There is serious shortage of effective medical help for patients with complex chronic pain and substance use disorders. Patients addicted to pain pills or other opiates often lack access to life saving medical care. There is an epidemic of opiate misuse. It could be argued that opiate related problems are one of America's primary public health concerns. What to do?
The first step generally involves helping yourself or a loved one. Afterwards, we can attempt to heal others and the community at large.
For yourself or a loved one:
1. Become informed. Even many physicians are ignorant or misinformed of state guidelines related to prescribing controlled substances to patients, particularly opiates. While pain management expertise is often lacking, the lack of specialized medical care for pain management in the context of substance use disorders, represents a major public health crisis.
The 2015 revised Washington State Guideline on Prescribing Opioids for Pain is available online at:
On page 40 it reads:
“ 1. Assess for opioid use disorder using DSM 5 criteria or refer for a consultation with an addiction specialist if a patient demonstrates aberrant behaviors suggestive of substance use disorder (Table 9 and Appendix H: Clinical Tools and Resources). Interagency Guideline on Prescribing Opioids for Pain [06-2015] 41. (Dr. Rotchford would add that if a patient has multiple risk factors for a substance use disorder that alone should prompt a referral.)
2. “Patients diagnosed with opioid use disorder should receive a combination of medication-assisted treatment and behavioral therapies.
Once a moderate to severe opioid use disorder has been diagnosed, there is strong evidence for efficacy of methadone or buprenorphine maintenance combined with behavioral therapies compared to non-medication treatment. (237-239) Maintenance treatment leads to lower rates of illicit opioid use and likely reduces health care utilization and criminal justice involvement. (240-243) There is very little evidence that antagonist therapy with oral naltrexone is effective for patients with opioid use disorder, and there is no evidence in patients with chronic pain. However, it might be considered in selected, highly motivated patients (e.g. impaired professionals). (244)
On Page 41 under evidence it reads:
“There is very little evidence that outpatient non-medication treatment for opioid use disorder is effective. (237,238) In these programs, patients are tapered off opioids and are expected to attend a treatment program one or more days per week to learn skills necessary to manage symptoms (e.g. pain, mood and anxiety problems, substance craving) without resorting to substance use.
Once a moderate to severe opioid use disorder has been diagnosed, there is strong evidence for efficacy of methadone or buprenorphine maintenance combined with behavioral therapies compared to non-medication treatment. (237-239)
Maintenance treatment leads to lower rates of illicit opioid use and likely reduces health care utilization and criminal justice involvement. (240-243) There is very little evidence that antagonist therapy with oral naltrexone is effective for patients with opioid use disorder, and there is no evidence in patients with chronic pain. However, it might be considered in selected, highly motivated patients (e.g. impaired professionals). (244)
Comment: In all areas of medicine contextual variables must be considered to assure optimal outcomes. (See above where they suggest that naltrexone care might be considered in highly motivated patients (e.g. impaired professionals). It is Dr. Rotchford’s opinion that if a patient has serious chronic pain management issues or has significant co-morbid mental health issues, even those patients who have been diagnosed with a mild opioid use disorders warrant a trial of medication assisted treatment. It is indicated based on the evidence, if for no other reason, to help minimize complications and promote good outcomes with co-morbid conditions.
The above is formal and state approved guidelines to help educate your physician of their professional responsibility to assist you in obtaining Medication-Assisted Treatment (MAT), particularly if you so choose.
2. Obtain a formal pain management or addiction medicine consult. These are unfortunately difficult to come by. Ask your doctor for suggestions.
There are many ways a pain management and an addiction medicine specialist can help patients:
- Work with other prescribers to assure that a patient is prescribed the safest and most effective medical regimen.
- Provide FDA approved medical care for for addictions. Besides buprenorphine, naltrexone is another FDA approved medication that can be helpful for treating opiate addiction and alcohol use disorders. It may also be used to help in some cases of chronic pain.
- There are non-pharmacological ways to manage pain and addictions. Since the early 1980s I have provided medical acupuncture and am skilled in a host of ways to treat pain without the use of addictive substances.
- There are effective treatments to help patients limit withdrawal symptoms. Much support is available even without the use of a controlled or addictive substance.
- There are a host of medications, supplements, and behaviors that promote healthy pain management and brain function. The best care is individualized.
3. Seek help, whether with Dr. Rotchford or others:
- List of providers - Worth checking out but I am afraid many patients struggle to find qualified providers particularly if they are insured by Washington State plan. Help us if you can keep this list updated.
- How to help your doctor properly prescribe pain medications for you.- Some suggestions on what might help.
- Memo to Colleagues regarding consultations and joint care.
- Methadone/Buprenorphine Clinics in Puget Sound Area - These are the default care providers for patients who are opiate dependent. Access is challenging, sometimes expensive, and makes it difficult to hold down a job if one lives or works far from one. Nonetheless, when one has a life threatening disease, such as opiate addiction, a move to a community which has a methadone clinic warrants serious consideration.
- Special information for patients with Washington State Insurance plans including DSHS, Apple Health, Basic Health, L&I. See Memo
Community wide action steps and support material:
- 2011 Memo with suggestions for supporting access
- Memo Regarding of lack of Access for Washington State covered patients.
- New York Times article on Effective Addiction Treatment
- Why the Prescription Drug Abuse Crisis? - A Public Health Concern by J.K. Rotchford, M.D.
- A Case Report - Published in the Pain Practitioner-Winter 2013. J.K. Rotchford, M.D.
- An Informal Review of Opioid Dependence (Addiction) Associated with Chronic OpioidAnalgesic Therapy (COAT) for Chronic Pain. (Title page only in Czeck) Journal ADIKTOLOGIE 15(3) 2015.- J.K. Rotchford, M.D.
- Go to Hospital Board/Commission meetings and clamor for access to effective medical care for pain and addiction. Jefferson General Healthcare in the past even had as a formal policy to not treat addictive disorders. While this policy is no longer in force, why yet do none of the physicians have the waiver to treat opioid use disorders? It only takes 8 hours of CME. This is unacceptable for a publicly funded institution. Other failures to provide the basics of Addiction Medicine screening and treatment appear common.