How to Support Patients With Chronic Pain and Substance Use Disorder

Clinicians are operating in the wake of challenges that have surfaced with treating patients with chronic pain conditions, marked by the juncture of the pandemic and an opioid crisis. Increasing the gravity of COVID-19 is the rise in emotional distress and pain due to the necessary enforcement of public health measures to minimize the spread of a novel coronavirus. Factors such as unemployment, social isolation leading to loneliness, and stress, compound the strain placed on people with preexisting pain and mental health comorbidity. The intersection of treating chronic pain with opioid pharmacotherapy and opioid misuse versus use disorder afflicts approximately 25% and 10% of people, respectively.

Concerns over fatal overdoses and suicidality seem to correlate with this tragic trend. Unfortunately, resorting to other substances (or misuse) is an inescapable risk for patients with uncontrolled symptoms, especially when patients are additionally experiencing greater amounts of pain, likely from the emotional toll this pandemic has caused. However, this is a pertinent patient safety issue since opioid misuse/substance use places patients at a substantial risk of death given the inherent mechanism of action risking unpredictable respiratory depression, among others. For patients who are struggling, self-medication is an overarching concern.

This also becomes more relevant when balancing the risks and benefits of treating chronic pain when mental health conditions are not well-managed can additionally predispose a patient to developing a use disorder—in essence, walking the proverbial tightrope of pain and addiction. As clinicians, this intersection is more prevalent during times of immense turmoil and melancholy. For physicians and practitioners alike who conduct direct patient care, there are key considerations when faced with the challenge of treating chronic pain and use disorder. In actuality, the primary essence of approaching patients involves maintaining a humanistic connection with them. This is defined by the ethical framework in which we adhere to especially with ensuring patient safety.

Here are 3 ways you can support your patients: 

1. Maintain a compassionate approach, but respect your own knowledge limits and comfort level.

Patients with complex, chronic pain conditions may not always be forthcoming when they’re misusing opioids or using other substances. Make sure that monitoring is a standard part of clinical practice when prescribing opioid therapy so that objective measures allow for enhanced transparency in treatment.

2. If aberrant behavior results, it’s critical to avoid a punitive attitude towards patients.

People suffering during difficult times likely won’t benefit from a paternalistic approach. It’s important to emphasize the need to ensure their safety and to do that with non-stigmatizing language. Discuss your concerns with them in a candid, non-threatening manner using language that emphasizes concerns over their personal safety when using substances that could result in a serious outcome when taken with opioids.

3. If the patient requires a more intensive level of care for their use disorder, approach this using a patient safety framework through handoff communication. This will require written consent from the patient.

The most important consideration is to avoid an abrupt discontinuation of opioid therapy for any patient (or abrupt discharge from the clinic) which can cause a prolonged withdrawal. Consider a slow, methodical taper of opioids, while leveraging the support of behavioral health expertise during the transition of care. If other treatment options are available such as switching the patient to buprenorphine, then try to expedite this transition of therapy for a rapid induction.

In retrospect of the past year’s events, patients who struggle with chronic pain and debilitating use disorders aren’t voluntarily making a choice to suffer. It’s critical that clinicians remember that addiction is a chronic, relapsing disease, and those who suffer from chronic pain may have a higher risk of relapse—a legitimate patient safety concern that ultimately deserves our therapeutic understanding and utmost compassion.

Author’s note: This is a brief op-med piece. As a result, it has limitations and doesn’t address all issues or that of dealing with challenging patients in which there isn’t a solid therapeutic relationship between patient and clinician.

This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.