Archived 02/02/2017

David Loffert was a success. He was two years into a Ph.D. program. He ran his own consulting firm. He’d published papers and developed a patent. He had just one problem: migraine headaches.

He consulted a doctor, who gave him pills for pain. He also gave him pills to sleep, pills to stay awake, and pills to manage anxiety. In just eight months, the doctor prescribed almost 7,000 pills to him, all of which were “controlled substances”– medications with abuse liabilities. These medications require that a practitioner have a Drug Enforcement Act (DEA) registration to prescribe them. “I knew about addiction, but I thought I was too intelligent to become addicted,” said Mr. Loffert. He was wrong. While the doctor lost his medical license, Mr. Loffert lost almost a decade of his life.

After being arrested for forging a prescription, he spent nine years “doctor shopping” for pills, losing jobs, and suffering overdoses and suicide attempts. After nine years, he made it through rehab and he has been sober since 2007.

Mr. Loffert’s trajectory is a common one. According to SAMHSA’s Treatment Improvement Protocol (TIP) 54, “Managing Chronic Pain in Adults with or in Recovery from Substance Use Disorders,” almost one third of chronic pain patients may have substance use disorders.

Treating pain in patients who have substance use disorders or are in recovery can be challenging, said Elinore F. McCance-Katz, M.D., Ph.D., SAMHSA’s Chief Medical Officer.

Opioids used for pain relief can prompt a relapse, for example. They can also interact with both illegal drugs and medications used to treat opioid addiction. Dangerous interactions can also occur with medications used to treat mental illnesses such as depression, which is common among pain patients.

That doesn’t mean pain patients with behavioral health conditions should never use opioid pain medications, according to Dr. McCance-Katz. “It does mean that they will require extra care, support, and monitoring to help prevent relapse. It also means that opioids should not be a first consideration for the treatment of pain in those with substance use disorders. There are many alternatives to opioids for pain relief and these should be considered first for patients with substance use disorders who are at risk for relapse,” she said.

When patients with chronic pain are evaluated, she said, health care providers should ask about the pain and underlying medical conditions that are contributing to the pain, and should conduct any needed examinations and testing to determine a diagnosis, previous response to treatment, history of substance use and mental health concerns, and family history of substance use disorders. Non-opioid pain treatments or other services, such as physical therapy or acupuncture, are better options for those who may need ongoing treatment for pain, particularly since there is little evidence for effectiveness of opioids in the long-term treatment of chronic pain. If other treatments have been unsuccessful, a trial of an opioid pain medication may be needed. Providers must closely monitor anyone prescribed opioid therapies for response to the medication and pay attention to signs of misuse. Patients must also be monitored for other drug use or dangerous medication interactions. For those with a history of substance use disorder, it is important to have a monitoring plan in place before starting opioid therapy.

Unfortunately, said Dr. McCance-Katz, most health care providers don’t get the training they need to care for patients facing both pain and substance use disorders. “In medical school, there’s not a lot of time devoted to either the recognition and treatment of substance use disorders or the appropriate management of pain,” she said, adding that dentists, pharmacists, and other health care professionals also lack training.

That’s why SAMHSA has developed resources, including a manual, training, and clinical tools, to help clinicians and others manage this high-risk patient population.

Age Matters

Aging adults have higher risk of medication misuse and higher rates of pain, insomnia, and anxiety than the general public, which means they’re also at higher risk of medication misuse, according to SAMHSA’s “Specific Populations and Prescription Drug Misuse and Abuse” fact sheet. About a quarter of older adults use prescription psychoactive medications with a potential for misuse or abuse. Plus, they may be living alone and no longer working so problems may be harder to spot.

Older adults often aren’t deliberately misusing medication. Cognitive decline could be behind some misuse, for example. With older people’s slower metabolism and increased sensitivity, even small amounts of medication can cause problems.

The prescription medications in an older person’s home aren’t just potentially dangerous for the patient. Many young people view prescription medications as safer than illegal drugs and may go exploring in the medicine cabinet. Screening for potential misuse or abuse is important, especially with individuals at high risk.

Promoting a Treatment Protocol

One crucial resource is SAMHSA’s Treatment Improvement Protocol (TIP) 54: “Managing Chronic Pain in Adults with or in Recovery from Substance Use Disorders.” The TIP offers guidelines for identifying and treating adults who have prescription medication misuse and other substance use disorders.

Developed by a panel of experts, the manual guides clinicians through the process of conducting a thorough assessment; developing a treatment plan that addresses pain, functional impairment, and psychological symptoms; and closely monitoring patients for relapse. It also explains the benefits of working in teams with other health care professionals, including psychologists, pharmacists, addiction counselors, and others. In addition, it explains how to engage caregivers, family members, and patients themselves in managing pain and improving quality of life. The TIP also includes a bibliography, assessment tools, sample consent forms, and other resources.

Training Providers

SAMHSA also supports online training resources.

The SAMHSA-supported Screening, Brief Intervention, and Referral to Treatment (SBIRT) course on Medscape provides a free online experience for providers to learn about evidence-based screening tools, motivational interviewing, and even billing codes for insurance reimbursement for the assessment. In addition, SAMHSA supports the Providers’ Clinical Support System for Opioid Therapies (PCSS-O) project that addresses safe opioid prescribing and provides evidence-based trainings, educational resources, and a mentoring program for health care professionals. The Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) aims to 1) develop a comprehensive electronic repository of training materials and educational resources to support evidence-based treatment of opioid use disorders; 2) create a mentoring program to provide guidance, direction and advice to help prescribers and key health professionals who are new to the field of medication assisted treatment; and 3) continue to offer waiver training for physicians interested in providing office-based treatment of opioid use disorders with buprenorphine under the Drug Addiction Treatment Act of 2000.

The mentoring program is especially helpful, said Project Director Kathryn Cates-Wessel, Executive Director of the American Academy of Addiction Psychiatry, which runs the sites under a SAMHSA contract. Clinicians can consult a “mentor on call” or get matched with a mentor for more intensive support. “In the old days, a mentor was someone who helped you define your career goals, but we’re finding people just want a place to go to get credible answers to questions,” she said.

Accessing Data

Another SAMHSA initiative helps stop prescription medication misuse by making it harder for patients to seek medications from multiple providers.

Clinicians often don’t consult their state Prescription Drug Monitoring Program (PDMP) database, which keeps a record of controlled substance prescriptions, before writing or dispensing prescriptions of their own. With SAMHSA’s Prescription Drug Monitoring Program Electronic Health Record Integration and Interoperability Cooperative Agreement, as well as the Electronic Health Record and Prescription Drug Monitoring Program Data Integration Cooperative Agreement, emergency rooms, primary care facilities, and pharmacies are integrating PDMP data into health information technology systems such as electronic health records, health information exchanges, and pharmacy dispensing systems to make checking easy. The two programs collectively have 16 grantees.

“Health care providers are very busy, with limited time,” said Project Officer Jinhee F. Lee, Pharm.D., a senior public health advisor in the Division of Pharmacologic Therapies. “Integrating PDMP data into their workflow makes it easier to access the information they need to make clinical decisions.”

The initiative doesn’t just stop doctor-shopping, added Dr. Lee. “Some providers may end up prescribing more because they realize a pain patient’s not being adequately treated,” she said.

Developing Policies

SAMHSA’s recently updated “Opioid Overdose Prevention Toolkit” gives communities and local governments the information they need to develop policies and practices to help prevent opioid overdoses and deaths. It also includes information for first responders, treatment providers, families, and people recovering from overdoses. For more information, see the resources listed below.

Related Article

Integrating Substance Use Assessment in Health Care

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