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Physicians Should Proceed Carefully But Avoid Undertreating Pain in Patients With Addictions: Presented at AAHPM

By Bonnie Darves

SALT LAKE CITY, UT -- February 21, 2007 -- Managing pain in hospice patients and those with life-threatening conditions who also have addiction disorders can be challenging, but physicians should generally employ the same principles and processes they use to relieve pain in nonaddicted patients, according to a presentation made here at the American Academy of Hospice and Palliative Medicine annual assembly (AAHPM).

In a session on February 16^th, Ronald Crossno, MD, FAAHPM, area medical director, VistaCare Hospice, Temple, Texas, discussed the treatment of patients with addition who require pain management.

Some modifications to the care plan may be warranted in the areas of drug choice, dosing, and titration for adequate pain control -- possibly avoiding partial agonists or antagonists that could precipitate or exacerbate withdrawal, or opting for pain-management agreements as warranted, said Dr. Crossno.

However, it is important to avoid undertreating pain in these patients. In fact, physicians may need to expedite pain treatment in some patients, to avoid adverse events such as compromising addiction recovery or propelling patients with active addiction toward potentially dangerous self-medication.

"The basic [pain management] principles are the same for addicts as for nonaddicts, but pain that is untreated [in addicted patients] may escalate and become even harder to control," Dr. Crossno said. That basic strategy should include using nonscheduled drugs only if the medications provide adequate pain control, and using long-acting opioids in higher and more frequent doses than might be required for patients without addictions, because of tolerance issues and to minimize "the high," he explained.

Patients on methadone maintenance regimens, for example, may be treated with other opioids for pain, but may not be good candidates for "rescue dosing." Use of maintenance medications (buprenorphine or buprenorphine/naloxone for opioid dependence, and naltrexone for heroin or alcohol dependence) may complicate pain management and may require temporary cessation, but should not deter physicians from prescribing adequate opioids to control moderate to severe pain.

In addition, physicians may need to assess addicted patients more frequently and engage in periodic dose-reduction strategies more actively, and they should ensure that only 1 provider "manages" the patient from the standpoint of prescribing.

Physicians might also consider using "pain-management contracts" with patients whose behaviors might compromise treatment, or to avoid potential liability issues or concerns, Dr. Crossno said. Such agreements might specify treatment terms and nonpermitted behaviors (such as requesting early refills or failing to go to scheduled appointments with providers), as well as a schedule for terminating certain treatments. He cited the agreement used by the University of Utah Hospitals and Clinics Pain Management Center(1) as a good working document. Such agreements, although nonbinding of necessity, also provide good documentation of the clinician's treatment and attempts to provide adequate pain control and appropriate treatment, Dr. Crossno said.

Physicians are also advised to avoid relying on their own assessments of pain when deciding what drug and dose to prescribe, Dr. Crossno explained, and should employ the patient self-report indicator as a guide to choosing a starting strength -- just as is done with nonaddicted patients. Often, physicians who are concerned about overdose or liability may underprescribe pain medications to their addicted patients, failing to consider that these patients -- especially those with opioid addiction -- may both require and tolerate well higher doses of pain medications.

Dr. Crossno concluded by reminding attendees that US federal drug-prescribing regulations do not delineate specific dosages or quantities of scheduled drugs provided the prescriptions meet legitimate medical needs. Dr. Crossno did, however, urge attendees to be aware of state or other laws that might govern or affect their prescribing activities.

REFERENCE:
1. Sample Medication Management Agreement. University of Utah Hospitals and Clinics Pain Management Center. Available at:

http://www.painedu.org/Downloads/NIPC/Sample%20Patient%20Treatment%20Agreement.pdf


[Presentation title: Management of Patients With Addictions. Session 431]

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