Pain Assessment and Issues in Screening
Russell K. Portenoy, M.D.

SUMMARY: Chronic pain is an extremely complex health issue, and a comprehensive assessment is essential in creating and sustaining a multimodal treatment strategy that can enhance comfort, improve functioning, and avoid complications in those with comorbid chronic pain recovering from substance abuse. Dr. Russell Portenoy discussed important aspects of the clinical assessment process, stressing that data collection should always involve elements related to substance use including: past history and current use of prescription drugs, prescription drug abuse, and illicit drug use; adverse drug-related consequences; drug abuse treatment; and family history of drug abuse. With this information, the clinician can develop a better understanding of the pain (etiology, pathophysiology, and syndrome), functional impairments, comorbidities that may influence pain treatment strategies, and risks of abuse; and provide the foundation for selection of a multimodal pain management strategy.

Assessing Aberrant Drug-Taking Behaviors in Medically Ill Patients with Pain
Steven D. Passik, Ph.D.

SUMMARY: In his presentation, Dr. Steve Passik discussed the multiple etiologies of aberrant drug-taking in medically ill patients with pain to focus attention on aspects of compliance with drug therapy and to differentiate the phenomenology of the pain treatment setting from that of the addiction treatment setting. Passik described the outcome domains of assessment and management of opioid therapy; provided data from studies of aberrant drug-related behaviors in patients with AIDS, cancer, and nonmalignant pain; and discussed clinical implications and future research directions.

The Development and Treatment of Opioid-Induced Hyperalgesia
Walter Ling, M.D.

SUMMARY: Dr. Walter Ling recently explored the development of opioid-induced hyperalgesia (OIH) in methadone- and buprenorphine-maintained, opiate-dependent patients by measuring cold pressor and electrically induced pain. Results of these studies indicate that methadone maintenance increases the level of OIH from baseline while buprenorphine neither increases nor decreases OIH over time. Ling also discussed findings from another study of opiate maintenance patients who appeared to be cross-tolerant to the effects of morphine. He pointed out that more and more people will be taking opioids chronically, either for pain or for addiction, and management of pain in these patients will be an increasing challenge.

Prescribing Pain Medication for Recovering Addicts with Chronic Pain
Richard L. Brown, M.D.

SUMMARY: Dr. Richard Brown reviewed ways in which many recovering addicts can be treated safely and effectively for chronic pain with opioid analgesics, nonopioid analgesics, and nonpharmacologic modalities. Brown outlined the parameters of medication agreements for the proper dispensation of pain relief medication as well as the clinician’s responsibility for monitoring patients for analgesia, adverse effects, activity, and adherence. He specified the patient’s responsibilities under these agreements, which include adhering to dosage instructions and obtaining potentially addictive medicines from only one clinician and pharmacy; participating in other recommended treatments for pain, addictions, and other psychiatric disorders; and submitting to urine drug screening on request. For most patients, a respectful, empathic approach with clear limit-setting allows continuation of opioids, promotes participation in addiction treatment, provides pain relief, and augments function.

Principles of Pain Treatment in Addictive Disorders
Seddon R. Savage, M.D.

SUMMARY: Dr. Seddon Savage presented a rational approach to addressing pain in persons with substance use disorders by discussing the neurobiology and clinical phenomenology of drug reward, abuse, and addiction, as relevant for pain treatment. She outlined key principles of acute and chronic pain treatment in persons with substance use disorders, and reviewed the many complications involved. For instance, opioid tolerance may dictate a need for high doses to achieve analgesia. Drug craving may shape pain reporting and clinicians often fear that opioids provided for analgesia will exacerbate substance-use problems or be diverted by patients. Chronic pain and addictive disorders each may adversely affect mood, sleep, function, and overall quality of life, and may reinforce one another. Savage argued that pain may be physiologically facilitated by episodes of intoxication and withdrawal, and behaviors driven by addiction may impair compliance with pain treatment.