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Managing Multimodal Care for Patients with Co-Occurring Pain and Addiction
By Greg Rudolf, MD
Do you treat patients who struggle with pain and addiction in your clinical setting? If you have a busy clinical medicine or behavioral health practice, then you surely do. But how do you best manage the complex, multimodal care required for effective treatment of patients with chronic pain and addiction?
Understanding Pain
Pain is a subjective, unpleasant sensory experience which involves highly complex neurobiological processing. It tends to be protective and to enhance survival in the acute phase. When it becomes chronic, pain can become maladaptive, with increased involvement of the brain’s emotional circuitry and amplification of central nervous system-mediated somatosensory signaling. Fortunately, the brain and nervous system can be retrained, and pain pathways can be revamped. Chronic pain treatment focuses on such strategies, aiming to dampen and filter excitatory pain signals from the body’s peripheral nerves, and to foster a sense of agency and self-efficacy that facilitates optimizing quality of life in accordance with the patient’s own values. Primary treatment approaches for chronic pain include movement therapies, psychological therapies, integrated programs, evidence-based treatment of co-morbidities, passive (bodywork and procedural) therapies, and medication management.
Understanding Addiction
The American Society of Addiction Medicine (ASAM) defines addiction as a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experience. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. Medications are the gold-standard treatment for opioid use disorder, particularly the medications buprenorphine, methadone, and naltrexone XR.
Implication for Treating Both Co-occurring Medical Conditions
Pain and addiction are often correlated. Opioids are not advised for long-term treatment of chronic pain, as they dysregulate the reward and stress systems over time, lowering reward function and increasing pain and stress. Primary treatment approaches for chronic pain and opioid use disorder similarly include the following: treating the person as a whole, with the aim to restore function and reduce suffering; using a combination of non-pharmacological and pharmacological approaches; treating co-morbidities, such as mental health and sleep disorders; and reducing or eliminating unnecessary or harmful medications and substances.
Register for ASAM's Virtual Pain & Addiction: Applied Skills Workshop:
Learn More
ASAM’s Pain and Addiction Essentials curriculum is designed to build your toolkit for working with patients presenting with these problems. Our multi-course offerings provide practical strategies to manage complex, challenging clinical cases using compassionate, evidence-based, whole-person approaches.
Download the free screening resource for pain and substance use disorder.
Review ASAM’s Clinical Guidelines.
Greg Rudolf, MD, is a physician board certified in addiction medicine, pain medicine, medical acupuncture and family medicine practicing at Swedish Pain Services in Seattle. Dr. Rudolf has also worked extensively in inpatient substance use disorder treatment settings. He is chair of the ASAM Pain and Addiction Course Planning Committee, serves on the board of directors of the Washington Society of Addiction Medicine, and is a clinical associate professor at University of Washington School of Medicine.