Complications of Pain and Addiction Treatments Examined

Thursday’s full-day course, Pain and Addiction Common Threads XII: Safety First: Best Practices, featured seven presentations focusing on topics that included clinical aspects of sedative dependence, sedative hypnotics, sleep issues, opioid and sedative use and misuse, the role of the family in addiction, and federal and state initiatives on prescription drug misuse.

Mixing BZDZ and Opioids Creates Problems
Benzodiazepines (BZDZ) are one of the most widely prescribed medications for anxiety, depression, or insomnia. In one year alone, more than 2 billion tablets of diazepam were prescribed in the United States.

But while BZDZs are widely prescribed, research shows that they lose efficacy over time. As the drug fails to treat the condition, patients are sometimes prescribed an opioid to assist the BZDZ. According to Edward Covington, M.D., of Cleveland Clinic Foundation, this dangerous cocktail can lead to addiction and fail to treat the chronic symptoms for which it was originally prescribed.

Dr. Covington discussed the research behind his findings and how to better treat patients with chronic pain in his presentation “Clinical Aspects of Sedative Dependence in Pain and Addiction.”

There is a group of people with chronic pain who use both opioids and BZDZs, often in high doses, who show high levels of functional impairment, pain, addiction, and comorbid psychiatric pathology, he said.

The highly addictive nature of BZDZs and opioids sometimes leads to criminal behavior. More than 1,800 pharmacies were robbed between 2008 and 2011, usually looking for oxycodone, hydrocodone, and alprazolam. In 2006, diazepam and clonazepam were selling for $2 to $4 a pill on the street. Buyers either purchased the pills for a quick feeling of euphoria or to cope with a current addiction.

Although these figures paint a bleak picture, Dr. Covington said BZDZ-use disorders are but a small portion in the scope of addictive disorders, both in the U.S. and around the world. Twelve percent of adults and 40 percent of pain patients either have, or currently use, some form of BZDZ. Most of the problems stem from alcoholics and opioid or cocaine addicts who use BZDZs because of chronic pain. Not only does the medication not help the pain, it impairs function and escalates the pre-existing levels of addiction.

Although these patients represent the minority, they are significant enough that alternatives should be used if appropriate, he said. If prescribing a BZDZ is absolutely necessary, it should only be for short-term use. Long-term BZDZ patients should be weaned off their prescriptions, and other antidepressants or automated external defibrillators should be used for anxiety and sleep disorders.

Physicians Need to Examine Alternatives to BZDZs
When a patient complains of anxiety, insomnia, or muscle spasms, BZDZs are frequently prescribed. But when trying to treat these symptoms, which are particularly common among patients being treated for chronic pain, physicians may unknowingly be planting the seeds for — or enabling — an addiction.

Michael Miller, M.D., medical director of the Herrington Recovery Center, Rogers Memorial Hospital, Oconomowoc, Wisconsin, explored alternative treatments in “Non-benzodiazepine Sedative Hypnotics That Cause Clinical Problems.”

“Patients without addiction can misuse pharmaceuticals by taking them by different routes or getting them from different sources than their doctor intended. We, as physicians, need to look for safer alternatives and methods,” he said.

Dr. Miller addressed the role of BZDZs and the incidence of addiction and withdrawal to BZDZ-receptor agonists. He discussed addictive non-barbiturate non-BZDZ sedative-hypnotics, as well as how to manage the discontinuation of, and withdrawal from, several classes of medications often used during chronic pain management.

Dr. Miller also noted that pain and addiction are complicated conditions that can cause much distress and dysfunction for patients. It requires skill to manage their chronic nature on an outpatient basis — especially when they co-occur.

“Some meds considered alternatives are not as safe and problem-free as physicians assume,” Dr. Miller said. “Unfortunately, there is no magic bullet or easy path. Physicians always need to be aware of benefits and risks in making decisions, these included.”

Treatments for One Condition Affect Others
It happens frequently: A patient complains of insomnia or chronic pain, so the physician writes a prescription to solve problem. In reality, that prescription may be compounding another condition said Lynn Webster, M.D., who discussed the relationship between sleep, pain, and addiction in “Pain and Addiction: Sleep.”

“People with addiction have pain problems most addictionologists are aware of, but they may not be aware of the relationship between pain and sleep,” said Dr. Webster, medical director and co-founder of Lifetree Clinical Research and Pain Clinic, Salt Lake City.

Besides discussing the relationships between pain, addiction and sleep, he also addressed the basics of sleep neurophysiology and treatment options for treating patients with sleep disorders, pain and the disease of addiction.

“We can’t treat a disorder in a silo,” Dr. Webster said. “Most patients with one of these have one or both of the other problems. Fifty to 60 percent of people with insomnia have pain. Individuals with a diagnosis of addiction have pain, and almost all have drug-induced sleep disorder.”

Dr. Webster also reviewed common therapies for pain, sleep, and addiction, and the ramifications a treatment for one condition may have on the other two, as well as long- and short-term pharmacology management strategies.

“Some (treatment options) treat pain effectively, but then have side effects,” he said. “Another therapy might not be optimal right now because the right resources aren’t in place or the meds aren’t as successful as we think.”

While there is no magic bullet to solve the problem, Dr. Webster said he hopes to get physicians thinking differently before they reach for their script pads.
“I think sometimes we prescribe sleep meds without considering other conditions,” he said. “We are complex organisms. It is very difficult to isolate a single disorder and treat it independently of other factors.”

Opioids and Sedatives: A Deadly Mix
High doses of opioids combined with sedatives have led to the deaths of celebrities Michael Jackson, Anna Nicole Smith, and Heath Ledger. This deadly mix also threatens the lives of people far from the spotlight.

“The combination of two very potent central nervous system depressants can act in an unpredictable fashion that can lead to respiratory depression and death,” said Mark A. Weiner, M.D., who presented “The Clinical Implications of Opioid and Sedative Use/Misuse in Patients with Addiction and Chronic Pain.”

Although seemingly innocuous, sedatives such as diazepam, alprazolam, and zolpidem are addictive substances that are associated with decreased activity levels, increased disability, and depression. Plus, the use of these benzodiazepines and benzodiazepine-like drugs can cause patients addicted to opioids to have either a cross-addiction or a stimulation of their opioid addiction.

According to studies, patients on opioid replacement therapy, such as methadone and buprenorphine, who are also using sedatives can experience a reactivation of their addiction.

“A large proportion of opioid replacement therapy deaths are not just from taking too much methadone,” said Dr. Weiner of Pain Recovery Solutions, and Pain and Addiction Medicine at Saint Joseph Mercy Hospital, Michigan. “In these deaths, we have found that many of our addicted patients are also using sedatives. The rate of sedative use in opioid replacement patients is very high, probably 50 to 80 percent.”

Patients who are addicted often turn to sedative drugs, rather than other relaxation techniques, when experiencing sleep disturbances, anxiety, and psychosocial stresses, such as unemployment.

Sedative use is also a growing problem for patients being treated for chronic pain.  “The patients who are prescribed methadone for pain are also reporting psychosocial stresses and sleep problems, and often being prescribed very high doses of sedatives on top of opioids,” Dr. Weiner said. “And those people are dying at a much higher rate than the addicted population.”

Combinations of sedatives and opioids can be dangerous and should always be used with caution, he warned. He recommended using substitution therapy or cross-taper with different medications, such as phenobarbital, to help patients who are dependent on sedatives kick the habit.

Families Important in Recovery from Pain, Addiction
Family members often play pivotal roles in the recovery of patients with chronic pain. In some instances, in fact, the beliefs and behaviors of spouses, children, parents, and significant others may perpetuate or even increase a patient’s pain.

“If there’s chronic pain within a family system, the clinician needs to pay attention to the family as well as the patient,” said Mel Pohl, M.D., FASAM, co-presenter with Claudia Black, Ph.D., M.S.W., of “Pain and Addiction: All in the Family.” “There is an extensive amount of co-dependency in a family where chronic pain is the predominant phenomenon.”

Understanding the impact of pain, especially when associated with drug addiction, on patients and their loved ones is key to successful treatment. Dr. Pohl pointed to the case of a woman with scoliosis, whose husband’s life revolves solely around her pain and drug use. Fixated on her treatment, he has given up his own independent activities. As she recovers, he may not be able to change his role and adapt to their new relationship.

“When someone’s pain is getting better, and his or her drug abuse is also being treated effectively, the family must respond accordingly,” said Dr. Pohl, medical director of the Las Vegas Recovery Center, where Dr. Black is a senior clinical and family service provider. “Unless they are attended to by a physician or a counselor, they can actually sabotage the recovery.”

A doting spouse may, in fact, make problems worse.

“Recent studies show that solicitous spouses may result in the person in pain experiencing more pain,” Dr. Pohl said.

Insights into family relationships and roles can help clinicians in the treatment of pain and drug addiction. Clinicians, in turn, can help families learn how best to work with the affected family member and assist in the recovery process.

Dr. Pohl urged caregivers to “be mindful of the family when treating someone with co-occurring pain and addiction” and to recognize that issues that come up are based on an emotional connection that can range from healthy to unhealthy.

Finding A Balance in the Use of Opioids 
In an Indian fable, six blind travelers come upon an elephant, and each forms a concept of the animal based on touching only one part, such as the ear, side, or tusk. Similarly, health care providers, pharmacists, patients, law enforcement officials, and legislators may see only a small piece of issues related to opioid use.

“Challenges associated with opioids are complicated, and what you see depends on where you sit,” said Seddon Savage, M.D., M.S., presenter of “Finding Balance in Policy:  Emerging Federal and State Initiatives on Pain and Prescription Drug Misuse.” “Pain specialists may want to promote pain treatment and may not see as much of the fallout from using opioids. But from the perspective of addiction specialists, virtually all prescription opioid addiction comes from being treated for pain.”

For nearly four millennia, people have been trying to find a balance between using opioids to relieve pain and avoiding the harm associated with misuse. For periods of time, opioids have been widely used therapeutically and then prohibited due to safety concerns.

Today, a number of solutions are being offered to address such challenges as climbing rates of opioid addiction and mortality.

“We’re hoping to get a handle on these problems using our scientific understanding of pain and addiction and the pharmacology of opioids as well as technology that allows us to communicate better,” said Dr. Savage, director of the Dartmouth Center on Addiction, Hanover, N.H.

A number of new and proposed federal and state initiatives aim to maintain quality health care for patients with chronic pain, while preventing prescription drug misuse and addiction. These include:

  • Provisions in the 2010 Affordable Care Act
  • Policies of the Office of National Drug Control Policy
  • State-based prescription monitoring programs
  • The Stop Oxy Abuse Act proposed by Rep. Mary Bono Mack (R-Calif.)
  • The Prescription Drug Abuse Prevention and Treatment Act of 2011 proposed by
  • Sen. Jay Rockefeller (D-W.Va.), which includes physician and patient education, and a national opioid death registry

“Solutions need to be multidimensional and engage stakeholders in diverse disciplines, from the public to health care providers to law enforcers to legislators,” said Dr. Savage. “We need to find a balance, listen carefully to one another, and work together.”