Substance abuse issues in chronic pain sufferers is always a concern – and doubly so, if there is an abuse history. Chance of abuse in high risk cases was 32%.
Drug Alcohol Depend. 2013 Jan 1;127(1-3):193-9.
Risk for prescription opioid misuse among patients with a history of substance use disorder.
Morasco BJ, Turk DC, Donovan DM, Dobscha SK. abstract here
- High risk cases had more mood issues and worse pains – “worse pain severity, interference, catastrophizing, depressive symptoms, and lowest self-efficacy for managing pain”. The increased severity of pain makes relieve even more critical though more dangerous.
- Pain catastrophizing was particularly a useful predictor.
Comment – I try to stick to fentanyl patches which they can trade in when the get new ones but come across a significant number “allergic” to them or find them ineffective. Nucynta CR and Tramadol varieties are a possibility but aren’t necessarily that strong. Kadian is my last choice with frequent testing and other measures they have whole talks on. I do manual and injection therapies and if they aren’t interested in these, then I might not want to just give them opioids. Some are better off in a methadone program and I can’t deal with. Opioids might give 20-30% relief – there is just too much hype on their effectiveness. With depression being an issue, an SNRI might bre indicated and I am not sure Cymbalta is necessarily much better than Venlafaxine. If there is potentially alcohol involved. non-sedating Wellbutrin might be better choice. I do make it very clear that opioids, alcohol and driving do not mix in any proportion. This is a big topic – but there are intermittent talks about this.