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Addiction & Pain Treatment
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CONTENTS
By: Seddon R. Savage, MD, Kenneth L. Kirsh, PhD, and Steven D. Passik, PhD. From Addiction Science & Clinical Practice (a NIDA publication). 2008(June);4(2):22pp.
By: Steven D. Passik, PhD and Kenneth L. Kirsh, PhD. From Medscape Neurology & Neurosurgery. 2008.
From: University of Utah, Genetics Science Learning Center. Updated 2008.
Particularly entertaining yet informative, and well worth a look, is the “Mouse Party,” which takes an interactive look inside the brains of animated mice on drugs, exploring molecular mechanisms of addiction. It provides a small glimpse into the chemical interactions at the synaptic level that cause drug users to feel “high” and want to repeat drug-abusing behaviors. Access checked 2/6/08.
Development of this site was supported by the National Institute on Drug Abuse (NIDA). Some animations require the Adobe Flash Player (available free at: http://www.adobe.com/products/flashplayer/).
Treating Chronic Pain in the Shadow of Addiction By: Penelope P. Ziegler, MD, FASAM; from Emerging Solutions in Pain, 2007.
This monograph addresses these issues, as well as assists clinicians in identifying aberrant behaviors suggestive of substance abuse or addiction. Recommendations are provided for treating chronic pain patients who present with or develop a de novo addictive disorder.
Safe Treatment of Pain in the Patient With a Substance Use Disorder By: Penelope P. Ziegler, MD; Psychiatric Times (CMP Medica), 24(1), 2007.
There is little research data on this topic; however, experiential and anecdotal reports collected over the past 3 decades indicate that there are safe and effective approaches to pain management in these patients. In general, the pain treatment regimen for a person recovering from an addiction involves the use of long-acting opioids, such as sustained-release oxycodone, methadone, or buprenorphine, administered on a fixed dosage schedule, with another person holding the medication. Specific dosing recommendations are provided.
From: Substance Abuse and Mental Health Services Administration (SAMHSA). Substance Abuse in Brief Fact Sheet. 2006(Summer);4(1).
Pain in Opioid-Addicted Patients Entering Addiction Treatment
Treatment of Acute Pain in Patients Receiving Buprenorphine/Naloxone for Addiction By: David Fiellin, MD; from the Physician Clinical Support System (PCSS), 2005.
ASPMN Position Statement: Pain Management in Patients with Addictive Disease From: American Society for Pain Management Nursing (ASPMN), September 2002.
Definitions Related to the Use of Opioids for the Treatment of Pain (incl. clarifications of addiction) Consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. 2001. Accessed 2/5/08.
http://pain-topics.org/opioid_rx/europad.php This official journal of EUROPAD (European Opiate Addiction Treatment Association) is a peer-reviewed publication for professionals wanting to stay informed on research and opinion on opioid misuse treatment in Europe and around the world. A particular emphasis is on medication-assisted treatments for opioid addiction, and many articles consider the interface of pain and addiction.
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The interface of pain and addiction is a common and vexing problem in clinical practice. This is complicated further by misunderstandings of distinctions between substance misuse, abuse, dependence, addiction, and pseudoaddiction.
Patients in pain may misuse a variety of substances to palliate their conditions. Continued misuse can become harmful abuse, which may lead to physiological and/or psychological dependence. Often patients develop “pseudoaddiction,” in which seemingly uncontrolled drug seeking is driven by self-attempted pain resolution rather than by the neurobiological disease of addiction. This section of Pain Treatment Topics focuses on the clarification, identification, prevention, and treatment of addictive disorders within the context of pain and, conversely, on pain management in persons with a history of addiction.
PDF available at: 
Pain and substance abuse frequently co-occur, and each can make the other more difficult to treat. A knowledge of pain and its interrelationships with addiction enhances treatment effectiveness for patients in both substance-abuse and pain-management settings. This article by experts in the pain and addiction fields discusses the neurobiology and clinical presentation of pain and its synergies with substance use disorders, presents methodical approaches to the evaluation and treatment of pain that co-occurs with substance use disorders, and provides practical guidelines for the use of opioids to treat pain in individuals with histories of addiction. The authors consider that every pain complaint deserves careful investigation and every patient in pain has a right to effective treatment.
HTML article available at: 
In this brief article, the authors assert that rapid-onset opioids for breakthrough pain are an important part of clinical practice in the pain management field. However, their clinical use must involve some caution and safeguards. They observe that mere exposure to opioid analgesics doesn't create addiction; rather, exposure in vulnerable people can engender addiction. These vulnerabilities need to be assessed and pain management tailored to accommodate them. This paper discusses the scope of the problem, appropriate patient-screening measures, and approaches that help healthcare providers protect their practices while delivering optimal pain relief.
At present there is no “gold standard” for patient assessment, screening, or documentation tools in pain management. Readers are advised to consult a number of resources and consider various tools before deciding on an approach that is best for their clinical practice.
This website – which is highly interesting, informative, and entertaining -- delivers interactive and print-based resources, free of charge, on the neurobiological actions of substances of abuse: heroin, cocaine, methamphetamine, marijuana, LSD, ecstasy, and alcohol. The presentations primarily depict how drugs interact with dopamine neurotransmitters within the brain's reward pathway. The influences of genetics on addiction are also discussed. Although the simplified mechanisms of drug action and other influences depict only part of the story, even experienced practitioners will find the material of interest as a refresher.
Balancing the treatment of chronic pain and the risks of developing or exacerbating an addictive disorder is a medical challenge. At times, it is necessary to prescribe opioid analgesia in a chronic pain patient who is at risk of addiction, or with an active addictive disorder. After conducting a comprehensive assessment of the patient and the reported pain, a strategic stepwise therapeutic approach is needed for improving care and containing risk.
Conditions associated with severe pain can and do develop in persons who have active addiction or who are in remission from an addictive disease, and these patients may require treatment for pain relief. This presents a challenge to clinicians: How can pain be relieved in these patients without exacerbating or reactivating the addictive disorder?
PDF available here for download: 
This evidence-based, government-sponsored publication is intended to assist healthcare providers in effectively managing pain with opioids, and to distinguish between physical and psychological dependence. The goal is to reduce patients’ risks of psychological dependence on opioids (addiction); however, the authors note that providing opioid analgesia to patients who are already psychologically dependent does not necessarily worsen their addiction, nor will withholding opioids increase their likelihood of addiction recovery. In fact, unrelieved pain can trigger addiction relapse. Opioid therapy only should be discontinued if more serious problems occur, such as prescription forgery, diversion of opioids, or ongoing inappropriate opioid use. If discontinuation is necessary, the opioid dosage should be tapered to avoid withdrawal symptoms and nonopioid pain therapies should be offered.
By: Stewart B. Leavitt, MA, PhD, revised July 2006. Adapted from Addiction Treatment Forum,
This brief document from the government-funded PCSS program addresses how to manage acute pain in a patient receiving buprenorphine/naloxone (Suboxone) for the treatment of opioid dependence. Buprenorphine, a tightly-binding mu-receptor agonist, effectively blocks the analgesic properties of other opioids that could be used to treat acute pain. Conversely, providing buprenorphine/naloxone therapy in a patient who has already been taking opioid medication to treat acute pain can result in precipitated opioid withdrawal.
Patients with addictive disorders have the right to be treated with respect and to receive the same quality of pain management as all other patients. Providing this care takes into account the potential for increased drug use or relapse associated with unrelieved pain. This paper discusses how nurses are in an ideal position to advocate for and intervene on behalf of these patients across all treatment settings.
Heroin Addiction and Related Clinical Problems