Case of the Month #8: Longstanding pain and opioid use

This patient’s chronic pain is complex and, like all patients who have refractory and disabling symptoms, a very detailed assessment of the many emotional influences on pain experience is essential. She was taking a combination of high dose long acting and short acting strong opioids without any significant improvement in symptoms. Although they can be useful in the short term, there is little evidence that opioids are helpful for long term pain. Mechanisms for loss of analgesic efficacy include pharmacologic tolerance and opioid induced hyperalgesia. The problems seen in patients taking opioids for pain vary and can be complex, including the psychosocial impact of continued opioid use. This patient had gradually required more and more opioid to get any effect, resulting in her swigging from the bottle in unmeasured doses, potentially in ever increasing quantities, consistent with opioid dependence syndrome. 

Pain management in patients with opioid dependence and addiction requires good communication and the development of a comprehensive plan that includes physical rehabilitation, exercise and psychological treatments to support self-management. In this patient’s case, the team were able to prepare her for opioid dose reduction by explaining the rationale for tapering opioids including the potential benefits of opioid reduction (avoidance of long-term harms and improvement in ability to engage in self-management strategies). The outcomes of opioid tapering were agreed at the outset, explaining that stopping medicines usually makes no difference to the pain but can make people feel better. 

This patient engaged well with the initial assessment and agreed to work with the team using an Acceptance and Commitment Therapy (ACT) based model of care. ACT is a process-based, third-wave, cognitive behavioural therapy (CBT) that is effective in a broad set of psychological problems and is associated with clinically meaningful long-term improvements in function and quality of life among patients with chronic pain. Patients with chronic pain usually put enormous effort into fighting against their experience of pain. This may include battling physical sensations, emotions, memories, images, and thoughts about pain. Patients may reduce their physical activity, distract, avoid thoughts of pain, avoid other people, constantly check for bodily changes, ruminate about the causes of pain, complain, endlessly seek information, obsess over medications, or repeatedly request second opinions or additional medical care. Avoidance of discomfort is usually followed in the short term by the reduction of unpleasant stimulation, and therefore these behaviours are negatively reinforced. In time, this can reduce pain tolerance and increase the severity of pain. It is only natural that if a person has pain, they will want it to stop. This goal is often unsuccessful. In contrast, the goal within ACT is to reduce the dominance of pain in person’s life through increased psychological flexibility. Unlike other approaches, ACT does not focus on symptom reduction (even though this can happen in ACT) but on making patients’ responses toward symptoms more successful in relation to their own goals. This success is achieved through increases in psychological flexibility. There is more detail on ACT approaches in the suggested reading section below. 

Beliefs about the body and pain play a powerful role in behavioural and emotional responses to pain. What a patient believes and how they respond to their pain can influence how disabled they will be by pain. Importantly, beliefs are modifiable and are therefore an important target for the treatment of pain-related disability. Addressing unhelpful beliefs can be useful, for example, this patient used catastrophic descriptors such as “Riddled with arthritis” and “Breakthrough” pain relief, akin to the terminology used in cancer pain management. It was important to explore this understanding during some of her initial sessions with the pain team.