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Treating Substance Abusers for Pain - Responding in the Era of Oxycontin Abuse
Anita Tarzian, PhD, RN and Diane Hoffmann, JD, MS
University of Maryland School of Law
November 2001

Individuals with a history of substance abuse who also have legitimate pain treatment needs may confront the greatest barriers when it comes to receiving adequate pain medication. Health care providers (HCPs) often have concerns about sanctions related to prescribing opioids in such circumstances but also take seriously their obligation to treat patients who are suffering from disease and painful conditions. HCPs undoubtedly face real dilemmas when confronted with a patient who they suspect is motivated to request pain medication as a result of an addiction. In such circumstances what are the HCPs obligations?

Clearly, some individuals do use pain medication to satisfy an addiction, or sell pain medication in order to support another substance addiction. The recent attention to the misuse of the long-acting opioid Oxycontin has drawn much attention to the latter. If a HCP is certain that an individual complaining of pain is drug-seeking merely to feed an addiction, that HCP has an obligation to address the addiction rather than provide a prescription for pain medications. The problem is that it's difficult to be certain that an individual complaining of pain is merely drug-seeking. This is especially difficult in the context of an Emergency Department visit when the physician has not had any prior experience with the patient. In assessing a patient's complaint, physicians confront three possible scenarios: (1) the patient has a substance addiction and is seeking pain medication for its high rather than its analgesic effect, (2) the patient has or had a substance addiction and has pain for which he or she seeks relief, and (3) the individual has no substance addiction but has a physical dependence on pain medication to relieve his or her pain. For several reasons, the first possibility looms largest for most HCPs, and influences the care provided to all three types of patients. Patients who fall into #2 or #3 above likely have developed a higher opioid tolerance, which simply means that they need more of the drug to achieve the same analgesic effect. Yet, HCPs are more apt to label them as "drug-seeking" and undertreat their pain. In focus groups with HCPs, patients, and family members, Ann Martino (1998) identified three principles that contribute to what she calls the "ethic of underprescribing" for pain: (1) "Just Say No: drug addiction and abuse harm individuals and society;" (2) "Grin and Bear It: pain happens;" and (3) "Avoid Risks: it ensures no harm done." It's important for HCPs to realize that this "ethic" predisposes them to err on the side of underprescribing for pain, even though many more individuals are undertreated for pain than are addicted to pain medications.

Ethically, HCPs strive to benefit the patient while avoiding needlessly harming the patient. If a patient has pain and a history of substance abuse, it is the HCPs' obligation to attempt to provide effective pain management without exacerbating the patient's addiction. Believe it or not, it is possible to do this. But, it's NOT easy! Typically, it requires consistency, commitment, trust, patience, respect, firm boundaries, and clear communication. Frankly, this cannot be accomplished in a one-time ED visit. The most the HCP in the ED can do is take an accurate history and refer the patient to a clinic or provider who has experience treating pain in former or active substance abusers. Skilled providers would then employ strategies that have the best likelihood of producing benefits for individuals with substance-abuse histories (e.g., developing a written plan of care and giving a copy to the patient, frankly discussing the treatment contract, establishing clear boundaries and consequences, asking for commitment to the plan, limiting prescription-writing to one physician, using a single pharmacy in which the pharmacist is informed, getting the patient's consent to share information with other HCPs, using medication and pain logs, employing periodic drug screens, and having regular face to face assessments). However, finding such clinics or qualified providers is no easy task, particularly with the reimbursement and regulatory barriers such providers confront.

In summary, it's important that the HCP be sure that the patient identified as "drug-seeking" isn't having actual pain relief needs dismissed. When in doubt, erring on the side of believing patients who complain of pain is more ethically sound than discounting a pain complaint, including patients with a substance-abuse history. If the patient reports abuse of drugs or there are good grounds for suspecting addiction and the HCP can't rule out that the patient's pain is contrived, the ED physician can refer the patient to an outpatient treatment program and prescribe a limited amount of pain medication, one that is less likely to be sold or abused (e.g., drugs like Dilaudid or Oxycontin should be avoided). Narcotics Anonymous and Alcoholics Anonymous have pamphlets called, respectively, "In Times of Illness," and "The AA member—Medications & other Drugs." These address the issue of substance-addicted individuals taking pain medications, and are available online at www.markelliot.com/naillness.html. Even if the provider doubts the patient will follow up with a treatment program, referrals and contact information should be provided.

As for the ED physician's fear of being sanctioned by the state medical board or drug enforcement agency (DEA) for improper opioid prescribing, this is unlikely if the patient's pain complaints and history/physical exam are properly conducted and documented. Those who face a greater challenge than what the ED physicians confront are those HCPs who try to maintain an effective provider-patient relationship with individuals who have pain and an active or past substance addiction. Unfortunately, those skilled enough to do this well are rare, and don't get the respect, recognition, and reimbursement that they deserve.

For more information on pain management when addiction is an issue, see D.R. Wesson, W. Ling and D.E. Smith (1993), "Prescription of opioids for treatment of pain in patients with addictive disease,"Journal of Pain & Symptom Management, 8(5):289-96.

Model guidelines for the use of controlled substances by the federation of state medical boards of the United States are available online at www.medsch.wisc.edu/painpolicy/domestic/model.htm.
For more background on the ethic of underprescribing for pain, see A.M. Martino (1998). In search of a new ethics for treating patients with chronic pain: What can medical boards do? Journal of Law, Medicine & Ethics, 26: 332-49.