‘We can treat pain for those who are treated with addiction. It takes a more modern mindset’
By Deborah Jeanne Sergeant
Because of the opioid epidemic, healthcare providers have become more careful about prescribing powerful pain medication. But when people with a history of substance use disorder need pain relief, that can cause difficulties.
“It’s a very important issue,” said physician Ross Sullivan,. He is the medical director of Helio Health in Rochester, Syracuse, Utica and Binghamton, medical director of medical toxicology and the fellowship director of the medical toxicology fellowship at SUNY Upstate, and the director of the Upstate Emergency Medicine Opioid Bridge Clinic. “In general, there’s an expectation of pain. Sometimes, the important thing to talk about with therapy and counseling is there might be learning to live with some pain.”
He advocates for treating pain both with medication and the right mental and emotional approach. People undergoing treatment for substance use disorder can use a multimodal approach to mitigate their pain instead of relying only upon medication.
“Opioids are the first line for acute pain,” Sullivan said. “Transitioning from a full opioid as quickly as possible to methadone or buprenorphine may be a strategy. These are conventionally used only for pain but can be used by someone with an opioid addiction to also treat the dependency and pain. Previously people would say, ‘You’re an addict; you can get no medication.’ That’s not what’s right for the patient.”
Sullivan said that the pain medication could include a muscle relaxer, NSAID such as ibuprofen, and pain patches to reduce pain and improve function. The provider could divide their suboxone regimen that is treating their substance use disorder from one daily dose to two smaller doses to help mitigate pain.
“We can treat pain for those who are treated with addiction,” Sullivan said. “It takes a more modern mindset.”
Non-pharmacological approaches may also help mitigate pain and help the person recovering from an illness or injury improve.
“Part of the answer is stretching, exercise and yoga,” Sullivan added. “The person could do physical therapy and any type of exercise program. It will always be beneficial. Acupuncture may help with chronic or acute pain. These are all things people should try. Our goal is to improve function. We want to be pain-free, but it’s not always going to be possible.”
Hemant Kalia, interventional pain and cancer rehabilitation consultant physician with Rochester Regional Health, believes that the opioid crisis intersects two public health challenges: reducing suffering and reducing harm from the use of opioid medication.
“We have to follow a delicate path and balance between pain management and addiction medicine principles,” he said.
The Comprehensive Addiction and Recovery Act of 2016 formed guiding principles for providers to address pain management issues.
“The guideline principles are the approaches of main management focused on biopsychosocial model of pain management,” Kalia said.
These must be individualized and multidisciplinary, but “more often than not, everyone gets focused on just the medication class for acute or chronic pain,” Kalia said. “Everyone gets focused on opioids. They key for successful pain management depends upon the plan being multimodal, individualized and multidisciplinary.”
He encourages more providers to suggest modalities like massage therapy, behavioral health, counseling, coping skills, cognitive behavioral therapy as part of a pain management program.
A team approach can also help. Kalia works with addiction medicine specialists, psychologists and physical therapist to develop a comprehensive plan to address acute and chronic pain.
As needed, patients receive referrals to in-patient or out-patient chemical dependency programs before leaving the emergency room.
“We also have a special program out of the ER where if someone comes in with active withdrawal from opioid medication, they don’t have to wait to see a provider for that,” Kalia said. “They get into the addiction program.
“The key here is to focus on individualized, multimodal and multidisciplinary approach to pain management. It’s the key to success for acute and chronic pain.”