Pain Management and Chemical Dependency—Reply

In Reply.— Our Commentary about pain and chemical dependency sought to highlight a disquieting situation: physicians who specialize in pain management or who treat patients with chronic pain in primary care know little about addiction medicine, and those who primarily treat patients with substance abuse know little about the management of pain. Given the overlapping importance of opioid drugs, the monitoring of drug-related behaviors in both of these disciplines, and the potential overlap in the neurobiological substrates of chronic pain and addiction, these deficiencies could compromise both patient care and research.

Patient care may be limited in many ways. Patients with chronic pain and no history of chemical dependency may not be offered a trial of opioid therapy solely because of exaggerated fears of addiction. Patients with pain and a history of chemical dependency (including those with cancer or acquired immunodeficiency syndrome) may never be given the option of good symptom control because of limited knowledge about pain and opioid pharmacology and exaggerated fears about addiction. Opioid-treated patients who engage in aberrant drug-related behaviors may not be assessed adequately, and, consequently, cases of true addiction may remain undiagnosed.

Our Commentary called for an ongoing effort to bridge the gap between pain and addiction medicine through educational initiatives and targeted research. The letters from Drs Streltzer, Donohoe, and Murphy generally support this view, but also reflect an undercurrent of concern, primarily focused on the potential for increased use of opioid drugs to treat chronic pain. These concerns relate to the safety and efficacy of this treatment and, as Murphy and Donohoe suggest, the risks associated with regulatory oversight and manipulation by the pharmaceutical industry.

Such concerns deserve an informed discussion among clinicians, researchers, regulators, and public advocates. Research that will provide the scientific underpinning for this discussion must be strongly encouraged. Unfortunately, research evolves slowly, while the need to redress deficiencies in patient care is immediate. Guidelines must be proffered on the basis of the current literature and shared clinical experiences. Misconceptions and biases may be avoidable if these guidelines develop through a dialogue between specialists in pain management and addiction medicine. The contribution to this dialogue by pain specialists may be to reassure clinicians that there are critical distinctions between the pain of an illness, such as cancer, and the psychological pain of an addict; that the labeling of tolerance as addiction is in fact an error; and that there has yet to be any clinical correlate in animals of antiopioid responses. The issues are indeed complex, and speculations may generate hypotheses that should be tested in clinical studies. However, speculations that are contradicted by extensive experience should not guide practice until studies are done.

Every relevant aspect of this fascinating interface between pain and chemical dependency should be evaluated, and, ultimately, the science will direct optimal patient care. The additional challenge, at present, is to confront every bias that could lead to the undertreatment of pain through an open discussion with colleagues whose interests overlap but whose experiences and literatures of reference vary.