Commonly used interventions intended to limit diversion and abuse in patients receiving opioid therapy for chronic pain: Clinical utility and empirical support

Abstract

Managing chronic pain in people suffering with addictions can be complicated. Clinicians try, as they do in the case of any other subgroup of people with chronic pain, to maximize the benefits of medical treatments and minimize the risks. The use of opioids can be particularly complex. In some pain syndromes, opioids are low in the "decision tree" for nearly anyone because of community consensus that they are less efficacious for these particular problems (i.e., migraine; fibromyalgia). When a person with addiction suffers with these pain problems, opioids may not be considered at all as their enhanced risk outweighs their unlikely benefits. But in the treatment of many other pain syndromes, the place of opioids in the decision tree has been established by community consensus (cancer; pain related to life-threatening diseases of all types) or they occupy their place at some point in the sequence of treatments. Avoiding opioids and leaving people in unrelieved pain can be a trigger to illicit drug use and rekindling of addiction perhaps as often as exposing people to opioids can be and so absolute avoidance of opioids is not recommended. Instead, the authors' collective clinical experience and the extant literature support the very careful use of opioids in these patients with risk management tools and techniques playing a prominent role. Additionally, careful opioid selection combined with recovery support can lead to satisfying outcomes in at least some of these high-risk individuals.