hyperalgesia - Padda Institute Center for Interventional Pain Management

Addiction and pain management


Get your life back! We specialize in Suboxone therapy for opiate addiction patient’s who also have chronic pain. The Padda Institute is an outpatient facility where we ease patients through the recovery process from addiction. We specialize in the confidential treatment of patients in both the physical and psychological aspects of addiction. Our experienced staff will develop a results based individualized treatment plan for you based on your addiction history and your specific needs.

Opiate Addiction and chronic pain are not uncommon

[learn_more caption=”Opiate Addiction and chronic pain are not uncommon”] Opiate addiction as well as chronic pain can impact so many aspects of a persons quality of life and sense of well being. We offer thorough evaluation and customized treatment plans to help patients achieve and maintain their best functional recovery from addiction, chronic pain or both. • Nearly 36% of people experience disabling pain in any given year. • In addition, 57% of people ages 65 and older experience pain that has lasted more than 12 months. • Reportedly 32% of chronic pain patients have addictive disorder, and nearly 60% of people addicted to opiates have chronic pain. These statistics, and my personal medical practice observation suggest that there is a tremendous overlap in patient’s who have chronic pain and also have addiction to medication. [/learn_more]

 

Specialized treatment is needed for patient’s with both addiction and chronic pain

Chronic pain and addiction are not static conditions. Both fluctuate in intensity over time and under different circumstances and

require ongoing management. Treatment for one condition can support or conflict with treatment for the other; a medication that may be appropriately prescribed for a particular chronic pain condition may be inappropriate given the patient’s substance use history. Other commonalities include the following:

  • Both are neurobiological conditions with evidence of disordered central brain function.
  • Both are mediated by genetics and environment.
  • Both may have significant behavioral components.
  • Both may have serious harmful consequences if untreated.
  • Both often require multifaceted treatment

Pain and addiction are related

[learn_more caption=”Pain and Addiction are related”] Pain Both pain and responses to pain are shaped by culture, temperament, psychological state, memory, cognition, beliefs and expectations, co-occurring health conditions, gender, age, and other biopsychosocial factors. Because pain is both a sensory and an emotional experience, it is by nature subjective. Addiction A person may use substances initially for several reasons, such as to experience the euphoric effects, to relieve stress, to overcome anxiety or depression (or both), or to blunt the pain. With repeated exposure, however, substance use in some people can become uncontrollable. Changes to the brain occur in a process that is mediated by both genetic and environmental factors, which result in an overvaluation of the substance, a devaluation of other things, andimpaired control of substance-related behavior. Evidence indicates that addiction is a chronic disease. The primary rewarding effects of addictive substances occur in the cortico-mesolimbic dopamine systems, where several structures link to control the basic emotions and connect them to memories, which drive behavior. These systems produce sensations of pleasure in response to actions that support survival (e.g., eating, sex) and sensations of fear in response to potential dangers. In a cascading effect, these sensations trigger the endocrine and autonomic nervous systems, stimulating bodily responses. The prefrontal cortex also plays a role in the formation of addictions, modifying pleasure and pain signals based on other considerations. Thus, the brain’s reward and stress systems reinforce life-sustaining behaviors. Development of addiction in pain patients: In some people, a cycle develops in which pain or distress elicits severe preoccupation with the substance that previously provided relief. This cycle—seeking pain relief, experiencing relief, and then having pain recur—can be very difficult to break, even in the person without an addiction, and the development of addiction markedly exacerbates the difficulty. The propensity to develop this cycle is influenced by genetic and environmental factors; some people will experience greater degrees of analgesia than others, and some will have more severe or prolonged abstinence symptoms. Genetic variability in susceptibility to these experiences may explain some cases of iatrogenic addiction. [/learn_more]

 

About our program for addiction and chronic pain

Suboxone therapy is a type of maintainance treatment for opiate addiction. Maintenance treatment is a method of minimizing opiate withdrawals and relapse episodes by using medications.  Suboxone was approved in 2000 for the maintenance treatment of opiate addiction. Suboxone effects the same area of the brain as other opiates. Suboxone also blocks the effects of any opiates that might be used. This eliminates cravings and diminishes the chance that the Suboxone will be abused. For opiate addicts, Suboxone has become an affordable, convenient, and safer alternative to Methadone. While regular monthly visits to the clinic are still required, the patient no longer has to visit the clinic every day.

 

Stated simply, Suboxone is designed to do two things:

1. minimize cravings

2. lessen the high felt when using an abused substance

 

We also advocate participation in AA (Alcoholics Anonymous) and NA (Narcotics Anonymous) which we believe can provide a strong support network for people in recovery.

 

 

We understand the process of recovery from addiction can be a long and painful one. By developing an individualized plan of care for each patient, we help aid the patient into sobriety. As clinicians’ we make the process as easy as possible by providing both medical support to minimize withdrawals and its symptoms  and psychological support that can increase the likelihood of treatment success.  We have three distinct phases of treatment:

 

Phase 1: Outpatient Detox and Titration

This involves an 8-12 hour stay at our facility for the first day. You will be given your first dose of Suboxone and monitored to determine the medication’s effectiveness. One or two follow-up visits will be scheduled over the next week to monitor your progress. (During this visit, a urine drug screen will be obtained.)

 

Phase 2: Maintenance Phase:

Following detox, you will progress to a monthly maintenance phase. This continues for the duration of the Suboxone treatment.

 

Phase 3: Weaning

A slow weaning phase is attempted after an appropriate period of time and if significant support is available as well as patient motivation.  After several months, patients will be gradually tapered off of Suboxone by lowering daily dose until patients no longer require Suboxone. At this time counseling is still strongly recommended to watch for any signs of relapse.

 

Detox can be the beginning of a new life for you… a life free from the chemicals that are causing such destruction and devastation in your life.

“Do It Yourself” detox from substances like Alcohol, Valium, Xanax, Klonopin, etc., can lead to life-threatening complications such as seizures, brain injuries, and death. The severity varies depending upon the person, the substance abused, the amount abused, and the frequency of abuse.  Detox should be medically supervised.

 

 

 

 

 

Opioids: use and misuse in chronic pain management

Opioids have been historically used for pain for thousands of years, but opioid therapy for chronic non-cancer pain remains controversial, despite the fact that opioids are one of the most commonly prescribed medications in the United States.  The prevalence of chronic pain in the adult population averages a median point prevalence rate of 15%, but some studies suggest rates of nearly 40%.  Prevalence rates are higher in the elderly, those suffering significant physically traumatic injuries, or malignancy.  Pain is often associated with severe functional limitations and difficulty in performing daily life activities.  Pain disables more people than heart disease and cancer combined, carrying a significant societal cost.

Papaver somniferum (opium poppy), is the species of plant from which opium and poppy seeds are extracted. Opium is the source of many opiates, including morphine, thebaine, codeine, papaverine, and noscapine.

 

 

Although pain is difficult to measure directly in individual patient, as it is considered a “subjective” symptom, its effects are abundantly clear in the suffering individual and their immediate caregivers, reducing individual and caregiver socioeconomic status. Reduced earnings are evident in not only the individual with pain, but their immediate associated caregivers by at least one quartile, which is reversed upon adequate relief of pain and return to function of the individual.

 

Judicious use of opioids in selected patients with chronic non-cancer pain who have not responded to other treatments and analgesic medications is considered acceptable, but remains controversial due to concerns regarding the long-term effectiveness, safety, risk of tolerance, dependence, and abuse.  Keep in mind that the efficacy of opioids for chronic non-cancer pain has been demonstrated in only short-term trials, including those for neuropathic pain, but the evidence is limited for long term chronic non-cancer pain.

 

Regulatory concerns by prescribers are neither inconsequential nor unfounded, due to the unprecedented diversion rates by unscrupulous “patients,” with up to 30% of patients diverting some or all of their medication for direct economic gain or for recreational abuse.  Simultaneously, empowered patients rightfully demand relief from suffering while regulatory bodies rightfully attempt to limit improper prescribing as a significant public health and policy concern.  Sophisticated illegitimate patients also leverage physician prescribing by threatening regulatory reporting for under prescribing or by fabricating physician quality of care concerns.

Legitimate prescribers often feel caught between the needs of patient’s presenting with subjective complaints, and their fear of improper prescribing to unscrupulous sophisticated “patients.”

Further muddying the waters, some individuals truly legitimate in their need for opioid analgesia, undergo neuroplastic changes in the peripheral and central nervous system (CNS) leading to a sensitization of pronociceptive pathways, resulting in a opioid-induced hyperalgesia (OIH).  The condition is characterized by a paradoxical response, whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to stimuli, resulting in a reduction in the opioid’s treatment effect in the absence of disease progression, often mimicking the neurobehavioral effects of addiction.  Escalating doses in chronic opioid therapy might cause OIH by inducing a vicious cycle of increasing dosage and anxiety for both the physician and patient.  Referral to a qualified interventional pain clinic for multimodal therapy to minimize opioid utilization is strongly encouraged for patient’s with suspected OIH, reducing both physician anxiety and improving patient care.

Safely navigating a course of care in these treacherous waters poses a difficult challenge to the prescriber, sworn to relieve suffering of the individual but cognizant of the unintended consequences to society and to self for inadvertent improper prescribing.

Although many of these challenging patients can be managed in a primary setting, the necessity for close monitoring for therapeutic use, overuse, abuse, and diversion of controlled substances is an absolute necessity and requires specific unwavering treatment protocols, which will result in occasional patient dissatisfaction, sometimes quite vocal. These protocols must include a methodology to monitor consumption against prescription dispensation, with an accurate cost effective biological validation, such as a qualitative in-office urine drug screen cross validated by a more sensitive quantitative laboratory analysis.  These protocols must also minimize the use of opioids overall, using adjuvant therapies which should include interventional, behavioral, non-opioid pharmaceutical, or physical therapy options.

Most importantly, a clearly defined prescriber exit strategy should exist when utilizing opioids to treat chronic pain because of the potential complications in managing these patients such as opioid dependence, addiction, and abuse.