Balancing Pain Treatment With Potential Addiction

It’s a conundrum for modern-day clinicians: The country is dealing with an epidemic of people addicted to opioids, yet patients in pain still need medication for relief. Among patients prescribed pain pills for more than a week, 1 in 7 will become dependent and will still be taking them a year later—through no fault of their own, according to Arwen Podesta, MD, ABPN, FASAM, ABIHM, author of Hooked: A Concise Guide to the Underlying Mechanics of Addiction and Treatment for Patients, Families, and Providers.

“There are so many examples of patients who start their opioid addiction with pain medications as prescribed by their doctors. And there are also examples of those in recovery who suffer from true pain and receive an opioid after maybe a surgery, relapse, and even die of overdose,” said Dr. Podesta.

The news, however, isn’t all bleak.

“These issues are mostly preventable,” she said, “as we have rational treatment and ways to contain this disease, even in the light of pain treatment.”

Dr. Podesta, who has subspecializations in addiction medicine, forensic psychiatry, and integrative and holistic medicine, will discuss evidence-based ways to assess and treat patients with opioid addiction and pain, during a session at Psych Congress. The talk will cover the basic etiology and epidemiology of both addiction (see Figure 1) and pain, and will provide the rationale for various types of treatment based on individual patient needs.

“This will be a jam-packed session with tons of information on treatment of addiction and pain,” she said. “Attendees will leave with tangible evaluation and treatment ideas, which will change lives.”

The subject matter is relevant to mental health clinicians of all kinds, she said, since at least half of patients seeking mental health treatment have or previously had an issue with substance misuse. Even if a patient is not seeking treatment for a substance-related issue (stigma and fear may render some silent on opioid misuse), providers should still be equipped to treat the whole patient.

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For many outside the specialty of addiction medicine, opioid addiction is a murky issue.

“MDs can get training in addiction either through the American Society of Addiction Medicine or through the American Academy of Addiction Psychiatry,” said Dr. Podesta. “There are few fellowships available nationwide, so training is not as prevalent as it should be to respond to the need. Other avenues into providing addiction treatment include selftraining and getting a specialized DEA number to prescribe buprenorphine, although that training is minimal and misses the larger picture of addiction treatment.

“Also, honestly probably the biggest barrier to providers going into or continuing to treat people suffering with addiction is that the reimbursement is low considering the complexity, and there are many barriers to getting paid: insurance, prior authorizations, stigma, fear, and much more.”

That’s unfortunate, Dr. Podesta said, because solid research has provided tools and best practices for treating opioid addiction.

Dr. Podesta is heartened by recent attempts to address the problem with opioids, including the expansion of Substance Abuse and Mental Health Services Administration (SAMHSA) funding and former Surgeon General Vivek Murthy’s report drawing attention to it.

“However, this is a very large problem with a lot of stigma,” she said, “and we need a comprehensive, multifaceted effort that includes education to make the changes necessary to combat this problem.”

During her session, Dr. Podesta will aim to do her part by providing that education to providers and equipping them with 2 essential intangibles.

“Hope and understanding,” she said. “This very complex disease results in complicated symptoms and often very difficult-to-treat patients. But there is treatment, and even prevention, available.”

—Jolynn Tumolo