Center for Addiction Medicine

07/03/2008 - Reviewing Our Approach to Chronic Pain, Abuse and Addiction

The prevalence of those who suffer from chronic pain is conservatively estimated at some 50 million Americans. Chronic pain interferes with the people's lives, making it difficult to work, do daily activities, exercise or enjoy hobbies. Family and social relationships are affected.

In treating chronic pain, doctors aim to reduce the level of pain patients experience in order to improve their quality of life, but in day-to-day practice, patients do not get complete relief from pain.

Finding a treatment that does improve the quality of life for someone with chronic pain takes time, and consists of a combination of treatments and therapies. Many patients believe they can be cured of pain, but with chronic pain diseases and disorders, that is usually not the case. For doctors, the focus is pain control with good disease management.

In severe cases, patients need to be referred to pain medicine specialists; however, primary care providers manage half of all patients with chronic pain. Many doctors have concerns about treating chronic pain because they don't have a great deal of education and background in doing so. Those doctors more than 10 years out of medical school probably did not get much specific training in pain management. Because of that and some regulatory concerns, many are reluctant to prescribe opioid pain medications. In addition, many physicians fear addiction.

Because primary care physicians handle so many cases of chronic pain, some basic tips will help doctors establish a pharmaceutical treatment plan that can help avoid addiction. Herbert Kleber, M.D., director of the Division of Substance Abuse for the New York State Psychiatric Insititute, reminded doctors at a presentation earlier this year that pain and disease are not static.

Pain levels should be frequently reassessed and medication dosages need to be adjusted over time. Urine drug testing can be an important tool in verifying adherence to a medication treatment plan. It can tell you whether there has been a relapse to use of illicit drugs or other medications that were not prescribed.

It's important to distinguish between physical dependence, tolerance and addiction if you are going to prescribe opioid pain mediations. Many chronic pain patients develop tolerance to pain medications, that is, they need more and more of the drug to get the same results. Long-term use of opioids may result in dependence, where the brain adapts to the repeated presence of the drug, so that not taking the medication produces withdrawal symptoms.

In chronic pain patients, a major concern with long-term treatment using pain medications is that a progression from physical dependence to addiction may occur. Addiction is a chronic pattern of use that involves a compulsion to take the drug and avoid withdrawal symptoms despite any health or social consequences. Addiction tends to be more prominent in individuals with predisposing factors, such as genetics.

Many primary care doctors miss the subtle signs of the progression from problematic use to addition.  It is crucial, then that doctors become familiar with the signs, symptoms and the disease of addiction. Just like you would with a patient with chronic heart condition or diabetes, these patients need to be referred to a physician that specializes in the disease.

Chronic pain is a serious condition that significantly impacts peoples' lives. While medication can provide great relief to chronic pain patients, a significant concern is addiction to opioid medications.

Solving this problem involves providing better training and education to physicians about both chronic pain and addiction. Despite some concerns, primary care physicians are best positioned to treat pain, and opioids and other pain medications can be safely prescribed to treat chronic pain with some strategies that address tolerance, dependence and addiction.

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