Speakers Give Tips on Managing Patients With Addiction or Chronic Pain

At the Dialogue session “Viewing Addiction as a Chronic Illness: Recognition, Diagnosis and Management,” held Sept. 28, at the AAFP Scientific Assembly, most of the audience’s questions focused on the management of chronic pain and determining whether patients who have an increasing need for pain medication are addicts. The Dialogue leaders and participants shared insights into the challenge of distinguishing patients with addiction from patients with dependence on pain medication.

“The most difficult patients are those who have an addiction; they are manipulative, dishonest and demanding. But once they are in recovery, they are probably the most wonderful patients you can have,” said presenter Heidi Pomm, Ph.D., medical psychologist and director of behavioral science at St. Vincent’s Family Medicine Residency Program, Jacksonville, Fla. Pomm led the session with her husband, Raymond Pomm, M.D., of Jacksonville, medical director for River Region Human Services Inc. and the Florida Physicians’ Recovery Network.

In introducing the topic of addiction as a chronic illness, Raymond Pomm said family physicians often are relied on to make the initial diagnosis of addiction, but they frequently are unable to detect the disease. “Patients with addiction are clever at hiding it,” he said, and family physicians typically do not take many hours of training in addiction.

Heidi Pomm explained the difference between dependence and addiction, noting that addiction is a physiological and psychological progressive illness that is fatal, if left untreated. Dependence, on the other hand, is a physical (not psychological) dependence on a drug.

The presenters said two conditions should be distinguished from addiction: tolerance and pseudoaddiction. With tolerance, higher doses of a drug are needed to achieve the same effect as the drug earlier provided. With pseudoaddiction, patients seek drugs for pain because the prescribed dose or drug is not adequate to manage their pain. The primary cause of pseudoaddiction, said Raymond Pomm, is inappropriate use of pain medication.

Depression often accompanies pain, and each condition can exacerbate the other, he said. Further complicating the issue are the potential side effects of opioids, which include depression and an increased sensitivity to pain. He recommended using a long-acting drug. “There are too many peaks and valleys with short-acting drugs,” he said.

The presenters acknowledged that trust is a central issue when managing patients who are or may be addicts. “With active addiction, lying is part of the illness,” said Heidi Pomm. Physicians should “gently confront” patients who they believe are lying, she said.

“Unfortunately, trust centers around the drug screen,” added Raymond Pomm. Drug screens must be random and can be done weekly at first and then monthly, he said. Also, it is important to specify what drugs the screen should include. Lorazepam, clonazepam and alprazolam will not be detected on a drug screen for benzodiazepines, and synthetic opioids or methadone will not be detected on screens for opioids. “You have to be very specific about what you ask for,” he said.

To help health professionals deal with the issue of trust, the presenters emphasized the importance of developing a treatment contract with the patient. It should establish strong boundaries, provide explicit details about expectations for compliance with treatment and state the consequences for not complying with treatment. As with other chronic diseases, relapse is frequent with addiction, and the contract should specify expectations in case of relapse, said the Pomms.