Pain Management versus Addiction Medicine

Sometimes pain management gets confused with addiction medicine. Although the medications, principles, and clinical situations are often similar, they are two distinct fields. We see a lot of patients with high opiate requirements and we manage opiate tapers, but we enlist our colleagues who are addiction specialists in the appropriate clinical situations. Many of our patients are tolerant to opiates, using whopping doses of morphine, methadone, or oxycontin to manage their chronic pain, but addiction is a separate phenomenon. Addiction is a behavioral pattern with craving, compulsive use, loss of control, and continued use despite harm to themselves or those around them. Working with these patients requires an extended skill set, one that psychiatrists often use. These patients split, become aggressive, deny use, and distrust physicians. Building the therapeutic relationship is a real challenge. I saw a patient recently who showed some hallmarks of addiction. He used compulsively, filling his prescriptions early, seeing multiple providers, using many pharmacies, going to the emergency department frequently. He had completely lost control, and this was impacting his personal relationships, his ability to take care of himself, and his work. We had an opiate contract with him, but because he continued to break it, we had to require him to see an addictionologist to get his refills. This is really tough because he will likely not follow up and may go through opiate withdrawal, a very uncomfortable but not medically dangerous process. This is a challenging clinical scenario for us, and unfortunately, this is not an uncommon occurrence in pain clinic.