Amid the many horror stories of pain patients being tapered off opioids or having the dose reduced, whether because their physicians are afraid of being investigated by drug enforcement or are misinterpreting federal guidelines as requirements, we wondered if there is any reason that these patients can’t be treated with methadone in an opioid treatment program (OTP) or with buprenorphine in office-based opioid treatment (OBOT) program.
Six years ago, when prescription opioid addiction was rampant, we wrote about OTPs being able to treat patients for pain, as long as their primary diagnosis was opioid dependence, based on an interview with the Substance Abuse and Mental Health Services Administration (SAMHSA) (see ADAW, January 17, 2011). Since then, however, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition has come out, eliminating dependence as a pathology and replacing it with substance use disorder (SUD). For opioids, the diagnosis is now opioid use disorder (OUD).
”Circumstances in the field have changed,” said Melinda Campopiano, M.D., medical officer for SAMHSA’s Center for Substance Abuse Treatment, which regulates both OTPs and buprenorphine (for OUDs) prescribers. In an interview with ADAW last week. “The challenge for waivered providers and OTPs is that their use of controlled substances is meant to be for the treatment of opioid use disorder,” she said. ”That’s distinct from dependence.”
And while both methadone and buprenorphine can be used to treat pain outside of the context of an OTP or a buprenorphine prescriber, those formulations and the treatment methodology are different for pain, she said.
“The FDA approves different formulations of methadone and buprenorphine for different indications,” she said. “And the use of opioids for pain management is different than the use of opioids for addiction treatment.”
Also, Campopiano isn’t convinced that being qualified to treat patients with opioids for an opioid use disorder necessarily makes a provider qualified to treat pain with opioids. “I think many providers who are involved in treating patients with opioid use disorder have the knowledge base to treat pain, but I don’t think all of them do,” she said. “I wouldn’t want to push people outside of their skill set.” SAMHSA wants people with pain and people with substance use disorders to “get safe, appropriate treatment,” she said. “But I’m not sure it’s to anyone’s advantage to try to combine them.”
When people with pain develop OUD, and vice versa
There is one circumstance in which it does make sense to combine treatment, and that is for patients who have both an opioid use disorder and chronic pain, said Campopiano. “This is an important area for pain specialists and addiction treatment providers to cooperate and collaborate on in terms of patient care,” she said.
There is a lack of evidence for the effectiveness of opioid in chronic pain, noted Campopiano. But when that patient is being tapered, it would be a good idea to take a careful approach. “There aren’t hard and fast rules,” she said, adding that addiction, not pain, is her expertise. “But generally, this needs to be approached slowly and steadily, much in the same way as someone who was in treatment for an opioid use disorder who is ready to stop taking their medication.” There is a slight difference, because with the pain patient, "the question is physiological dependence, not addiction,” she said. For example, a pain patient tapering from a short-acting opioid is not the same as someone with an opioid use disorder trying to come off of heroin, which is also short-acting, on their own, she said.
There is also the pain patient who develops an OUD because of the prescribed opioids. These patients are the ones who should be treated for addiction, said Campopiano. She is particularly concerned about pain prescribers who discharge patients who are misusing their opioids — for example, running out of medication too soon or testing positive for illicit opioids. “When that prescriber who is treating someone with an opioid for chronic pain becomes aware of aberrant behaviors, more often than we would like, they are discharging that patient from care,” she said. This just sends someone who is not only opioid-dependent but also has a substance use disorder (SUD) out into the street, to suffer withdrawal on their own or to seek drugs elsewhere. “We would like to see more careful attention as to whether that person meets diagnostic criteria for SUD, and a facilitated transfer to care,” she said. “Risk management has eclipsed the patient safety and patients outcomes management.”
We asked other experts about the use of buprenorphine or methadone for pain patients who are being tapered off their medication.
“It depends on the type and source of the pain,” said Charles O’Brien, M.D., Kenneth E. Appel Professor of Psychiatry and vice chair of psychiatry in the Perelman School of Medicine at the University of Pennsylvania. “Some patients may function well on long-term opioids, but the goal should be moving to zero dose and continuing cognitive behavioral therapy. Both methadone and buprenorphine can relieve pain, but the behavioral treatment is also essential.”
“The issues are what works and what is best for the patient,” said H. Westley Clark, M.D., Dean’s Executive Professor of Public Health at Santa Clara University. “The current belief is that there is little justification for chronic opioids. The question should be whether anyone can function well on chronic opioids. If they can function well without psychosocial decrements of function, they should not have to be treated by an addiction specialist. However, if an opioid-stable patient cannot receive treatment from primary care, then addiction docs should be involved. If a pain patient has both chronic opioids and illegal opioids, addiction doctors should be involved.”
“Without addressing the questions of legality, let me simply state that patients with chronic pain often respond well to buprenorphine therapy,” said Stuart Gitlow, M.D., M.P.H., American Society of Addiction Medicine immediate past president. “Given the safety profile of buprenorphine when compared to morphine-like alternatives, it appears quite reasonable to utilize buprenorphine as a treatment approach, particularly when non-opioid-related alternatives have failed. Further, given buprenorphine’s efficacy for long-term maintenance of patients with opioid use disorders, it would seem to represent a clear direction in patients with both opioid use disorder and chronic pain.”
The bottom line: Opioids for chronic pain “are more dangerous than we thought and not as effective as we thought,” said Campopiano.