Should Alcohol Abusers Not be Treated for Pain?
Alex DeLuca, M.D., MPH; Pain Crisis blog of the Pain Relief Network; 2008-07-14.
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It seems to me an uncivilized and insane notion that just because someone in current moderate to severe pain had a history of an alcohol or drug problem, or even a current substance abuse problem, that you would deny them opioid therapy if that was the best medication to relieve their suffering. But this seems to be a point of confusion that increasingly comes up from patients, doctors, and regulators alike. So, in this post, let me make the medical standard of care in this situation perfectly clear.
One way to become an “addiction medicine” specialist is to become American Society of Addiction Medicine (ASAM) certified. Usually this is accomplished by attending a three day Certification Review Course, and then passing a written examination. Since the 1990’s, the ASAM Certification Review Course has included a lecture on the Management of Chronic Pain in the Patient with a History of Addiction, and in the 2000 course (I chaired the Review Course in 1998 and 2000) I selected Dr. Howard Heit (1), who has a national reputation as a medical educator and expert in addiction medicine and pain medicine, to give this important talk.
In his slide entitled: Patient Characteristics for Opioid Use in Chronic Nonmalignant Pain he emphasizes, “Active, or past history of, substance abuse is not a contraindiction to opioid pain management.” (2) Compare that to this statement from Washington state’s Agency Medical Directors Group (AMDG): “With active substance or alcohol abuse, providers should not prescribe opioids.” (3)
Huh!? So a person with alcohol abuse (like, 5-10 percent of the population by the usual criteria), who suffers severe chronic pain for which no other treatment has worked, should be left to writhe in preventable pain (and very likely drink more), by his physicians? Madness. Unbelievable. And very NOT the medical standard of care. Which is part of the reason the Pain Relief Network is suing WA.
Medical Society Consensus Statements:
The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM) and the American Pain Society (APS) have issued two Consensus Policy Statements that make very clear the position of the expert professional medical community on the use of opioid analgesics for the treatment of pain in a patient with a history of addiction or current behaviors perhaps indicative of current substance use disorder (DSM terminology). In Definitions Related to the Use of Opioids for the Treatment of Pain, 2001, they emphasizes the very important concept of pseudoaddiction:
“Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and may otherwise seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.” [See also: Opioid Pseudoaddiction: An Iatrogenic Syndrome (4)]
The second of these consensus statements is entitled, Public Policy Statement on Rights and Responsibilities of Healthcare Professionals in the use of Opioids for the Treatment of Pain, and was approved in 2005 and updated in 2006. First they review the core ethical obligation of physicians to relieve pain, employing opioids as medically necessary. Second they very clearly state that despite the risks and difficulty and time required to care for often complicated patients, this caring is a MEDICAL act and, ultimately and properly, is the responsibility of the individual physician upholding the individual patients best interests:
“Healthcare professional (HCP) concerns regarding the potential for harm to patients, as well as possible legal, regulatory, licensing or other third party sanctions related to the prescription of opioids, contribute significantly to the mistreatment of pain. HCPs are obligated to act in the best interest of their patients. This action may include the addition of opioid medication to the treatment plan of patients whose symptoms include pain [and] opioids are often indicated as a component of effective pain treatment. It is sometimes a difficult medical judgment as to whether opioid therapy is indicated in patients complaining of pain because objective signs are not always present.
“A decision whether to prescribe opioids may be particularly difficult in patients with concurrent addictive disorders, or with risk factors for addiction, such as a personal or family history of addictive disorder. For such persons, exposure to potentially rewarding substances may reinforce drug taking behavior and therefore present special risks. It is, nonetheless, a medical judgment that must be made by a HCP in the context of the provider-patient relationship based on knowledge of the patient, awareness of the patient’s medical and psychiatric conditions and on observation of the patient’s response to treatment.”
Other Consensus Documents:
There is one Consensus Statement that achieved national attention, notoriety, and indeed infamy in medical circles in the first half of this decade. In 2004,the DEA itself, in collaboration with Last Acts Partnership, and the academically prestigious Wisconsin Pain & Policy Studies Group released, with great public fanfare, a document entitled, Prescription Pain Medications: Frequently Asked Question and Answers for Health Care Professional, and Law Enforcement Personnel (5) (aka The DEA FAQ). I will not review throughly here the history of what has been called, “The Amazing, Vanishing DEA FAQ.” (6) Several of those thirty Questions and Answers relate directly to the issue of prescribing opioid analgesics for the treatment of pain in patients with current or past substances use disorders:
“Question 22. Is it legal and acceptable medical practice to prescribe long-term opioid therapy for pain to a patient with a history of drug abuse or addiction, including heroin addiction?
“It is within the scope of current federal law to prescribe opioids for pain to patients with a history of substance abuse or addiction.” (As outlined above, Washington state law, circa 2004, was not more restrictive than federal law on this issue.)
“Question 21. If a patient receiving opioid therapy engages in an episode of drug abuse, is the physician required by law to discontinue therapy or to report the patient to law enforcement authorities?
“Federal drug laws do not require physicians to report to law enforcement authorities patients who have engaged in drug abuse. The controlling federal legal standard is that the physician must issue prescriptions for controlled substances only for legitimate medical purposes and in the usual course of medical practice.” … In states with no specific legal requirement on this subject, if continued opioid therapy makes medical sense, then the therapy may be continued, even if drug abuse has occurred.” (As outlined above, Washington state law, circa 2004, was not more restrictive than federal law on this issue.)
“Question 26. Can methadone be used for pain control, and, if so, is a clinician required to have a special license to prescribe it?
“Methadone is approved by the Food and Drug Administration as safe and effective for medical use as an analgesic… State and federal regulations do not restrict the use of methadone to treat pain.
Footnotes:
1. Having worked with Dr. Heit for many years on various ASAM committees and efforts, I consider him a friend; he is a kind, intelligent man, a truly expert clinician, and a giant in the field of Addiction Medicine. Having said that, I think it is important to stress that Dr. Heit represents the conservative mainstream. In fact, he is best known as a proponent for what is know in the field as the “principle of balance,” which I am most definitely not, and for his efforts to work with DEA as if they were colleagues, for example on the infamous “DEA FAQ (PDF),” 2004, a strategy I believe has been tried and failed, repeatedly, over many decades. See also his peer-reviewed work, including “Dear DEA,” 2004, “Healthcare Professionals and the DEA: Trying to Get Back in Balance,” 2006, and “Universal Precautions in Pain Medicine,” 2006. This last approach I believe is ethically questionable because it essentially puts patients in a position of proving their innocence or worthiness to be cared for in order to satisfy drug war imperatives I believe are amoral and without a scientific / medical basis.
2. Heit, H. Management of Chronic Pain in a Patient with a History of Addiction. Slide/Lecture given at the American Society of Addiction Medicine Certification Review Course; Course Chairman: DeLuca, A.; Chicago; 2000.
3. Agency Medical Directors Group. Washington State’s New Guidelines for Opioids for Chronic Non-cancer Pain - Frequently Asked Questions (PDF). 2007-03-01.
4. Weissman, D.F., & Haddox, J.D. Opioid pseudoaddiction: An iatrogenic syndrome.; Pain, 36, 363-366; 1989.
5. DEA, Last Acts Partnership, and the Pain & Policy Studies Group (”Academic Pain Management and Law Enforcement Experts”). Prescription Pain Medications: Frequently Asked Question and Answers for Health Care Professional, and Law Enforcement Personnel (consensus document); 2004. (PDF)
6. Borden, D. Now You See, Now You Don’t - The Amazing, Vanishing DEA FAQ. Drug War Chronicle; 2004-10-15.
