients is increased by the infrequent assessment typical of routine chronic pain and drug abuse treatment pro- grams [7, 8]. These problems would be reduced if routine treatment were modified to: (1) incorporate detailed assessments that begin with an extensive history of both prior pain and drug use problems, (2) provide for testing of weekly urine specimens for opioids (prescribed and illicit) and other drugs, and (3) offer ongoing, appropriate positive reinforcements for reporting the use of opioids prescribed by other practi- tioners to account for the detection of these potentially illicit substances in the urine specimens. Substance abuse treatment programs should expand their services to address any and all of the comorbidities posing barriers to successful drug rehabilitation. Given the high prevalence and negative impact of chronic pain, new pain management services should be integrated with the drug treatment program and adapted to the patients’ need for more intensive treatment. If applied to the problem of chronic pain, a model substance abuse treatment program of integrated stepped care would improve out- comes for patients with both of these devastating types of disorders. Interdisciplinary Treatment Plans Interestingly, the treatment of chronic pain in people with substance use disorders remains focused on how to use opioids. There is comparatively little discussion about whether other modalities of therapy might be more effective, safe and appropriate. The assumption that opioids are the first- line therapy for this population further stig- matizes these patients. This position implies that a comprehensive evaluation and treatment plan usually provided to patients without substance use disorders should only be implemented as a last resort in patients with both drug abuse and chronic pain. This recommendation simply accepts that patients with substance use disorder do not have access to high-q uality medical care and reinforces the belief that they do not deserve it or that they would reject a priori any alternative to opioid- based treatments. For example, in the care of this population, there is little discussion of nono- pioid medications for the treatment of neuropathic pain problems, inter ventional approaches to reducing musculoskeletal pain, and active physical therapies to enhance efforts of rehabilitation. Multidisciplinary pain treatment programs have not been incorporated into substance abuse treatment programs, which are not staffed to provide pain evaluation and management. Multidisciplinary pain treatment programs usually seek to avoid patients with clear opioid dependence disorder. The ‘hot potato’ patients with both problems receive inadequate or no treatment, thereby reinforcing the prophecy that these are ‘refractory’ cases to be weaned off. From Stigmatized Neglect to Active Engagement 3 Treating Psychopathology to Optimize Outcomes with Long- Term Opioid Therapy As a rule, an active substance use disorder is a relative contraindication to chronic opi- oid therapy. However, opiate therapy can be used successfully if the clinical benefits are deemed to outweigh the risks. A strict treatment structure with therapeutic goals, landmarks to document progress, and contingency plans for noncompliance should be made explicit and agreed upon by the patient and all the providers of healthcare. The first step for the patient is to acknowledge that a problem with medication use exists. The first step for the clinician is to stop the patient’s behavior of misusing medi- cations. Then, sustaining factors must be assessed and addressed. These interventions include treating other medical diseases and psychiatric disorders, managing person- ality vulnerabilities, meeting situational challenges and life stressors, and providing support and understanding. Finally, the habit of taking a medication inappropriately must be extinguished and replaced by more productive, goal- directed activities. The patient should be engaged in an addiction treatment program that reinforces taking the medication as prescribed and examines the possible reasons for any inappro- priate use. Relapse is common and patients with addiction require ongoing monitoring even after the prescription of opioids has ceased. Group therapy is the backbone of treat- ment for these patients and traditional outpatient drug treatment or 12- step programs can provide a supportive structure for recovery. Relapse prevention should rely on fam- ily members or sponsors to assist the patient in getting prompt attention before further deterioration occurs. If relapse is detected, the precipitating incident should be examined and strategies to avoid another relapse should be implemented. Although the misuse of medications is unacceptable, neither total abstinence nor complete compliance is always possible. Restoration of function should be the primary treatment goal and may improve with adequate, judicious and appropriate use of medications, even if setbacks occur [9]. A comprehensive formulation is necessary for the determination of why long- term opioid therapy is not working to control a patient’s pain and causing deterioration in function. Approaching patients by investigating the different perspectives of acquired diseases, inherent vulnerabilities, disruptive choices and unfulfilling encounters focuses the physician on treatable causes of disability instead of blaming the patients or their opioids for a lack of rehabilitative progress. Future Research There is a growing consensus that the prevalence of cooccurring chronic pain and substance use disorders is high and presents a significant burden to the healthcare system and society. Treatment approaches that target either one of these problems run the risk of ignoring the other and compromising the overall care and progno- sis of these patients. Cartesian dualism in any form is an inadequate model for the assessment, formulation and treatment of patients. These patients cannot be clearly 4 Clark · Treisman