Treatment Strategies for Chronic Pain in People Dependent on Opioids

As the opioid crisis turned national epidemic continues to plague our country, controversy rises on how to continue to treat patients for chronic pain without putting those same patients at risk of abusing medication or developing addictions.

Pointing fingers is not uncommon when it comes to discussing the opioid crisis, however, there is no one single villain nor is there one simple solution. All along the supply chain, from the manufacturer to distributors, from retail pharmacies to the provider, persons responsible for discharging potent opioid drugs safely to the end user—people battling acute or chronic pain—often fail. Some failure is can be attributed to naivety or unwitting error, as many well-intentioned providers prescribed opioids—fully trusting the manufacturers’ word of the safety and nonaddictive nature of their product. For some providers, the failure was more calculated, as highlighted in recent indictments. These indictments and convictions shed a light on the deceptive marketing and excessive distribution practices that paint a culture of greed, often difficult to imagine when lives were and are being destroyed because of it.

Although these faces are the true and dark icons of the epidemic, the faces of the addicted and chemically dependent are the real story. Despite strong scientific evidence and years of understanding that addiction is a disease like other physical illnesses, the addicted person in the popular mind is often still one of character limitations, flaws, or criminality. Behavior leading to substance addiction remains more blameworthy than behavior leading to cancer, or diabetes, or heart disease.

“The stigma is the feeling that these people did it to themselves, it is their choice,” said Andrey Ostrovsky, MD, chief medical officer and vice president of behavioral health, Solera Health.

This misunderstanding continues to block quality care of persons addicted or chemically dependent on substances. It is this concept, a stigmatized wall that thwarts efforts to curb the trajectory of the epidemic turned public health crisis currently reaching into every corner of the country. A costly crisis, in terms of lives lost, incarceration, and health care systems burdened with people cycling in and out of care without receiving the care that they need to stop the cycle. 

“How are we going to deal with this [opioid crisis] moving forward?” questioned surviving addict, Robert Riley II, founder of the Missouri Network for Opiate Reform and Recovery, and addiction counselor, Clayton Behavioral, St. Louis, MO. The answer, he continued, is “when we stop demonizing persons with a substance use disorder and treat them like humans and come up with a good treatment plan like we do for other conditions.”

Developing Quality Treatment Plans: 

Clinical Judgement

One of the major problems faced by persons with substance use disorders or those who are chemically dependent on opioids
(See “Dependence vs Substance Abuse”) is the lack of knowledge or reluctance by clinicians on how to effectively and safely treat chronic pain.

The main initiative has been to simply reduce or eliminate opioids for chronic pain, an approach taken by many clinicians since the 2016 Centers for Disease Control and Prevention (CDC) guidelines on prescribing opioids for chronic pain emphasized nonpharmacologic approaches. While the guidelines emphasize the need for clinicians to use clinical judgement when working with individual patients and to consider exceptions for certain populations (cancer, sickle-cell disease, and end-of-life care), fallout from guidance has led to eliminating opioid prescriptions even for people who need them. Pushback from a range of specialty groups, including those who work with substance use and addiction, highlights the adverse effects of the
2016 guideline which has made it more difficult for persons whose opioid treatment needs to be managed differently than simple elimination.

In response to the pushback, the CDC reiterated the need for clinicians to use clinical judgement when providing treatment guidance for individual patients with chronic pain. CDC emphasized that the guidelines are not consistent with “inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt taping of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice.”

This clarification came on the heels of a warning issued by the US Food and Drug Administration (FDA) on April 9, 2019 of the danger of the abruptly discontinuing or rapidly decreasing opioids.

Mr Riley, whose work with the Missouri Network for Opiate Reform and Recovery includes educating health care professionals about substance use disorder and chemical dependency, emphasized the need for a better understanding of alternative treatment plans for titrating patients off opioids to other less addictive or chemically-dependent medications for managing chronic pain.

“What I’m seeing is that doctors are now not as willing to prescribe opioids and they are cutting them off of these meds without any treatment plans going forward,” Mr Riley said. “We’re seeing people who have been taking opioids for years, for maybe back pain, and are now being cut off and not even on a taper.”

Such a draconian approach inadvertently caused those deprived of their pain management to cause further damage to themselves and create the largest faction fueling the opioid epidemic—people turning to illicit drugs, which, in turn, leads to high rates of overdosing and death.

“We are seeing that when people who have been physically dependent [on opioids] have been cut off, they turn to illicit opioids,” said Mr Riley.

Statistics show what happens when people turn to illicit opioids—many of which now are laced with fentanyl or other dangerous synthetic opioids.  Overdose and deaths related to opioids increase dramatically. In 2017, more than 28,000 of the deaths due to overdose involved synthetic opioids.

Dr Ostrovsky, whose work at Solera Health helps health insurers find high-quality providers for substance use disorder, underscored the need for insurers to recognize the high cost of a scenario in which a patient overdoses, then requires expensive inpatient care, and afterwards, potentially rehab and residential care.

Instead, Dr Ostrovsky said that a smarter, more cost-effective strategy for insurers, such as managed care organizations that focus on utilization management, is to ensure what the evidence shows is effective in managing opioid dependence in these patients—medication-assisted treatment (MAT). 

Emphasis on the “M” in MAT

“The research clearly shows that if we administer medication-assisted treatment—the medication part of MAT is the most efficacious part—administering that medication is what actually helps people to avoid overdose and enable them to start the journey to recovery,” said Dr Ostrovsky.

MAT is the use of medications such as buprenorphine (Suboxone), methadone, or naltrexone (Vivitrol) to help people with opioid use disorders by reducing the negative symptoms of withdrawal and cravings for opioids. Patients with substance use disorder treated with MAT are less likely to relapse than those not treated with MAT.

Dr Ostrovsky emphasized that patients with substance use disorder can have acute exacerbations of the disease, similar to a person with a diabetic flare, which requires immediate attention. “If an individual with an opioid use disorder is beginning to experience withdrawal symptoms, they are either going to get MAT to stop withdrawal symptoms or they will find another way to get an opioid, and that alternative is a street drug.” 

Providing MAT during this critical window is in Dr Ostrovsky’s opinion, the key to reducing the opioid epidemic.

However, Dr Ostrovsky said clinicians are often hampered with obstacles in providing such care because MAT currently requires prior authorization by most insurance companies.

“One of the lowest hanging fruits or opportunities to reduce the opioid overdose rate is to eliminate prior authorization for medication-assisted treatment,” said Dr Ostrovsky.

More difficult are the challenges of motivating people to get help for their opioid use and getting past the stigma providers and insurers have in offering treatment. It is critical to have a clear way to help them find a new treatment approach to manage their chronic pain.

For motivating people, Mr Riley recommends that providers start by meeting the person where he or she is. “Maybe a person is not yet ready to go off a substance they have been using for years and the very thought of losing a drug sends them into a panic attack,” he said. “I recommend sitting down with the person with a nonjudgmental, humanizing instruction about what a treatment plan looks like to find a less harmful way to treat pain.”

Identifying a Person With A Substance Use Disorder

Although patients with chemical dependency and substance use disorder share a physical dependency on opioids, it is important to distinguish these patients from each other to ensure appropriate treatment.

A key difference is that people with a substance use disorder have a medical disorder in which the brain tells them they need the substance to survive, said Mr Riley. As such, the daily life of a person with substance use disorders is often interrupted by thoughts of obtaining or using substances. For those people, referral to a substance use disorder specialist or program is often necessary. 

People with chemical dependency, without a substance use disorder, on the other hand, can function quite well and if their opioid use is not interfering with daily life, and they are not needing increasing doses for pain relief, then the goal of their care should be pain control, according to Dr Ostrovsky. 

“The tricky part is if you have chronic pain and you develop an opioid use disorder,” Dr Ostrovsky said, adding that then the goal is twofold—maintaining functional health until you get to recovery and adequately managing pain. 

One important change that could help providers identify a person with a substance use disorder is having access to prescription drug monitoring programs (PDMPs), which contain information on controlled substances prescribed and dispensed to individuals. 

“The ability to monitor and identify patients at risk of substance use disorder is hampered by the inability of managed care organizations to access state run PDMPs,” said Susan A Cantrell, RPh, CAE, chief executive officer, Academy of Managed Care Pharmacy, Alexandria, VA. “Many state PDMPs include real-time or near real-time information that would aid managed care organization decision makers in identifying patients at risk for substance use disorder and those in need of immediate treatment.”