Treating Comorbid Opioid Use Disorder In Chronic Pain

​This in-depth text addresses how to approach and treat the chronic pain patient struggling with problematic opioid use. It discusses the approach for patients who may be at high risk of problematic use, such as those with a history of mental illness or substance use disorder. The first part covers diagnosis and treatment, focusing on common best practices that practitioners can adapt to any practice. Two of the chapters detail alternative and replacement therapies for opioid. Two more cover special issues in the treatment of women and older patients. The second part reviews the ethical, legal, regulatory, and policy issues surrounding the treatment of patients with comorbid pain and addiction. The book includes strategies for documentation that mitigate the risk of legal issues or ethical boundary crossings. The last part of the book addresses treating comorbid pain and opioid use disorder in different medical settings and the treatment of co-occurring mental illnesses and substance abuse. Treating Comorbid Opioid Use Disorder in Chronic Pain is of great value to psychiatrists, pain physicians, primary care providers, social workers, drug rehabilitation centers, and other behavioral health professionals. ​

Drug overdose, driven largely by overdose related to the use of opioids, is now the leading cause of unintentional injury death in the United States. The ongoing opioid crisis lies at the intersection of two public health challenges: reducing the burden of suffering from pain and containing the rising toll of the harms that can arise from the use of opioid medications. Chronic pain and opioid use disorder both represent complex human conditions affecting millions of Americans and causing untold disability and loss of function. In the context of the growing opioid problem, the U.S. Food and Drug Administration (FDA) launched an Opioids Action Plan in early 2016. As part of this plan, the FDA asked the National Academies of Sciences, Engineering, and Medicine to convene a committee to update the state of the science on pain research, care, and education and to identify actions the FDA and others can take to respond to the opioid epidemic, with a particular focus on informing FDA's development of a formal method for incorporating individual and societal considerations into its risk-benefit framework for opioid approval and monitoring.

The opioid crisis in the United States has come about because of excessive use of these drugs for both legal and illicit purposes and unprecedented levels of consequent opioid use disorder (OUD). More than 2 million people in the United States are estimated to have OUD, which is caused by prolonged use of prescription opioids, heroin, or other illicit opioids. OUD is a life-threatening condition associated with a 20-fold greater risk of early death due to overdose, infectious diseases, trauma, and suicide. Mortality related to OUD continues to escalate as this public health crisis gathers momentum across the country, with opioid overdoses killing more than 47,000 people in 2017 in the United States. Efforts to date have made no real headway in stemming this crisis, in large part because tools that already existâ€"like evidence-based medicationsâ€"are not being deployed to maximum impact. To support the dissemination of accurate patient-focused information about treatments for addiction, and to help provide scientific solutions to the current opioid crisis, this report studies the evidence base on medication assisted treatment (MAT) for OUD. It examines available evidence on the range of parameters and circumstances in which MAT can be effectively delivered and identifies additional research needed.

The relationship between chronic pain and addiction Patients with chronic pain understandably seek relief from their distress and discomfort, but many medications that alleviate pain are potentially addictive, and most chronic pain conditions only have a temporary response to opiate analgesic drugs. This volume reviews the fundamental topics that underlie the complex relationships of this controversial domain. The authors review behavioral models and practical methods for understanding and treating chronic pain and addiction including methods to formulate patients with complex comorbidity and screen patients with chronic pain for addictive liability. Finally, the authors describe the current findings from clinical and basic science that illuminate the role of opiates, cannabinoids and ketamine in the treatment of chronic pain. Up to date and comprehensive, this book is relevant to all professionals engaged in the care of patients with chronic pain or addiction and all others interested in these contemporary issues, particularly non-clinicians seeking clarity in the controversy over the best approach to patients with chronic pain.

The United States is facing an opioid use disorder epidemic with opioid overdoses killing 47,000 people in the U.S. in 2017. The past three decades have witnessed a significant increase in the prescribing of opioids for pain, based on the belief that patients were being undertreated for their pain, coupled with a widespread misunderstanding of the addictive properties of opioids. This increase in prescribing of opioids also saw a parallel increase in addiction and overdose. In an effort to address this ongoing epidemic of opioid misuse, policy and regulatory changes have been enacted that have served to limit the availability of prescription opioids for pain management. Overlooked amid the intense focus on efforts to end the opioid use disorder epidemic is the perspective of clinicians who are experiencing a significant amount of daily tension as opioid regulations and restrictions have limited their ability to treat the pain of their patients facing serious illness. Increased public and clinician scrutiny of opioid use has resulted in patients with serious illness facing stigma and other challenges when filling prescriptions for their pain medications or obtaining the prescription in the first place. Thus clinicians, patients, and their families are caught between the responses to the opioid use disorder epidemic and the need to manage pain related to serious illness. The National Academies of Sciences, Engineering, and Medicine sponsored a workshop on November 29, 2018, to examine these unintended consequences of the responses to the opioid use disorder epidemic for patients, families, communities, and clinicians, and to consider potential policy opportunities to address them. This publication summarizes the presentations and discussions from the workshop.

An in-depth analysis of complex clinical situations involving multiple concurrent diseases, this book reviews the clinical presentation and management of interactions among medical conditions, including myofascial pain, headache, fibromyalgia, visceral pain, hypertension, diabetes, osteoarthritis, low back pain, obesity, depression, and anxiety. This is a must-have volume for clinicians who treat chronic pain patients, general practitioners, clinical psychologists, medical students, nurses, and clinical investigators.

Cancer Pain Management, Second Edition will substantially advance pain education. The unique combination of authors -- an educator, a leading practitioner and administrator, and a research scientist -- provides comprehensive, authoritative coverage in addressing this important aspect of cancer care. The contributors, acknowledged experts in their areas, address a wide scope of issues. Educating health care providers to better assess and manage pain and improve patientsrsquo; and familiesrsquo; coping strategies are primary goals of this book. Developing research-based clinical guidelines and increasing funding for research is also covered. Ethical issues surrounding pain management and health policy implications are also explored.

Chronic pain, often defined as pain lasting longer than 3 months or past the time of normal tissue healing, is extremely common. According to a recent Institute of Medicine report, up to one-third of U.S. adults report chronic pain. Chronic pain is a major cause of decreased quality of life and disability and is often refractory to treatment. There has been a dramatic increase over the past 10 to 20 years in the prescription of opioid medications for chronic pain, despite limited evidence showing long-term beneficial effects. In addition, accumulating evidence indicates that prescription opioids may be associated with important harms, including accidental overdose, abuse, addiction, diversion, and accidents involving injuries (such as falls and motor vehicle accidents). Perhaps of most concern is the dramatic increase in overdose deaths associated with opioids. In 2011, there were 16,917 fatal overdoses involving prescription opioids. Prescription opioid misuse and abuse resulted in almost 660,000 emergency department visits in 2010, over twice as many as in 2004. Substance abuse treatment admissions for opiates other than heroin increased more than six-fold from 1999 to 2009. Opioids are also associated with adverse effects such as constipation, nausea, and sedation. Finally, data indicate potential associations between long-term opioid therapy and other harms, such as adverse endocrinological effects and hyperalgesia. These data underscore the complexity of clinical decisionmaking around long-term opioid therapy, which requires individualized assessments of the balance between benefits and harms; appropriate opioid selection, dose initiation, and titration strategies; integration of risk assessment and mitigation strategies; and consideration of the use of alternative, nonopioid therapies. Risk mitigation strategies that have been suggested for patients prescribed long-term opioids include use of opioid medication agreements, application of dose thresholds that warrant increased caution, regular clinical followup and monitoring, urine drug screens, use of abuse- deterrent opioid formulations, and use of data from prescription drug monitoring programs. Understanding benefits and harms of long-term opioid therapy for chronic pain is a challenge because effects may vary depending on patient characteristics (e.g., age, sex, pain condition, psychosocial factors, comorbidities), opioid characteristics (e.g., specific opioid, short- versus long-acting opioid, mode of administration, dose), dosing strategies (e.g., round-the-clock versus as-needed dosing, application of dose thresholds), concomitant therapies (e.g., use of benzodiazepines or other drugs that may interact with opioids), and characteristics of the clinical setting. The purpose of this report is to systematically review the current evidence on long-term opioid therapy for chronic pain.