Look beyond opioids for substance use disorders in patients with chronic pain
LAS VEGAS — The majority of opioid-related overdoses can be linked to illicit heroin and fentanyl, not opioids prescribed by physicians to patients with legitimate chronic pain, according to a presentation during PAINWeek 2022.
“The opioid crisis has obscured the equally important issue of pain and other substance use disorders” in patients suffering from chronic pain, said Martin Cheatle, PhD, an associate professor in the department of psychiatry at the Perelman School of Medicine at the University of Pennsylvania.
Only 8% to 10% of patients with chronic pain who are prescribed opioids will develop opioid use disorders, Cheatle said. However, this group of patients is at risk for other types of substance abuse, including alcohol, nicotine and cannabis.
The number of prescriptions for opioids has dropped significantly over the past 6 years, he said, while the rate of opioid overdoses has dramatically increased.
Primary care providers, who are typically not trained in addiction medicine, often make the diagnosis and prescription, Cheatle said. Opioids are often misused for sleep and anxiety. The legitimate prescriptions enter the community, “and the reservoir is diverted to people at risk for addiction and misuse.”
Many patients with pain would benefit from opioid therapy, he said, but those patients need to be evaluated for risks and benefits and undergo close monitoring.
Alcohol use disorder and pain are common comorbidities, Cheatle said, which may exacerbate the neural dysfunction.
“Heavier drinking is associated with greater pain severity, pain interference and less pain coping among chronic patients receiving long-term opioid therapy,” he said. “The combined use of alcohol, opioids and sedatives increases the risk for overdose.”
Cheatle added: “Anyone can walk to the liquor store. They can manage the pain if you don’t. If we don’t find a way to treat their pain, they’ll find a way to treat it.”
The link between nicotine use and pain is also important, Cheatle said.
“Smoking in the general population has declined, but smoking rates remain high among those with co-occurring pain,” he said. “Smoking can lead to the development of chronic pain, and pain can motivate nicotine and tobacco use.”
Patients with chronic pain who smoke tend to have poorer outcomes with regard to function, mood and pain intensity, Cheatle said.
A range of assessment tools are available for each type of substance use disorder, he said, but for potential alcohol use disorder, ask the patient two simple questions.
“Ask patients if they have ever had drinking problems, and ask if they have had any alcohol to drink in the preceding 24 hours,” Cheatle said. “If the answer to both questions is positive, the sensitivity for alcohol problems is 92%.”
Medications for treating opioid use disorder include methadone, buprenorphine and extended-release naltrexone, Cheatle said.
“It can cut all-cause mortality rates by a half or more,” he said. He noted that buprenorphine also has an anti-suicide effect in addition to helping with pain.
Adjunctive medications include nonsteroidal anti-inflammatory drugs, acetaminophen, muscle relaxants, antidepressants, anti-epileptics and lidocaine patches.
FDA-approved medications for nicotine dependence include nicotine replacement therapy, sustained-release bupropion HCl and varenicline.
Pharmacotherapy for alcohol use disorder includes acamprosate, disulfiram and naltrexone.
“We default into a biomedical approach, but it has to be greater than that,” Cheatle said. “We have social support, CBT [cognitive behavioral therapy], ACT [acceptance and commitment therapy] and CAM [cognitive and affective mindfulness]. Social support mitigates relapse.”
According to Cheatle, “Building in social support with buprenorphine might be a really good add-on – it works well with methadone.”
He noted that computerized CBT for substance abuse disorders has been successful.
“Clinicians caring for patients with chronic pain should be cognizant of other substance use disorders beyond opioids,” Cheatle concluded.