Seddon Savage, MD, is a clinician, educator, and policy advocate in the fields of addiction medicine and pain medicine. She is Advisor to the Dartmouth Hitchcock Substance Use and Mental Health Initiative and Associate Professor of Anesthesiology on the adjunct faculty of the Geisel School of Medicine at Dartmouth. She also serves as Medical Director of the Chronic Pain Recovery Program at Silver Hill Hospital. Dr. Savage spoke recently with freelance writer Laura Kiesel to discuss pain, addiction, and the connections between the two. Below is an edited transcript of their conversation.
What ignited your interest in addiction medicine and pain medicine, and the intersections between the two?
I have always been very interested in mind-body interactions. There are few conditions that more prominently highlight those interactions than pain and addiction. People can suffer enormously when they have either condition, and especially when they have both.
Pain is a perception that signals impending harm to the body, but that perception can persist long after the body has healed, so the complex neuropsychobiology of pain [the neurological, psychological and biological contributors to pain] is really fascinating. There’s also a complex neuropsychobiology of addiction. When pain and addiction come together, it creates a really complex puzzle for us to identify the various components of each and help people work through them.
Who is predisposed to opioid addiction?
For many people who become addicted, there are predisposing genetic factors. We also know that people who have prior experiences of severe trauma, such as sexual trauma, physical abuse, or severe neglect—particularly in childhood—seem more predisposed to developing addiction. There’s a relatively high prevalence of trauma in people who develop chronic pain as well, so it may be that there are some common predisposing factors for developing both of these conditions.
We also know that people who are isolated, or who are living with chronic inescapable stress and having difficulty coping with that, may also be more predisposed to addiction. Having a major mental health condition, such as bipolar disorder, schizophrenia, or major depression, may also increase the risk of opioid addiction, though that’s less clear.
However, people who have a prior history of opioid addiction are in the highest risk group. People who have a prior history of any kind of substance use disorder seem to have a higher risk of addiction to opioids when they use them for chronic pain. That said, there are many people with alcoholism or other past addictions who seem able to use opioids on a short-term basis, and sometimes on a long-term basis when they’re needed, without developing addiction to opioids. Conversely, sometimes people with no personal or family history of addiction become addicted to opioids.
How do doctors determine who should or should not get opioids?
Opioids are the most powerful class of drugs we have to treat pain. They’re also very powerful in causing harm when they are misused or irresponsibly prescribed, so we’re always trying to find a balance. We select a treatment if we believe that it has the best balance of benefit to risk for an individual patient.
When we think about treating pain, the things we consider are the cause of pain, whether it’s injury or illness related, and what factors may have contributed to the pain persisting in those with chronic pain. Then we have to consider the other conditions patients may have, their risk factors for developing problems with opioids, and whether they have co-occurring conditions that could make opioids more risky for them, including certain respiratory conditions, such as sleep apnea. We consider the benefit we expect the patient to derive from the medication, and whether it’s a short-term or long-term benefit, and make a decision with that individual whether a trial is appropriate.
If opioids are not the best treatment option, I would consider other approaches, as there are many other tools for pain management.
Are opioids effective as a long-term treatment for chronic pain?
In my experience, opioids can be a helpful component of care for selected patients for whom other treatments are ineffective or pose more risk. We often hear there’s no evidence that opioids are effective for chronic pain. But it’s important to understand that absence of evidence of effectiveness does not mean there is evidence that opioids are not effective. It just means that, in terms of long-term definitive studies, we don’t have good evidence either way.
We do have studies that go out up to three months and most of them show that some patients benefit from opioids. And if you survey patients who have been taking opioids for many months, many of them feel that they do experience pain relief. On the other hand, some large epidemiologic studies demonstrate greater pain and poorer functional outcomes in people using opioids. We clearly need more studies to determine who may benefit and who may be harmed.
Understandably, the people who are most passionately against the long-term use of opioids for chronic pain often are those who treat patients with opioid use disorder, many of whom started using opioids for chronic pain; from that perspective, 100% of people who use opioids for chronic pain develop addiction to them. When you talk to family practitioners or pain clinicians, however, most of them have a subgroup of patients who appear to do well on opioids. They not only get relief from pain, but many are also able to improve their level of function and their engagement in their work and with their families.
Are there professional guidelines for doctors to help them decide whether to prescribe opioids?
There are many guidelines out there. Of particular relevance are those issued in 2016 by the Centers for Disease Control and Prevention (CDC). The CDC guidelines suggest that doctors consider all pain treatment options before using opioids on a long-term basis, monitor patients carefully using tools such as urine drug screens and prescription drug monitoring, and that they consider consultation with the appropriate specialists and carefully justify opioid use for patients taking higher doses or undergoing prolonged treatment. We find that the management of most patients on opioids who benefit from them fall well within the guidelines, though not all.
An indiscriminate rush to discontinue opioids without a reasonable clinical rationale for doing so simply on the basis of concern about prescribing them can have unintended negative consequences. If doctors want to make changes in an opioid prescription, particularly if they’re considering tapering opioids, it is important to have a conversation with the patient to justify that decision and then to support the patient with alternative treatment as they withdraw from the medications. Sometimes there are good reasons for discontinuing opioids: if the patient is functionally deteriorating rather than doing better, is over-sedated, seems to be misusing the medication, or is supplementing it with substances obtained from friends or from the street. All of these factors should raise concerns.
But for patients who are able to engage fully in their lives, do their work or household chores and engage in activities that have meaning and value to them, and aren’t showing signs of overusing or misusing the medication, then it may be appropriate to continue the opioids even if the dosing is outside of the guidelines. But if a doctor is uncertain, it is often helpful to seek out another opinion.
What spurred the opioid epidemic?
When pain became a higher priority for treatment in the late ‘80s and through the ‘90s, there was a real emphasis on addressing pain aggressively and there was increased prescribing of opioids; it’s easier to write a prescription than to address pain in a more holistic way. Unfortunately, as we saw increases in the prescription of opioids for pain, we saw parallel increases in the demand for treatment of opioid addiction, and in opioid overdose deaths, as illustrated in a widely circulated graph published by the CDC in 2011. What this suggests is that as opioids became more available for pain treatment, they also became more available for misuse and related harm.
According to the National Survey on Drug Use and Health, about 70% of people who misuse opioids or use them for nonmedical purposes get their opioids from a friend or a family member, about 80% of whom in turn were prescribed the drugs by a physician. So we clearly need to find ways of prescribing the needed doses without there being significant excess. Patients need to secure their medications so that they can’t be diverted and misused and to dispose of the medication when it is no longer needed.
So opioid prescribing contributed to increased opioid availability and increased nonmedical use of opioids. Along with this appetite for opioids in the US, we increasingly see problems with heroin and with fentanyl—not pharmaceutical fentanyl but fentanyl that is manufactured in countries like Mexico, Columbia, and China and is coming in over our borders. These drugs are so pure so that people no longer have to inject the drugs; they can be snorted instead. This means people no longer have to cross the psychological line of having to inject themselves to initiate use of these illicit opioids.
It is important to remember that it is not opioids alone that result in harm, but rather the interaction of the drugs with an individual who may be vulnerable to misuse or addiction due to complex factors, such as genetic factors, trauma or pain, current isolation or other stressors.
If someone is predisposed to opioid addiction because of past alcohol addiction, how do you work with that person when deciding on a possible opioid regimen for pain?
If somebody is in recovery from alcohol or other substance dependence, that person may have higher risk of opioid use disorder. I would take particular care that less risky interventions had not been successful in managing their pain before initiating opioids, particularly for a chronic problem. In our treatment program we treat many people with co-occurring chronic pain and substance use disorder. Our focus of care is to engage people in an intensive program of self-management as a foundation of treatment. This means becoming aware of the things that increase and decrease their pain, changing behaviors to reduce pain, and cultivating wellness through a system of exercise, attention to posture and movement, attention to stress, a daily practice of meditation, and so on.
Someone with a history of alcohol or other substance disorder who wants to consider a trial of opioids should have a conscious program of recovery. It’s not Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) for everybody, but usually it’s some form of group support, as well as having a therapist, sponsor or some other mentor or partner to work with to help cultivate recovery.
Once individuals are engaged in a meaningful recovery program for both the substance use disorder and for the chronic pain, those people need a provider who is very savvy and will monitor them very closely for a trial of opioids, while keeping significant others engaged. Things to look out for are whether the patients are using the medication even if they are not having pain, but rather to improve their mood or to sleep, and whether they are using the opioids as prescribed. Objective information such as urine drug testing and prescription drug monitoring are critical in this context. For people with a history of opioid use disorder, opioids can usually only be safely provided through an addiction treatment paradigm, such as through a certified buprenorphine provider or methadone maintenance clinic.
What type of training in addiction medicine and pain medicine do medical professionals receive?
Most people in medical school receive just a few hours of training in addiction and about the same in pain management despite the fact that these are very common conditions. That’s beginning to change, but we definitely need more training in medical school and in pertinent residencies and fellowships in identifying and treating addictions and supporting recovery, and in multidimensional management of chronic pain. None of these topics are part of most core medical school curricula in any meaningful way.
I consulted on a project that some colleagues at Yale were doing a couple of years ago where they had surveyed a number of directors of addiction medicine fellowships and pain medicine fellowships to see how many have training in the other field. They haven’t published the survey yet, but their findings generally indicated that neither type of training program included extensive training in the other. Addiction fellowship training programs were more likely to require some training in pain than pain fellowships were to require training in addiction. Likely this is because much of pain management training focuses on non-opioid approaches to treatment that do not raise addition issues, while addiction fellows regularly treat people with opioid dependence related to opioid use for pain. Nonetheless it is clear that as long as opioids are part of pain treatment, both specialties need some familiarity with the other.
Most of us who treat people with co-occurring pain and addiction would say that you can’t treat addiction without understanding pain, and you can’t treat pain without understanding addiction. Clearly, increased cross-training and collaboration between the fields would be helpful for patient care.
There is a lot of interest in medical marijuana for pain. What are your thoughts about cannabis?
Cannabis is a very complicated herb containing over 70 cannabiniods [the active ingredients in cannabis] and at least 500 potentially biologically active other chemicals. Some cannabinoids do have analgesic properties; there’s enough evidence to say that. We also know that some cannabinoids have appetite-stimulant and anti-nausea properties. And there is emerging evidence that others may have anti-anxiety properties, anti-spasticity activities as well as anti-seizure activities. As a complex herb, cannabis’ effects depend on the particular batch of cannabis a person uses.
THC is the cannabinoid that’s been most well studied with respect to pain and it’s thought to have analgesic properties, but it’s also the cannabinoid that seems to be responsible for the euphoria and cognitive changes observed with cannabis use. Another promising cannabinoid is cannabidiol (CBD), which may have anti-anxiety and anti-inflammatory activities, as well as other effects, without the euphoria of THC, though studies are ongoing. Many other cannabinoids are yet to be studied in detail.
So there is clearly promise in herbal cannabis but much more work needs to be done to determine what cannabinoids, in what combinations, may be helpful for different clinical problems. The challenge here is that there is a parallel pharmaceutical industry growing up in the cannabis world that isn’t subject to federal or state oversight, and research within usual channels has been slow to evolve due to restrictions on cannabis research.
There are two FDA-approved medications that contain THC or something very similar to it. These medications have been approved for treatment of weight loss and loss of appetite in HIV and for nausea and vomiting associated with chemotherapy. It’s also legal to use those medications off-label for the treatment of pain, though it’s not done very often.
Cannabis hasn’t been well studied in the context of medical use, but in the context of recreational use we know that about 9% of the general population develops addiction to cannabis. This percentage is higher in people who begin using cannabis at a younger age, with one study suggesting up to 17% of people who start using marijuana regularly at the age of 13 or 14 have difficulty stopping it and use more than they intend. Marijuana does not seem to have an overdose risk when used alone.
Is cannabis safe for those already taking opioids?
There are few studies detailing the additive effects cannabis might have if someone is also using opioids. For example, it is unclear whether cannabis-related sedation might tip over someone using opioids into overdose, as can happen with benzodiazepines, though I am not aware of reports of this. Some observations suggest that people who use cannabis or cannabinoid medications for pain may actually use lesser amounts of opioids.
There is some literature suggesting that some people with pre-existing coronary disease can have cardiac events when using marijuana since it increases heart rate and there are other side effects. So there are possible benefits and risks, as with all drugs. Marijuana may relieve pain and other symptoms in some people, but it’s not an entirely benign substance. That said, it does not carry the risk of overdose like opioids, at least when used by itself.
What types of studies are needed to better understand whether cannabis is safe?
As far as I know, there is no state in the US collecting individual outcomes data on patients who use cannabis for clinical purposes. When New Hampshire was considering clinical cannabis legislation, I lobbied to require collection of data related to the use of marijuana, such as what type of marijuana people use; whether it in fact helped patients’ symptoms or improved their quality of life; and if they experienced any side effects or signs of addiction, but in the end this was not adopted. I think it’s critically important to collect this kind of information because otherwise use of marijuana in clinical care is an experiment with unstudied outcomes. It may be a helpful, but we just don’t know at this point in time.
What studies related to pain and/or addiction are you doing now?
Most of my work is clinical care or related to healthcare provider education. I am not a researcher myself, though our clinical team is continuously engaged in studying our outcomes in order to improve our care. My real passion is for helping people find the things they can do to best manage their pain, and that is my focus at this time. In our program at the Chronic Pain Recovery Center at Silver Hill Hospital, we treat those who have chronic pain that’s impacting their level of function and who have not found satisfactory treatment. We engage them in a program of self-care, including exercise, meditation, cognitive behavioral therapy, acceptance and commitment therapy, and movement therapies such as qigong and tai chi. We individualize our decisions for each patient about how to manage their medications.
Overall we have found our patients experience a significant reduction in pain, as well as a more dramatic reduction in pain interference with activities and enjoyment of life, with 63% getting off of opioids, 19% transitioning to medication-assisted treatment for opioid addiction, and 18% continuing on opioids at a much lower dose—on average a 75% reduction. That’s from one study we’ve completed in the context of a natural treatment environment. Though not a randomized, controlled clinical trial, it is heartening to have indications that an interdisciplinary program that engages patients in self care can have such a positive impact on their quality of life.
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