Managing Pain in Patients With Addiction

The relationship between addictive behavior and prescription pain medication is a really complex one.  It’s almost always hard to predict.  There are some obvious clues, like a previous history of substance abuse, or potential clues such as a family history of substance abuse, or maybe some underlying psychopathology, but it’s something that is very hard to address and I think that prescribers and dispensers share a very difficult role in it. We’re trying to be caring clinicians and treat our patients with pain, but also we have to be investigators too and these can be two very difficult roles to reconcile. There are many ways that patients who are misusing, abusing or diverting can present fraudulent prescriptions and if we as pharmacists don’t do our due diligence we’re faced with a great deal of liability. And so pharmacists may be perceived as being hypervigilant in verifying the validity of pain therapy and prescriptions, and as being a barrier to care—and I understand this quite well as a prescriber myself.  So it’s a difficult dance that we share in trying to ensure access to care for our patients while not contributing to drug abuse, misuse, and diversion. If prescribers and dispensers just talk more, I think that can go a long way to resolve some of the problems and ultimately end in better patient care. If you’re a physician, get to know your local community pharmacist.

In looking for the warning signs of the addicted patient, the self-escalating dose is one of them.  It can be a big indicator or a minor one depending on what the cause is.  If it’s uncontrolled pain, maybe there is something else that you need to look at other than just worry about addiction. Doctor shopping, pharmacy shopping, lost prescriptions are other signs and using our prescription drug monitoring programs can help with that. Things coming up on a urine drug screen that aren’t supposed to be there, or things not showing up on a urine drug screen that are supposed to be there.  Those are all flags that we can use from the prescriber side to help identify potential addictive behaviors. From the pharmacist perspective, some of the signs that we look for would be patients who are perhaps traveling a long distance to the pharmacy, as an indication of pharmacy shopping. Certain combinations of medications are red flags like Norco and Soma for example. If the patient is not known to you, that can prompt you to inquire further as to whether or not their use is valid. But all of these tools have to be taken for what they’re worth.  For example, if we run a prescription drug monitoring program report and we see multiple prescribers on it, from the pharmacy standpoint you can’t get too worked up about it. Maybe they’re all from the same group. It’s important to understand the nuances.

The challenge, for both prescribers and dispensers, of helping patients deal with denial and recognize their own addiction is a big one. People who suffer from addiction, or who are just on long-term opioid therapy often don’t have insight into the risk that they run. I think that everyone has to have their own light bulb moment and for different addicts, it’s different times, different places that the turning point is—and some people may never have that moment. What I’d like to pass on to our primary care audience is that chronic pain management, as well as addiction and deaths from overdose is something that requires attention. It’s everyone’s job to get educated, to educate others, and to protect your patients and yourself. Do your part in every possible way.

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