Comorbid Pain and Opioid Addiction: Psychosocial and Pharmacological Treatments

Abstract

Treating comorbid pain (nonmalignant) and opioid addiction is a complex endeavor that requires cooperation of multi-modal treatment teams incorporating pharmacological, psychological, and social components. There are multiple barriers for patients, mental health practitioners, and physical health practitioners to provide complete treatment for this difficult treatment population. In this article, we will review which treatments have been empirically validated in this treatment population, where further research is required, and considerations for potential “best approaches” to use for patient treatment while waiting for empirically validated treatment data. We will also discuss some complementary and alternative medicine approaches that have empirical validity in treating either pain or addiction individually, though empirical validity for the treatment of comorbid pain and addiction has not been established.

RÉSUMÉ

Pain comorbidités et des toxicomanies aux opiacés: traitements psychosociaux et pharmacologiques

Traitement de comorbidité de la douleur (non cancéreuse) et la dépendance aux opiacés est une entreprise complexe qui nécessite la collaboration de équipes de traitement multi-modales incorporant des facettes pharmacologiques, psychologiques et sociaux. Il existe multiples obstacles pour les patients, les praticiens de santé mentale, et des praticiens de santé physique à fournir complète traitement pour cette population difficile à traiter. Dans cet article, nous passerons en revue les traitements qui ont été empiriquement validées dans cette population, les zones où des recherches supplémentaires sont nécessaires, et des considérations pour "meilleures approches" éventuelles pour le traitement des patients en attendant des données de traitement validé empiriquement. Nous allons également discuter de certaines des approches complémentaires et parallèles qui ont une validité empirique pour le traitement indiviudel de la douleur ou la toxicomanie, si la validité empirique pour le traitement intégré de la douleur et de comorbidité toxicomanie n'a pas été établie.

RESUMEN

Comorbilidad de dolor con adiccion a opiaceos: tratamiento psicosocial y farmacologico

El tratamiento de la comorbilidad de dolor (no maligno) con la adicción a opioides es una tarea compleja que requiere la cooperación de los equipos de tratamiento con una aproximación multimodal que incluya componentes farmacológicos, psicológicos y sociales. Hay múltiples barreras para que los pacientes y los profesionales de salud, incluida la salud mental, puedan proporcionar un tratamiento integral para esta población de difícil tratamiento. Este artículo revisa las intervenciones que han sido validadas empíricamente para el tratamiento de esta población y además identifica los vacios donde se requiere más investigación. Igualmente, se presentan las intervenciones que se consideran las “mejores prácticas” a utilizar para el tratamiento del paciente, mientras se esperan los resultados de los tratamiento empíricamente validados. También se discute algunos enfoques de medicina alternativa y complementaria que tiene alguna validez empírica en el tratamiento del dolor o de la adicción por separado, aunque la validez empírica para el tratamiento integrado de esta comorbilidad de dolor con la adicción a opiáceos aún no ha sido establecida.

• Keywords chronic pain
• opioid addiction
• dependence
• psychological
• pharmacology
• complementary and alternative medicine

THE AUTHORS

Dr. Amy Wachholtz, Ph.D., MDiv, is an Assistant Professor of Psychiatry at the University of Massachusetts Medical School, and a Health Psychologist on the Psychosomatic Medicine Consult Service at UMass Memorial Medical Center. Dr. Wachholtz graduated Cum Laude with a Master of Divinity degree from Boston University where she specialized in Bioethics. She then continued her education to earn a Masters and PhD in Clinical Psychology from Bowling Green State University where she had a dual specialization in Behavioral Medicine and Psychology of Religion. She completed her internship and fellowship at Duke University Medical Center where she focused on medical psychology. Her current research interests focus on: (1) bio-psycho-social-spiritual model of chronic pain disorders, and (2) the complexities of treating comorbid pain and opioid addiction in both acute and chronic pain situations.

Douglas M. Ziedonis, MD, MPH, is the Professor and Chair of the Department of Psychiatry at the University of Massachusetts Medical School and UMass Memorial Health Care. Dr. Ziedonis received his MD degree from Pennsylvania State University Medical School and his MPH. degree from the Yale University School of Public Health. He is a Diplomat in Psychiatry, American Board of Psychiatry and Neurology, and is board certified in Addiction Psychiatry. Dr. Ziedonis is internationally regarded for his cutting-edge research in co-occurring mental illness and addiction. His research on depression and addiction has included medication development, behavioral therapy development, and health services research. He has written over 100 peer-reviewed publications and chapters. He is the recipient of numerous awards and grants from the National Institute of Mental Health (NIMH), National Institute of Drug Addiction (NIDA), Center from Substance Abuse Treatment (CSAT), Foundations, and other agencies. Most recently, Dr. Ziedonis served on the Massachusetts Governor's Heroin and Oxycontin Commission and the Institute of Medicine Committee on Gulf War and Health.

Gerardo Gonzalez, MD, is an Associate Professor of Psychiatry, Director of Addiction Psychopharmacology Research Unit, Director of Addiction & Comorbidity Treatment Service (ACTS) and Director of the Addiction Psychiatry Fellowship program at the University of Massachusetts Medical School and UMass Memorial Medical Center. His research has focused on the neurobiology and pharmacotherapy of cocaine and opioid dependence. Specifically, his studies have evaluated the extent that enhancing GABA neurotransmission may have in modifying cocaine and opiate taking behavior. In addition, his current project focuses on evaluating whether modulation of glutamate neurotransmission by NMDA receptor antagonist during opioid agonist treatment may improve treatment outcomes and reduce early relapse in young adults with opiate dependence.

Notes

1 The often used nosology “drugs of abuse” is both unscientific and misleading in that: (1) it mystifies and empowers selected active chemicals into a category whose underpinnings are neither theoretically anchored nor evidence-informed and which is based upon “principles of faith” held and transmitted by a range of stakeholders representing a myriad of agendas and goals, and (2) active chemical substances of any types—“drugs”—are used, misused, or not used. Editor's note.