FIRST DRAFT 1 FIRST DRAFT 9 First Draft Erica K. Fernandez Argosy University Pain Management for Patients with Addiction Problems Thesis Statement The ability of clinicians to keep patients in check has proven to be a challenge, especially with concerns regarding the legitimacy and physical functions affecting overall pain management in patients with an addiction problem. Background The treatment modalities for chronic pain using COT in active drug users or those who are in remission present a significant challenge for clinicians who oversee the effectiveness of the intervention. Moreover, such notions are correlated to the concerns of patients experiencing a relapse to substance abuse during the duration of therapy since analgesics may obscure drug-seeking behaviours that are characteristic of addictive diseases. This results in poor treatment outcomes where patients are likely to be discharged prematurely from pain care treatment (Ballantyne & Mao, 2003). Additionally, there is the widespread misconception that chronic pain patients with an addiction problem often encounter health professionals who possess inadequate training in clinical guidelines that are related to comorbidities of chronic pain and related addiction issues. Moreover, there exists a dilemma for the treatment of abstinent and former heroin addicts as they are at a high risk of relapsing to addiction if they are exposed to opioid drugs. They also face the risk of relapsing if they are not accorded sufficient care. For people who are already on opioid medication such as methadone often experience challenges responding to pain relievers when they are hospitalized. In such as case, the fundamental principle of management denotes the prevention of withdrawals by initiating methadone for heroin users while providing additional analgesia as recommended while confirming whether the pain relief is satisfactory (Chou et al., 2009). Additionally, most physicians have developed a phobia of over prescribing narcotics as pain relievers. Perhaps this may be attributed to the fear of the legal repercussions that may ensue including the divergences in federal guidelines on matters about the use of narcotics as a pain reliever. Thus, it is the responsibility of the individual practitioner to offer pain management using opioids for legitimate standard and by the regulation of medical practice. Objective The purpose of this research is to evaluate the challenges that are faced by clinicians in pain treatment for patients with addiction problems. On the other hand, the study focuses on offering a counter-argument to the thesis by providing ideal solutions for pain management for patients with SUDs. Additionally, the research intends to highlight the complex interconnection that exists between pain management and addiction to opioids. Supporting Points For clinicians, the hardest challenge is perhaps knowing the right way to handle patients who require pain medication, ...

1. FIRST DRAFT 1
FIRST DRAFT 9
First Draft
Erica K. Fernandez
Argosy University
Pain Management for Patients with Addiction Problems
Thesis Statement
The ability of clinicians to keep patients in check has proven to
be a challenge, especially with concerns regarding the
legitimacy and physical functions affecting overall pain
management in patients with an addiction problem.
Background
The treatment modalities for chronic pain using COT in active
drug users or those who are in remission present a significant
challenge for clinicians who oversee the effectiveness of the

2. intervention. Moreover, such notions are correlated to the
concerns of patients experiencing a relapse to substance abuse
during the duration of therapy since analgesics may obscure
drug-seeking behaviours that are characteristic of addictive
diseases. This results in poor treatment outcomes where patients
are likely to be discharged prematurely from pain care treatment
(Ballantyne & Mao, 2003). Additionally, there is the widespread
misconception that chronic pain patients with an addiction
problem often encounter health professionals who possess
inadequate training in clinical guidelines that are related to
comorbidities of chronic pain and related addiction issues.
Moreover, there exists a dilemma for the treatment of abstinent
and former heroin addicts as they are at a high risk of relapsing
to addiction if they are exposed to opioid drugs. They also face
the risk of relapsing if they are not accorded sufficient care. For
people who are already on opioid medication such as methadone
often experience challenges responding to pain relievers when
they are hospitalized. In such as case, the fundamental principle
of management denotes the prevention of withdrawals by
initiating methadone for heroin users while providing additional
analgesia as recommended while confirming whether the pain
relief is satisfactory (Chou et al., 2009). Additionally, most
physicians have developed a phobia of over prescribing
narcotics as pain relievers. Perhaps this may be attributed to the
fear of the legal repercussions that may ensue including the
divergences in federal guidelines on matters about the use of
narcotics as a pain reliever. Thus, it is the responsibility of the
individual practitioner to offer pain management using opioids
for legitimate standard and by the regulation of medical
practice.
Objective
The purpose of this research is to evaluate the challenges that
are faced by clinicians in pain treatment for patients with
addiction problems. On the other hand, the study focuses on
offering a counter-argument to the thesis by providing ideal
solutions for pain management for patients with SUDs.

3. Additionally, the research intends to highlight the complex
interconnection that exists between pain management and
addiction to opioids.
Supporting Points
For clinicians, the hardest challenge is perhaps knowing the
right way to handle patients who require pain medication, yet
they have a history of addiction to drugs. When speaking about
pain medication, opioids are among the first class of drugs to
come to mind. There is also a clash that exists between
prescribing opioid medication to patients with a history of
heroin abuse. Most doctors, fearing the legal ramifications of
their actions, often shy away from overprescribing pain
medication to patients with a history of drug addiction.
Numerous misconceptions are surrounding this topic, such as
patients with chronic pain symptoms encountering physicians
who do not have enough experience to handle their unique needs
(Fishbain et al., 2007). Important to note is that, the main issue
of concern is knowing the right way to treat a patient with a
history of drug abuse without causing abstinent patients to
relapse, or to administer small dosages of pain medication
which may lead to the patients being discharged before the right
time for their therapy has elapsed, or even designing the proper
care interventions that will ensure patients do not relapse.
Consequently, the fundamental principle of care for patients
with SUDs prompts the need for identification of physical
dependence on illicit opioid use or the addictive ailment well in
advance to facilitate the formulation of an effective treatment
plan. Moreover, addiction ought to be perceived as a co-
occurring medical issue which is pervaded by challenges such
as increased medication requirement and tolerance and such
problems need to be accommodated while also according respect
to the patient during treatment.
There exists no perfect formula for calculating the right amount
of opioid doses to administer for pain medication therapies.
There are no studies that deeply delve into the issue of how
patients with a history of substance abuse should be handled

4. when it comes to administering pain medication to them. For the
patients already using opioids illegally, there is a serious
challenge during pain management should a time come when
they require such interventions (Michna, 2004). With the
current legal system, physicians may face legal ramifications
for over prescribing, meaning they are almost always afraid to
make prescriptions. In a bid to safeguard against the advent of
adverse legal implications in pain management, clinicians are
advised to prescribe long-acting, scheduled or continuous
opioids with the reservation to utilize the pro re nata medication
scheme solely for dose titration (Oderda, 2012). In the long run,
the pain physician can provide analgesia at the same time he
avoids compelling the patient to make frequent requests for
opioids thus averting the controversy that is associated with
misinterpretation for drug-seeking behaviors. In extreme cases
that is characterized with medical challenges such as trauma,
surgery or illness, the patient with an active addiction ought to
be particularly open to the possibilities of entering addiction
treatment.
In the medical world also, there exists a complicated
relationship between pain management and patients with
addiction problems. Physicians may discharge patients early
from pain management programs, meaning the patients
encounter problems both regarding pain and also regarding their
drug abuse problem (Martell, 2007). More so, improper
communication has made physicians shy away from taking on
patients with substance abuse problems, especially since opioids
are the essential components required for pain management, and
administering such medication exposes the patients to a high
risk of a relapse during or after the pain management therapy.
Moreover, patients who have experiences with untreated pain
and addiction are likely to develop the syndrome dubbed pain
facilitation (Volkow et al., 2014). This phenomenon may be
attributed to the alternating intoxication ad withdrawal as a
result of unstable blood levels of the drug. COT patients may
also experience such challenges where the sympathetic nervous

5. system may be activated leading to the advent of irritability and
tension further aggravating discomfort and pain.
Lastly, the bureaucracies associated with pain management for
patients with drug abuse problems make it difficult for
healthcare settings to do their work properly. Notably,
physicians lack the proper support from their healthcare
facilities to address pain management for patients who have a
history of drug abuse (Gourlay, 2005). The absence of acute
management teams in most facilities also means that for a
healthcare facility to take on patients struggling with drug use,
there needs to be written procedures and policies, which are
mostly not properly adhered to. For instance, the employment of
collaborative efforts amongst pain clinicians and mental health
professionals would be instrumental in reconciling the
ambiguities that exist between personality disorders and pain
management. Research indicates that chronic pain patients with
untreated depression respond poorly to pain treatment
mechanisms (Pud, Zlotnick & Lawental, 2012). This problem is
further compounded by functional limitations where pain
patients become isolated and are incapacitated in regards to
participation in social and physical activities which
significantly contributes to severity of chronic pain experience
Counter Arguments
Before admitting patients into the COT program, clinicians need
to conduct a comprehensive risk assessment for opioid misuse.
The evaluation comprises of identified risk factors for addiction
problems such as family or personal history of substance use,
psychiatric symptoms, functional impairments and childhood
adverse events (Oliver et al., 2012). As such the identification
of pain symptomologies would comprise of identifying the
causative factors that perpetuate pain; the documentation of
pain-related risk factors for relapse and opioid abuse and the
demarcation of efficient and nociceptive components of the
occurrence of pain. Moreover, screening tools such as Addiction
Behaviour Checklist (ABC) and Diagnosis, Intractability, Risk,
Efficacy (DIRE) may be used in the stratification of patients as

6. being either high, medium or low-risk group of opioid misuse
(Ives et al., 2006). Consequently, patients who are categorized
as being high or moderate risk require frequent monitoring,
especially in medication use. Moreover, frequent urine drug
testing and monthly reviews of Prescription Monitoring
Program (PMP) reports are recommended including the attempt
to prescribe opioids in small doses.
The pain medication given to patients needs to be
regulated. Access to more pain medication drugs may lead to a
false sense of pain in the patients. Knowing the pain medication
is at their disposal, patients may take medication for pain that is
not severe enough to warrant medication (Thorn, 2017). The
success of the COT module may be determined through the
regulation of the number of units of opioid medication that is
made available to the patient and the frequency in which the
drugs are dispensed. In contemporary practice, patient
commonly receives analgesics on a monthly basis while those
who indicate minimal risk of substance abuse are provided with
up to 3-month supply. Nonetheless, it is recommended that for
pain patients with SUDs smaller quantities be administered
more frequently to avoid instances of misuse. Pain medication
should be administered through a third party, and not directly to
the patient. This may work to reduce the possibility of a relapse
in the patients. Therefore, administration of pain medication,
especially opioids, should be structured in such a way that
patients have limited direct access to the drug (Chou, 2009).
The medication is only availed to the patients at the prescribed
times and for the specified amount of time.
Conclusion
It is complicated to accurately ascertain the amount of pain
that a patient is going through. The limited nature of research
into the correlation between pain therapy and patients with a
history of drug use also makes it difficult to correctly match the
level of pain as described by the patient, with the right pain
medication dosage. With the current legal system defining the
conduct of healthcare practitioners, most physicians are afraid

7. of the legal issues they may face when they are accused of
prescribing more opioid pain medication that is supposed to be.
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