Reexamining opioid addiction as a co-occurring disorder: A clinical perspective on the “Chronic Pain Paradox”

Abstract

The use of opioids as an anodyne for chronic pain was not prevalent before the 1980s1. Students in medical schools had learnt to avoid prescribing opioids, considered highly addictive for treatment of non-malignant chronic pain1. Yet, from the early 1990s, prescription opioids emerged as a widely accepted method of treating chronic pain and palliative care2. Previously, chronic pain was treated in multidisciplinary clinics with coordinated care which included physical exams, medication management, biopsychosocial evaluation, cognitive behavioral treatment, physical therapy, and occupational therapy2. Starting in the early 1990’s, under dubious antecedence, opioid analgesics were promoted as the proprietary remedy for chronic pain and received endorsement and support from care providers across the United States3. Non-cancerous chronic pain, as a phenomenon, was thus elevated to an ailment or a medical condition by its own right from its erstwhile status as a corollary to another medical condition. This led to an increase in opioid analgesic prescriptions, followed by a wide-ranging abuse by patients, converting opioid use disorder (OUD) to a problem of epidemic proportions4. Apart from the legal course of action initiated against Perdue Pharma, in 2020, the maker and distributor of Oxycontin that resulted in a $3.8 billion lawsuit settlement, in which Perdue Pharma pleaded guilty; since the recognition of this problem, new measures have been adopted to counter the opioid epidemic by clinicians. There has been a significant shift towards circumvention by physicians prescribing opioids for non-cancerous chronic pain. In a few instances, providers have resorted to putting a temporary moratorium on prescribing opioids to all non-cancerous chronic pain cases5. The Center for Disease Control (CDC) and various state agencies have passed protocols, installed prescription monitoring programs (PMPs), and created taskforces to rein in flagrant prescription practices by medical providers. Mental health counseling and alternative, non-prescriptive pain management procedures have been reintroduced in treatment as a new way of approaching the problem6,7. The Substance Abuse and Mental Health Administration (SAMHSA) have suggested hybrid programs such as medically assisted treatment (MAT) which utilizes the medical approach of prescribing slow releasing drugs with concomitant counseling for patients, as one of the best practices to intervene with opioid use disorders8. An integrated healthcare approach brought primary care physicians, nurses, and physician’s assistants together with addiction counselors and social workers to coordinate and implement treatment for opioid misuse9,10. These new approaches are laudable and effective, yet we argue, in this paper, for ascertaining the treatment of chronic pain as a co-occurring disorder to addiction. While acknowledging the two original transgressions of the opioid epidemic: a) the delineation and decontextualization of chronic pain as an independent medical phenomenon, and b) the over-prescription of opioid analgesics to treat chronic pain; we argue that recognizing chronic pain as a co-occurring disorder with addiction and psychological trauma could help providers contextualize it better, leading to an improved treatment protocol. Over last two decades, persistent over-prescribing has set forth a culture of righteous demand among patients to obtain opioids and receive instant pharmacological sedation as an antidote to chronic pain. This culture, which may have taken roots, could cause resistance among chronic pain patients towards any change to alternative treatment plans. This could frustrate medical providers and reformers as they usher in the new treatment procedures promulgated by SAMHSA and the CDC. Thus, a co-occurring diagnostic framework could provide a pathway to better understand this treatment dilemma. The co-occurring disorder lens of diagnosis could provide a pathway to understand this treatment dilemma. In this paper, we do a critical, non-systematic review of existing literature that explores the intersection of chronic pain and OUD to make a case that these issues should be treated as co-occurring disorders and not as disconnected, independent phenomenon. We review the scope of the problem and provide an analysis of the complex relationship between chronic pain and usage of opioids from both pharmacological and psychological viewpoints and explore the challenges to treatment. We take an ecological and exchange theory perspective to understand the co-occurrence of pain and opioids addiction from a trauma-informed lens to unpack the complexity that OUD poses in juxtaposition to chronic pain. Furthermore, we explore the strategies to develop an integrated healthcare workforce from a co-occurring disorder perspective. Furthermore, we explain the context of co-occurring pain, addiction, and psychological trauma and identify the pertinent questions that such co-occurrences pose for treatment protocols. We draw our argument from a critical review of the literature as well as the incidence and prevalence of OUD.