Treatment of Pain in Patients with Addiction

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Recently I was discussing the finer points of management of pain with a colleague, and it occurred to me I hadn’t done a recent post on the management of pain in opioid addicts.

I think about pain in two categories: acute and chronic. While there are some conditions that defy this handy concept, most types of pain fall into one of the two types.

This post will address only about acute pain; I will do another post about chronic pain in future posts.

To reiterate, I’m not talking about pain from chronic conditions like arthritis, chronic back pain, pelvic pain, fibromyalgia, and the like. In contrast, acute pain examples include broken bones, surgery, physical trauma from an accident, and other conditions that begin suddenly, and resolve over a period of weeks to months.

Just because a person has the disease of opioid addiction does NOT mean she needs to suffer through acutely painful conditions without the blessed relief opioids can bring. Obviously, any time a person with opioid addiction is given a bottle of opioids, pain or no, we worry about the risk of relapse. And we know relapse can be serious, even life-threatening. However, safeguards can be put into place to defend against a relapse.

Acute severe pain is more difficult to manage if the patient is taking buprenorphine than methadone, but pain relief can still be achieved.

Many patients in recovery from opioid addiction are surprised to discover that mild to moderate acute pain can often be treated with non-opioid pain medication like anti-inflammatories such as ibuprofen or acetaminophen. While in active addiction, many of my patients never even tried such measures, and are happy to find that they can be effective. Other options like massage, heat, ice, or elevation can also help.

But moderate to severe acute pain usually requires opioid pain medications.

For patients on methadone, the standard approach is to continue the methadone at the patient’s usual dose, and add short-acting opioids. Best results for the patient are seen when the opioid treatment program doctor communicates with the doctor treating the condition causing the acute pain.

When I collaborate with other doctors, I tell them to prescribe whatever they would prescribe for any other patient, except my patients will probably need about fifteen to twenty percent higher dose, to make up for their existing tolerance to opioids.

I don’t worry about a relapse while the patient is in the hospital. While hospitalized, the patient’s response to opioid medication can be controlled and adjusted. It would be difficult for the patient to abuse the opioids they are being given while hospitalized.

The greater risk occurs after the patient leaves the hospital. I suggest the patient give their bottle to a dependable non-addict who can dispense one dose at a time, or at least one day’s dose at a time. So long as someone else controls the opioid medication, my patient will be safer. I also recommend prescribing smaller amounts of opioids with more frequent follow-up, but that’s not always possible.

With buprenorphine, it gets tricky. Some patients on buprenorphine get pain relief from short-acting opioid prescribed in addition to the usual buprenorphine daily dose, but I’ve had plenty of patients tell me they could not get pain relief from opioids until after buprenorphine was stopped for several days. To be on the safe side, if a patient has a surgery scheduled, I’ll ask my patient to stop dosing the day prior to the surgery, and stay off buprenorphine until after the pain resolves enough to get by without short-acting opioids.

For patients who were more fragile in their recovery, I’ve used an approach that I learned from other doctors at addiction medicine conferences: I reduce the usual maintenance dose of buprenorphine down to 2 mg sublingual daily, starting the day before surgery. Theoretically, this low dose of buprenorphine prevents euphoria from short-acting opioids, while not blocking the analgesic (anti-pain) effect of these opioids.

For a planned surgery, I prefer to work out details of pain control with the other doctor prior to the surgery. Duh. I hate getting post-operative calls from the nurses of surgeons telling me I am expected to manage the patient’s pain, since the patient has addiction and Dr. Surgeon does not “believe” in prescribing opioids for opioid addicts.

Oh no. That does not work for me at all.

I’m not a surgeon, so I don’t know how long patients usually need opioids after this type of surgery. I also won’t know when the degree of pain may indicate some complication from surgery. Not to mention that I wasn’t the one who got paid for doing the surgery, and was not consulted pre-operatively.

I’m happy to collaborate with the surgeon, and of course prefer to do this prior to the surgery. I tell the surgeon I prescribe methadone/buprenorphine to treat addiction, not pain, and that the usual maintenance dose of either will not help with acute pain. I give the doctor some guidance regarding my patients’ opioid tolerance. I tell her our opioid treatment program will watch our shared patient more closely for signs of relapse, and that the counselor will work with the patient to get a dependable non-addict to handle the bottle of pills. I tell the surgeon that we are happy to do pill counts when needed, for additional accountability.

My patients tell me they hate to tell a surgeon or other new doctor about being in medication-assisted recovery. They say when they tell a new doctor about being prescribed methadone or buprenorphine, they sometimes detect a change in attitude, like judgment, increased brusqueness, or even hostility. They fear they will not be believed if they report pain.

I can’t blame them for being worried, because even when I call other physicians, I sometimes detect a bit of insolence from the physician on the other end of the phone. I often feel my legitimacy as a physician is being questioned, even though, ironically, I have more data to support what I do now as a doctor than I ever had as a primary care physician. I often sense a real reluctance for surgeons and other doctors to go along with what I’m recommending, and that’s a shame, because I have evidence-based information they can use.

My goal when talking with another physician is primarily to make sure my patient gets appropriate care including pain control. It’s a bonus if I can educate that doctor about medication-assisted treatment, and try to give them a better understanding of addiction and recovery.

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12 responses to this post.

  1. I keep my suboxone patients on their regular dose prior to surgery then they can add short acting agents on top of that as needed. Sometimes, I’ll temporarily increase their dose of suboxone during the acute recovery period if they only need 2-4 mg more. So far, I’ve had good success with this model.

    Reply

  2. Posted by Icecutter on December 14, 2015 at 6:15 pm

    Dr. Burson
    I had cancer last year. I have been on MAT for 15 years. There was a 4 week period of intense pain and my oncologist gave me increasing doses of short acting opioids to be taken as needed to manage the pain. I required about 90 mgs of oxycodone or oxycontin a day. After the period of bad pain passed, I reduced my dosage over a period of 2 weeks. I remained on my usual dose of methadone the entire time. To my surprise and delight, I had no withdrawal symptoms after the last oxy pill was stopped. This was because I had the methadone in me to protect me from it. I did not need all the oxys I had and I then destroyed them. My addiction was never an issue because am an addict already, all my physicians knew it and they treated me for pain appropriately. Honesty with them throughout my cancer treatment made my addiction a non-issue in my treatment. I am well today and I want others who have acute pain and addiction to hear about my experience.

    Reply

  3. Posted by William Taylor, MD on December 15, 2015 at 7:43 pm

    Jeff Junig, MD addresses the same issue in his latest post at http://www.suboxonetalkzone.com. He likes to keep patients at 4 mg of buprenorphine and allow agonists as needed for analgesia. The fact that this works, even though the high-affinity buprenorphine should completely block agonist actions, suggests that we don’t understand opiate receptor pharmacology as much as we think we do.

    Reply

  4. Posted by kevin on December 16, 2015 at 2:23 am

    I have had 2 Polinatal cyst surgerys. The second one was the end of January of 2015. They have left me open both times to heal from the inside out. BTW I still have not healed almost 1 yrs later. Anyway the doctor did not go up on the dose like you suggested, I was also getting ibuprofen 800mg. Along with percocet sometimes 5 or 10, 1 pill every 4 to 6 hrs. I never had pain control. Never, I honestly never abused them. I couldn’t take the ibuprofen due to it making me bleed too much. After about 6 weeks of being on pain meds I had to see my doctor at the clinic. I got in trouble for still being on the percocet I was told NO YOU SHOULD HAVE ONLY HAD THAT FOR A COUPLE DAYS, YOUR ON 150 MG A DAY OF METHADONE AND THAT SHOULD HAVE HELPED WITH THE PAIN, needless to say I have complained for 3 yrs that my dose does not last and also they left me open. I can’t sit or anything. My legs would hurt from having to lay a certain way. I’m still in a lot of pain. Like I said it’s been almost a yr. I’m currently laying on a towel cause I have bled for 3 days almost not stop and heavy at times. I can’t heal, and I can’t go to the doctor cause of lack of insurance for other reasons.

    Reply

  5. Posted by Icecutter on December 18, 2015 at 7:10 pm

    Kevin,
    I am so sorry for you. I think I might have killed myself during my cancer treatment if I had not had adequate pain control. Only one of the doctors in my treatment thought that my methadone could reduce the pain. We educated him as best we could. Thanks to Dr. Burson’s blog and people like you posting what the reality is, hopefully more and more doctors will understand how to implement pain control for people on MAT. You are in my prayers, Kevin. Don’t give up!

    Reply

  6. Posted by Renae on December 20, 2015 at 11:22 am

    I am on Suboxone for pain pill addiction. I just found your site and it has so much valuable information. I also appreciate your attitude and compassion towards addicts.
    I have Crohns disease and have had to go to the ER for bowel obstructions which is severe pain. Many ER Drs have no knowledge about Suboxone. I did have one that was very educated on Suboxone and used a method of adding Valium which allowed me to need less narcotics. I have asked my addictionologist about creating an “instruction card” on how to treat acute pain for patients taking Suboxone. He thought this was a good idea and said he would talk to the Suboxone Rep about it. I’ve reminded him a couple of times but I think he just must be very busy. Right now I keep on me instructions I found on the internet written by an MD but it is lengthy and Im concerned an ER Dr will be offended by my telling him what he/she should do. My question is: Should I ask my addictionologist to write out instructions on his letterhead so an ER Dr will take it seriously? Is there a short version that is written by an accredited association that an EM Dr will appreciate?
    Thank you

    Reply

    • I think an ER doc isn’t likely to read anything given to him/her. It’s more likely the doc would be willing to call and speak with the addiction medicine doc. My office phone is forwarded to a cell phone we carry when away from the office, so I can handle such a situation quickly.

      Reply

  7. Just and anecdote. Some years back when I directed a halfway house we had a young patient, David, with severe Crohn’s disease. He had 2 bowel resections but this disease tends to skip around.It is also aggravated by stress. He began abusing his pain meds and went to a rehab which told him he could never take opiate meds again. We reasoned differently. He was tiny, about 5’4″ and 112 lbs. He was also meek and timid, never standing up for himself. The treatment plan with him included assertiveness training, learning how to stand up for himself, including with his (very wise) counselor, Ed. One occasion which I witnessed the young man came to the office to say it was time for his pills. He did so almost apologetically. His counselor ignored him, in fact it was as though he never entered the room. He repeated meekly once more, same result. He took a big sigh then very assertively said, “He Ed, give me my f*!#ing medication. Ed looked up and said, Sure Dave. Dave left on virtually no pain meds and remained on reduced medication on our follow up.

    Reply

  8. Posted by Mina on March 31, 2016 at 11:08 pm

    As a suboxone patient who also suffers from chronic pain, I’m surprised by some of the information and treatment plans described in some of these posts and am just curious about one thing: I was under the impression that it is possible to take bupenorphine alone (a.k.a. “subutex”) with other opiates, but not suboxone, as suboxone also contains the antagonist naloxone that not only blocks the effects of other narcotic medications (which defeats the purpose of pain medication to begin with) but can also throw the patient into severe withdrawal if taken with or even within 24-48 hours of other short-acting opioids. Am I wrong about this? Any medical advice offered would be extremely helpful, as I may soon need to temporarily switch from suboxone maintenance to opioid therapy due to a recent setback that has significantly increased my pain level.

    Reply

    • The active ingredient in both Subutex and Suboxone is buprenorphine a partial opioid with very high affinity for the opioid receptors. Suboxone has naloxone added to it but that part of the suboxone isn’t absorbed under the tongue. It’s only in there to make it more unattractive to inject, since the naloxone should cause withdrawal.
      If you are already on buprenorphine, you can take short-acting opioids for pain, but they may not be very effective, since the buprenorphine won’t allow other opioids to bind to the receptors. The other full opioids won’t make you sick, though.
      However, if you are taking a full opioid pain pill, and take buprenorphine soon after, that can cause withdrawal because the buprenorphine will throw other opioids off the receptor. Though buprenorphine is a partial opioid, it doesn’t give as strong an opioid effect as full opioids, thus the withdrawal.

      Reply

  9. Posted by Mikael on January 16, 2017 at 8:14 am

    Thanks for the excellent explanation of precipitated withdrawal. I had seen all the phrases and key terms before now, but your explanation made it coherent instead of alphabet soup.

    Reply

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