Post-its from Practice:
Don't forget pain in the recovery debate (Apr 2011)
Two months ago one of my partners came to see me to ask about a patient. Johnny had been registered for six years, had used opioids for twelve years and then two years ago had become drug-free after successfully completing rehab. Johnny had started using heroin as he hadn't been able to get effective relief for pain in his hip and pelvis, which he had smashed up badly in a motor bike accident. He found heroin really worked, began to use more and soon developed a dependency on it.
Johnny was requesting that my partner prescribed dihydrocodeine, which he had been using for several months, as his pain had returned with vengeance after he became drug-free. She was concerned that she would be helping to trigger a relapse. I agreed to see him the next day to assess.
When Johnny walked in I could see he was a man in great pain. Having experienced chronic pain I know how all pervasive it is and I could tell he was in pain before uttering a word. He explained that the pain had restarted days after leaving rehab but by using meetings and psychological support he had been able to avoid use of any analgesia for several months. He had then started buying codeine preparations, had not injected and had slowly began to feel better and was able to use his on-going counseling and meetings constructively again. He had been using 2x30mg dihydrocodeine for four months, had not used more and had picked up no other drugs.
Chronic pain is too often forgotten in people who use drugs. We know 10-25% of people who use opioids say they start because of pain and the prevalence of chronic pain is between 30 and 50% in treated substance users, compared with 10-15% of the general population.
Under-treatment is common and is often based on a whole series of misconceptions including: OST provides adequate analgesia and the pain complaint may simply be a manifestation of drug-seeking behaviour. Pain is subjective and person-defined; it is always unpleasant.
The assessment of chronic pain in the context of substance use is complex and time-consuming and needs not only to take account of the pain history but also provide a mental state assessment. The early prescription of adequate effective analgesia reduces the risk of persistent pain (Ref 1).
Plus there is no evidence that using opioids to treat pain will trigger relapse. It is more likely that inadequate analgesia and the stress associated with pain will play a role in relapse and continued use.
With this in mind we agreed to prescribe for him weekly because the risks of forcing Johnny to use the black market were far greater. I saw him yesterday in the emergency surgery where he had attended with his son who had a temperature. He looked cheerful and said he was well, now on the list for a new hip, his pain management remained the same and his home support meeting had not barred him for using analgesia.
In our move towards a recovery-focused system let us never forget about the role of pain and always give it the respect and treatment it needs in its own right.
1. Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care - see extended section on pain.