Assessing comborbid pain and opioid addiction

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Published: 21 Apr 2015
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Dr Amy Wachholtz - University of Massachusetts Medical School, Worcester, USA

Dr Amy Wachholtz, Director of Health Psychology at University of Massachusetts Medical School in Worcester, USA talks to ecancer on her presentation at IAPCON 2015 regarding research on chemical dependence and the appropriate treatments.

Understanding the psychophysiology of pain and addiction is beneficial for effective assessment of comborbid pain and opioid addiction in patients.

Dr Wachholtz discusses other areas that could affect pain and describes patients with sleep issues and the importance of gaining good quality sleep. 

My name is Dr Amy Wachholtz, I am an Assistant Professor of Psychiatry at the University of Massachusetts Medical School and the Director of Health Psychology at the UMass Memorial Medical Centre.

My work is primarily in the area of pain management, looking at the psychophysiology of pain management, looking at better treatment methods for pain management and also looking at the areas of health and wellbeing that intersect with pain management, so particularly in the areas of pain and sleep, pain and addiction, particularly opioid addiction.

Those are my primary areas of clinical and research work.

What was your presentation about?

Comorbid pain and opioid addiction is an extremely complex problem that is influencing how people interact with their pain medications, how people interpret pain, how people move forward with their pain management.

There are legal complications, there are ethical complications, there are medical complications with all of these.

So some of my research particularly is looking at how do we best assess people with comorbid pain and opioid addiction so that we can develop better treatments because at the present time we really don’t have any good treatments for comorbid pain and opioid addiction, either on the pharmacological side or on the psychological side.

The best that we’ve been able to come up with is looking at treatments that can treat pain and have been empirically validated to treat pain and treatments that have been empirically validated to treat addiction and kind of mushing them together.

But we hadn’t really took a step back and said, well, first we need to find out a little bit more about this population because this population is not just a pain population and this population is not just an addiction population.

They have unique needs, they have unique psychophysiological processes when it comes to triggers, when it comes to pain management and so we need to take a step back and first assess what are the needs of this very unique population.

And that’s when my research started with looking at the psychophysiological responses that people with comorbid pain and opioid addiction have when they’re triggered by a pain experience.

And so we asked people into the laboratory that had… they were either opioid naïve but had chronic pain; they had comorbid pain and opioid addiction and were currently on methadone or they had comorbid pain and opioid addiction and were currently on buprenorphine and naltrexone.

Then we had a fourth group that had a history of comorbid pain and opioid addiction that continued to have chronic pain but they’ve been at least abstinent from their opioids for a minimum of six months.

In our study it was approximately two years with a standard deviation of six months, so most of our patients were either eighteen months to 2½ years out.

Then we asked them a series of questions about their response to opioid use, their response to pain, what their mood was like, what their sleep was doing.

And then we actually exposed them to a pain trigger and we used a cold water test to expose them to a pain trigger and asked them to report when they first experienced pain and then we also measured how long they were able to endure that pain while also measuring some of their psychophysiological responses to the pain trigger as well and asked then how they dealt with the cravings for opioids after they experienced the pain.

What we found out was actually rather disturbing from a clinical perspective.

When patients were exposed to or had a history of prolonged opioid use they were much more likely to be much more sensitive to pain and have much less tolerance to pain, even though it was the exact same pain trigger that was given to everyone.

The people that had the chronic opioid use had much less sensitivity and much less tolerance.

So what this means is that they’re going to be much more likely to be triggered for pain, they’re much more likely to use or abuse opioids or relapse into opioid addiction when they’re triggered by pain.

And the other concerning piece is that when we looked at the people that had the prolonged opioid abstinence, so people that had a history of being on chronic daily opioids but then had been off of the opioids for a series of time, for at least, again on average about two years, they showed the same pain sensitivity and tolerance compared to the opioid naïve group.

So this suggests that even after people get off of chronic opioids they’re still going to continue to have much more sensitivity to pain and much lower tolerance to pain over time.

This is very concerning, especially if we’re talking about helping people get on prolonged opioids without necessarily sharing with them about some of the long-term challenges that may come into play, particularly for patients for whom we’re looking at more of a palliative care perspective and less of a hospice perspective where they might be struggling with pain for a prolonged period of time.

We should really help educate the patients and the providers about what this challenge may be for them long-term.

What do these findings mean for a healthcare professional?

It means that we need to be much more sensitive to the fact that they are likely going to need more pain medications in order to achieve the same level of pain relief, in order to help them improve their functionality.

It also means that what we really need to do is stop looking at either a 0-10 or 0-100 pain scale, saying how much pain do you have?

What we really need to do is start prescribing from a functionality point of view rather than a pain point of view.

So does increasing an opioid dose help the patient become more functional in their daily life?

Does it help them engage with their family members more?

Does it help them maintain their quality of life?

Does it help them improve their cognition and general engagement?

Because if it does not, and again we’re talking in a palliative care perspective rather than the very, very end of life which is a very different story, but for the individuals that are trying to maintain their quality of life long-term, or at least over the course of a couple of months, we really need to look at opioid prescribing as a level of functionality rather than just that 0-10 pain scale.

So if someone is giving high levels of opioids and it’s actually making the person less functional in their daily life then that is not a healthy prescription level of opioids.

The other thing we need to really consider is to look at adjuvant medications and other psychosocial interventions as well which have a lot of empirical evidence behind them as far as helping manage pain.

There’s a lot of evidence that shows that things such as acupuncture, meditation, cognitive behavioural therapy specifically for pain management, acceptance and commitment therapy, all of these things can have a very powerful impact on the level of pain that a person experiences and the level of pain that they report.

So if we’re able to address those areas, including those areas such as depression and anxiety as well, either anxiety about their terminal illness, about depression around that area, anxiety about the pain itself because pain catastrophising can also be a major issue related to the pain experience, all of these pieces come into play and so we really need to look at a total pain perspective and a holistic pain treatment approach as opposed to simply getting out the prescription pad.

What other areas could potentially affect pain?

Particularly in the other area of looking at pain and addiction and sleep issues, that’s another area where we know that if somebody is not getting sufficient sleep, that is going to impact both their pain and their addiction.

What we really want to be sure about is we’re not just talking about quantity of sleep, we’re talking about the quality of sleep.

So that’s one of the challenges that we also have in the psychological and the medical communities because oftentimes the medications that we have influence the quantity of sleep but actually do not improve the quality of sleep.

So helping patients take a step back, looking at sleep hygiene practices and healthy sleep practices, helping patients improve their quality of sleep as opposed to simply looking at quantity of sleep so that we can help patients stabilise their rapid eye movement stage sleep which impacts cognition, impacts patients’ ability to problem solve outside of their chemical coping strategies that perhaps they’ve relied on in the past, helping them identify what pain management strategies they might be able to use to better target their pain.

All of those are going to be critically important and those directly relate back to the REM stages of sleep.

The other really important component of sleep is what called slow wave sleep.

The slow wave sleep is critical to helping patients improve their pain levels.

So we know that when patients do not get a sufficient amount of slow wave sleep they’re going to be much more likely to experience an increase in their current pain or their various pain levels.

So it becomes critically important to address, again, not just quantity of sleep but quality of sleep for a patient, especially if they’re struggling with both comorbid pain and opioid addiction.

How can patients improve their quality of sleep?

Part of that is helping them maintain, as much as possible, a regular sleep schedule.

So helping them identify areas of the day when they’re feeling more tired, helping them if they’re taking naps, making sure that those naps are either in the twenty minute or in the two hour time blocks.

Twenty minutes is very good because it can help with catnap level sleep, help refresh someone, help give them a little bit more energy to continue on with their day.

A two hour block of time would allow someone to get through a complete REM cycle.

If someone lies down to sleep for about an hour, they’re interrupting that cycle and then what ends up happening is they get disjointed sleep then later on in the day.

So helping people really narrow their blocks of time from either two hours or twenty minutes.

Other pieces of the components are making sure that they have a quiet dark room.

That may include things such as an eye-blinder, it may include ear plugs, help them avoid caffeine, alcohol or other drugs right before sleep because all of those things can also affect the quality of sleep.

Again, we’re not just talking quantity, we’re talking quality of sleep and all of those medications and drugs can help with that.

Working with the physician and the prescribers to find out if there are certain medications that are better to take at night versus in the morning to help manage sleepiness because there are some 24 hour medications that maybe they come on stronger in the morning or they might come on stronger at night.

And helping work with the prescriber to find out which ones are better to be taken in the morning and which ones are better to be taken in the afternoon.

Some of the other pieces are helping patients not lie in bed at night or lie in bed during the day when they’re not asleep.

Again, we’re talking more of an energy management strategy rather than a truly end of life strategy.

But, for the most part, if they’re just lying in bed during the day and they’re wide awake, that’s actually increasing their time in bed but not increasing their functional sleep.

So it actually diminishes the quality of sleep that they have when they do actually fall asleep.

They’re much more likely to be in that catnap level of stage of sleep, rather than engaging in some of the deeper quality levels of sleep that they need to function better, both cognitively and physic