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Beyond Narcotics: Pain Management for People With Co-Occurring Chronic Pain and Addiction
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This story is designed to help PATH providers understand the challenges of managing pain for consumers suffering from opioid addiction. The article will help PATH providers advocate with medical professionals to meet the pain management needs of their clients.

Mr. D first came into the syringe exchange outreach clinic at the Tom Waddell Health Center 15 years ago. His clothes were disheveled, his hair matted from sweat and grime. Mr. D was apprehensive. He did not feel comfortable at the syringe exchange and the younger crowd that hung around the park across the street intimidated him. During their first meeting, he told Dr. Barry Zevin that he had a painful leg ulcer and he was hopeless, worn down, and suicidal. He was using heroin to cope and self medicate.


We all have pain. Pain from a strained back, pain from walking too many blocks on our way to the bus station, or pain from a headache that always seems to come on around 5 p.m. Two of the most common medications in the world are pain medications: analgesics, medications like Acetaminophen or Tylenol, and anti-inflammatories, medications like Ibuprofen or Advil. These medications help many of us but they are not nearly enough to break the cycle of chronic pain.

The only relief from chronic pain is often found through pain medication, medication that is addictive. It is only through the help of patient care teams, a “team” of healthcare providers (physicians, nurses, behavioral health specialists), that collaborate and monitor the effects of pain medication, that they ever get relief.

The chronic aspect of “chronic pain” indicates that a need for ongoing care and management is imperative.  For people experiencing homelessness, the uncertainty of their housing, employment and lifestyle makes it difficult to develop the type of long term relationship necessary to address their care needs. A history of addiction can make it nearly impossible for a person experiencing homelessness to develop a holistic approach to their pain needs because the addictive medications used to manage chronic pain may be seen as counterproductive to the treatment of their addiction.

The Story of Mr. D:

On occasions Mr. D would stop by the clinic and allow Dr. Zevin to perform dressing changes or to review his medical history.  After a number of visits, Mr. D became comfortable enough that he allowed Dr. Zevin to take on his primary care. 

Over time, Mr. D confided his interest and desire to find a way to stop his injection drug use and “cut down” on his use of other substances. Dr. Zevin prescribed methadone for Mr. D’s chronic pain. This helped the pain and Mr. D stopped using heroin. An antidepressant was prescribed for Mr. D’s depression and his mood slowly started to change. One day he came to the clinic and declared that he decided to follow-up with a referral that Dr. Zevin had made a number of times to a surgical clinic at San Francisco General Hospital. Dr. Zevin referred Mr. D. to a surgeon to save the viable tissue in his poorly healing leg ulcer. Dr. Zevin knew this treatment would decrease Mr. D’s chronic pain.  Mr. D. had not been receptive to the referral until that day.

Pretty soon, Dr. Zevin started seeing Mr. D in different activities around the city – “I even saw him riding his bike.”

Developing a Pain Management Policy:

Dr. Zevin sees many Mr. Ds. As a result, he and his team were charged with putting together a pain management policy that could “really make sense.” The concept behind the policy was simple, develop a set of guidelines to help patients and providers work together around the issue of chronic pain and co-occurring addictions. The development of that policy was anything but easy.
“We had to build a policy that was broad enough to deal with the varied concerns of our work force. Our task was to cast a very wide net that could make a safe, evidence supported environment for everyone,” notes Dr. Zevin. The Pain Management Policy provides clear guidance on prescribing, working with patients with co-occurring pain and addictions, and options for alternative care.  The policy is a tool for patients and providers to better meet their care needs.

Advocating for Consumers:

Dr. Zevin feels that the best way to manage chronic pain with a client who is actively using is to “focus on the patient.” Dr. Zevin encourages programs to incorporate a multi-disciplinary team and always work with prevention, treatment, and care management.  Dr. Zevin believes that the future of pain management in patients with co-occurring addictions will based on de-stigmatizing the patient and focusing on the whole person and all of the care needs they have.

“I want to make certain that I get across the idea that pain and a history of addiction are both really hard diagnosis – and that they are incurable, but very treatable problems. I want my patients to know that they are not alone.”

Dr. Zevin works with his clients to help them understand that their pain may require them to take potentially addictive substances and that he recognizes that their background disorder (substance use and addiction) is often in direct conflict with treatment. He lets his patients know that the “good news” is that there are tools to help them and that he is willing to work with them for the “long haul.”

Most of all, Dr. Zevin emphasizes that starting a chronic pain management treatment plan with a person with a history of addictions requires careful attention to the various needs that may be in the background of their lives. He said that he always looks into trauma, loss, and emotional pain that maybe pervasive in his clients lives.

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