Addiction and Pain Management Options: The Doctor Weighs In

Dr. Harry Gould III, MD, PhD. is the author of Understanding Pain and Professor of Neurology at LSU and is one of the foremost authorities on managing pain.

Q: If I am a person who has experienced addiction in the past, what kind of pain management options would be best for me?

 Dr. Gould: Addiction is an all too frequent complication seen by pain management specialists. It occurs more often when treating individuals with severe and intractable chronic pain because many of the pharmacological options used in treatment carry a significant risk of addiction.

It is addiction and the associated problems that limits many physicians from prescribing, limits many patients from using, and limits society from accepting the appropriate use of opioid analgesics. The risk is higher for those with a past history or family history of addiction and/or substance abuse or whose psychosocial environment is conducive to participating in risk-taking behavior. That said, prior history of addiction should not preclude one from receiving care for pain, but the risk of sliding back into old and distructive patterns is high.

For those with previous history of addiction, I recommend seeking a comprehensive pain center to approach the problem, because these centers are more likely to have the resources to offer the necessary evaluation and determination of risk and the greatest array of treatment options from which to determine the best care at the lowest risk, albeit this is not a guarantee of success.

Comprehensive pain centers are more likely to be able to help devise a plan that sets realistic goals and expectations within strict, strong, appropriate and fair boundaries, provide sufficient education about treatments including risks, benefits, and predictable response, have the resources for managing adverse effects of treatment, and have the ability to monitor for compliance and early detection of addictive behavior.

The evaluation should include a complete determination of the reasons for the prior addiction, e.g., psychological, behavioral, developmental, social environment, a completed physical, psychological and psychosocial determination of need for pain management and an assessment of the treatment options to avoid and be available for use. The selection of management plans should target modalities treat the underlying cause of the pain, i.e., physical and psychological, and managing the pain with modalities having the greatest likelihood of success and the least potential for addiction. Non-pharmacologic options are preferred to reduce reinforcement of the behavior to reach for a pill at the first hint of pain [society’s universal response]. When necessary, pharmacological management should be used at the lowest doses necessary to provide reasonable improvement in pain [which may not be complete pain relief] and should include regular assessment for possible reduction of dosing over time.

Opioid options might include mixed agonist-antagonist formulations like Suboxone. In the end, the success of treatment will depend on the patient’s commitment to the goals of treatment, a strong working relationship based on mutual trust between patient and providers entrusted with the care, and an understanding that treatment is provided with primary directive “do no harm.”