Prescribing opioids for analgesia: "walking on ice" for psychiatrists

Opioids are commonly prescribed for chronic pain. In the United States, opioid prescribing increased 4-fold in the early 2000s, accompanied by increases in opioid-related overdose and addiction. Thus, efforts are being made to cut-down inappropriate or unnecessary opioid prescriptions. Because the prevalence of psychiatric conditions is high in those with chronic pain, psychiatrists can play an essential role in management. Five key things to be remembered by psychiatrists in this situation are summarised below:

I. Opioids are NOT the first line analgesics. Nonopioid medication and non-pharmacological therapies are recommended for chronic pain, with opioids reserved for appropriately selected and monitored patients with persistent symptoms. Psychological therapies are a vital option for chronic pain along with. A broader approach more consistent with biopsychosocial framework, is thus more recommended as it deals with more biologic, psychological and social factors in pain.

Cognitive behavioural therapy (CBT) is a well-established first-line chronic pain treatment, addressing maladaptive thinking patterns and goal oriented behavioral and functional change. It may be most effective when administered as part of inter-disciplinary rehabilitation, in conjunction with exercise and other components, and may reduce use of opioids.

Other psychological approaches for chronic pain include motivational interviewing techniques, mindfulness-based stress reduction, biofeedback, and other relaxation techniques.

II. Trilogy of pain, depression, and antidepressants.

Psychiatric conditions (such as PTSD, depression, and anxiety) are common in patients with chronic pain and often augment one another, can cause decrease adherence to treatment, and can lead to self-treatment with medications or substances. They are at high risk of suicide and overdose. Antidepressants vary in analgesic properties. For example, noradrenergic antidepressants such as TCAs and SNRIs have analgesic effect while SSRIs appear less effective. The SNRIs duloxetine is approved for treatment of chronic low back pain and neuropathic pain. Off-label use of tricyclic antidepressants for chronic pain has diminished because of anticholinergic adverse events and an inferior safety profile.

III. "The pain keeps me up all night!!" Pain is often compounded by insomnia and other sleeping disorders. Poor sleep exacerbates pain and makes it difficult to increase function and activity levels. Obstructive sleep apnea is common in chronic pain and opioids are associated with central sleep apnea, potentially increasing respiratory depression risk. Clinicians should avoid use of benzodiazepines or non benzodiazepines with opioids for insomnia, anxiety, or other psychiatric conditions because of increased overdose risk with these combinations. PCBT for insomnia is a 1st line therapy, although it is underused. Melatonin and melatonin agonists are another option. Orexin receptor antagonists are a new class of medications approved for insomnia treatment, but data on their interaction with opioids are lacking.

IV. Booze and opioids- the "mismatched couple". Concurrent use of alcohol and opioids is common. Recognition is important because of increased risks. Alcohol contributes to a significant proportion of opioid over dose deaths. Various treatment options are available for patients diagnosed with alcohol use disorder. Naltrexone is contraindicated in patients taking opioids because of precipitated withdrawal. Acamprosate and disulfiram can be used in those taking opioids but require alcohol abstinence. In those unwilling or unable to reduce alcohol intake, opioid tapering may be necessary for patient safety.

V. Identifying an addict. To remain vigilant to opioid use disorder (OUD) and misuse potential. Identifying patients with addiction or misuse is critical for reducing overdose risk and other harms. In persons prescribed opioids, tolerance and physical dependence are excluded as diagnostic criteria because they are a physiological phenomenon that occurs with regular exposure. Rather, an OUD diagnosis is based on a problematic pattern of opioid use (including misuse) resulting in clinically significant impairment or distress. Patients prescribed opioids should be periodically assessed for OUD using criteria. Management may involve referral to an opioid treatment program, addiction specialist, or office-based therapy. There are 3 effective US FDA approved medications for OUD.

(a) Methadone is an opioid agonist that must be dispensed in an opioid treatment program.

(b) Buprenorphine is an opioid partial agonist with a superior safety profile compared with opioid agonists, including methadone. Buprenorphine can be prescribed in office-based setting by clinicians who have undergone training and obtained a waiver.

(c) Naltrexone is an opioid antagonist available in injectable form that can be prescribed in office-based settings without a waiver; it may  be most suitable for highly motivated persons wishing to avoid opioid substitution therapy.

To summarise, psychiatrists, seeing patients prescribed opioids for chronic pain can play an important role in optimizing care. This includes providing or facilitating psychological therapies for pain, optimizing management of psychiatric conditions and sleep disorders, addressing alcohol use, and diagnosing and treating (or facilitating treatment) for OUD. Given the ongoing lack of access to evidence-based therapy for OUD, psychiatrists are encouraged to consider obtaining a waiver to enable office-based management with buprenorphine.

Source: JAMA Psychiatry. 2021;78(2):220-221. doi:10.1001/jamapsychiatry.2020.3547