Skip to main content
SpringerLink
Log in
Book cover

Controlled Substance Management in Chronic Pain pp 251–280Cite as

Controlled Substance Management: Exit Strategies for the Pain Practitioner

  • Chapter
  • First Online:

  • 1027 Accesses

Abstract

The use of opioids for the treatment of chronic pain has exploded over the past 2 decades. Side effects and complications include but are not limited to physical dependence, addiction, abuse, misuse, diversion, and various adverse effects such as constipation, pruritus, hyperalgesia, and hypogonadism. In addition, benzodiazepines are all too often utilized to treat associated anxiety and sleep disorders, with complications as well. In many instances, the pain practitioner may find it necessary to discontinue both opioid and benzodiazepines therapy. Exit strategies in these cases should be developed that facilitate a controlled withdrawal from these medications. Medically supervised withdrawal from opioids utilizing opioid agonist therapy (OAT) is one effective technique that can be done safely in an office setting. Weaning from benzodiazepines and sedatives although challenging can be also be accomplished in the office setting. Risk mitigation strategies and overdose prevention are both essential and practical for the treatment of patients while treating patients using controlled substances for the management of pain.

This is a preview of subscription content, log in via an institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   69.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   89.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD   99.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. Silverman SM. Medically supervised withdrawal for opioid dependence. In: Kaye DA, Vadivelu N, Urman RD, editors. Substance abuse, inpatient and outpatient management for every clinician. Springer: New York; 2015. p. 549–66.

    Google Scholar 

  2. Manchikanti L, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: parts 1–2. Pain Phys. 2012;15:S1–116.

    Google Scholar 

  3. Chou R, et al. American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. J Pain. 2009;10:113–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Institute of Medicine. Relieving pain in america: a blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press; 2011.

    Google Scholar 

  5. Model Policy for the Use of Controlled Substances for the Treatment of Pain. The Federation of State Medical Boards of the United States. Inc., May 2004.

    Google Scholar 

  6. Manchikanti L, et al. Prospective evaluation of patients with increasing opiate needs: prescription opiate abuse and illicit drug use. Pain Phys. 2004;7:339–44.

    Google Scholar 

  7. Manchikanti L, et al. Patterns of illicit drug use and opioid abuse in patients with chronic pain at initial evaluation: a prospective, observational study. Pain Phys. 2004;7:431–7.

    Google Scholar 

  8. Manchikanti L. Prescription drug abuse: what is being done to address this new drug epidemic? Testimony before the subcommittee on criminal justice, drug. policy and human resources. Pain Phys. 2006;9:287–321. ISSN 1533-3159.

    Google Scholar 

  9. CS/CS/HB 7095: Prescription Drugs; Florida Senate; Chapter No. 2011-141.

    Google Scholar 

  10. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med. 2005;6(6):432–42.

    Article  PubMed  Google Scholar 

  11. Kochanek K et al. National Vital Statistics Report 2011: 60:1-117. CDC Vital Signs. Prescription Painkiller Overdoses. Use and abuse of methadone as a painkiller. 2012.

    Google Scholar 

  12. Warner M, et al. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief: 81. Hyattsville, MD: National Center for Health Statistics. 2011.

    Google Scholar 

  13. National Center for Injury Prevention and Control. Division of Unintentional Injury Prevention. Policy Impact. Prescription Painkiller Overdoses: Nov 2011.

    Google Scholar 

  14. IMS Institute for Healthcare Informatics. The use of medicines in the United States: Review of 2011: April 2012.

    Google Scholar 

  15. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The DAWN Report: Benzodiazepines in drug abuse-related emergency department visits: 1995–2002. Rockville, MD; 2004.

    Google Scholar 

  16. Ghitza UE, et al. Self-report illicit benzodiazepine use on the addiction severity index predicts treatment outcome. Drug Alcohol Depend. 97(1–2):150–157.

    Google Scholar 

  17. Manchikanti L, et al. Opioid epidemic in the United States. Pain Physician. 2012;15:ES9–ES38.

    Google Scholar 

  18. O’Brien CP. Benzodiazepine use, misuse and dependence. J Clin Psychiatry. 2005;66(Suppl. 2):28–33.

    PubMed  Google Scholar 

  19. Lintzeris N, et al. Pharmacodynamics of diazepam co-administered with methadone or buprenorphine under high dose conditions in opioid dependent patients. Drug Alcohol Depend. 91(2–3):187–94.

    Google Scholar 

  20. De Wet C, et al. Benzodiazepine co-dependence exacerbates the opiate withdrawal syndrome. Drug Alcohol Depend. 76(1):31–5.

    Google Scholar 

  21. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (December 13, 2012). The TEDS Report: Admissions Reporting Benzodiazepine and Narcotic Pain Reliever Abuse at Treatment Entry. Rockville, MD.

    Google Scholar 

  22. Diagnostic and Statistical Manual of Mental Disorders (5th ed.) American Psychiatric Association 2014:1000 Wilson Boulevard, Suite 1825, Arlington, Va. 22209–3901.

    Google Scholar 

  23. Adopted by the ASAM Board of Directors. American Society of Addiction Medicine 4601 North Parke Avenue, Upper Arcade, Suite 101 Chevy Chase, MD 20815‐4520. 19 April 2011.

    Google Scholar 

  24. Gardner E. The mesolimbic pathway of reward. Brain Reward Mechanisms. In Lowinson JH, et al, editors. Substance abuse: a comprehensive textbook. Philadelphia: Lippincott; 1997. pp. 51–8.

    Google Scholar 

  25. Gold M, et al. Clonidine blocks acute opioid withdrawal symptoms. Lancet. 1978;1:929–30.

    Article  CAS  PubMed  Google Scholar 

  26. Tetrault J, O’Connor P. Management of opioid intoxication and withdrawal (Vol. 12). In Ries R, et al, editors. Principles of addiction medicine. 4th ed. Philadelphia: Lippincott Williams and Wilkins: 2009. pp. 679–84.

    Google Scholar 

  27. Mattick RP, et al. Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients. Addiction. 2003;98:441–52.

    Article  PubMed  Google Scholar 

  28. Ling W, et al. A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network. Addiction. 2005;100:1090–100.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Ahmadi J, et al. Controlled, randomized trial in maintenance treatment of intravenous buprenorphine dependence with naltrexone, methadone or buprenorphine: a novel study. Eur J Clin Invest. 2003;33:824–9.

    Article  CAS  PubMed  Google Scholar 

  30. Ling W, et al. Buprenorphine maintenance treatment of opiate dependence: a multicenter, randomized clinical trial. Addiction. 1998;93:475–86.

    Article  CAS  PubMed  Google Scholar 

  31. Ripamonti C, et al. An update on the clinical use of methadone for cancer pain. Pain. 1997;70(2–3):109–15.

    Google Scholar 

  32. Johnson RE, Fudala PJ, Payne R. Buprenorphine: considerations for pain management. J Pain Symptom Manage. 2005;29(3):297–326.

    Google Scholar 

  33. Silverman SM. Opioid induced hyperalgesia: clinical implications for the pain practitioner. Pain Phys. 2009;12:679–84.

    Google Scholar 

  34. Yokel Michael A, et al. Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review. Curr Drug Abuse Rev. 2011;4(1):28–41.

    Article  Google Scholar 

  35. Ling W, et al. A clinical trial of buprenorphine: comparison with methadone in the detoxification of heroin addicts. A controlled trial of buprenorphine treatment for opioid dependence. Am J Psychiatry. 1994;151:1025–30.

    Article  Google Scholar 

  36. Kakko, et al. A stepped care strategy using buprenorphine and methadone versus conventional methadone maintenance in heroin dependence: a randomized controlled trial. Am J Psychiatry. 2007;164:797–803.

    Article  PubMed  Google Scholar 

  37. Lange RW, et al. Safety and side-effects of buprenorphine in the clinical management of heroin addiction. Drug Alcohol Depend. 1990;26:19–28.

    Google Scholar 

  38. Fareed A, et al. Safety and efficacy of long-term buprenorphine maintenance treatment. Addict Dis Treat. 2011;10(3):123–30.

    Article  Google Scholar 

  39. Kakko, et al. Buprenorphine Improved Treatment Retention in patients with Heroin Dependence. Lancet. 2003;361:662–8.

    Article  CAS  PubMed  Google Scholar 

  40. Wesson DR, et al. The clinical opioid withdrawal scale. J Psychoactive Drugs. 2003;35:253–9.

    Article  PubMed  Google Scholar 

  41. Zubieta JK, et al. Buprenorphine-induced changes in mu-opioid receptor availability in male heroin dependent volunteers: a preliminary study. Neuropsychopharmacology. 2000;23(3):326–34.

    Article  CAS  PubMed  Google Scholar 

  42. Jones HE, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363:2320–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Compton P, et al. Pain intolerance in opioid-maintained former opiate addicts: Effect of long acting maintenance agent. Drug Alcohol Depend. 2001;63:139–46.

    Article  CAS  PubMed  Google Scholar 

  44. Koppert W, et al. Different profiles of buprenorphine induced analgesia and antihyperalgesia in a human pain model. Pain. 2005;118:15–22.

    Article  CAS  PubMed  Google Scholar 

  45. Scherer R, et al. Complications related to thoracic epidural analgesia: a prospective study in1071 surgical patients. Acta Anaesthesiol Scand. 1993;37(4):370–4.

    Article  CAS  PubMed  Google Scholar 

  46. Inagaki Y, et al. Mode and site of analgesic action of epidural buprenorphine in humans. Anesth Analg. 1996;83(3):530–6.

    CAS  PubMed  Google Scholar 

  47. Celleno D, et al. Spinal buprenorphine for postoperative analgesia after caesarean section. Acta Anaesthesiol Scand. 1989;33(3):236–8.

    Article  CAS  PubMed  Google Scholar 

  48. Matsumoto S, et al. The effect of subcutaneous administration of buprenorphine with patient controlled analgesia system for post-operative pain relief. Masui. Jpn J Anesthesiol. 1994;43(11):1709–13 (in Japanese).

    CAS  Google Scholar 

  49. Varrassi G, et al. Intra-articular buprenorphine after knee arthroscopy. A randomized, prospective, double-blind study. Acta Anaesthesiol Scand. 1999;43(1):51–5.

    Article  CAS  PubMed  Google Scholar 

  50. Candido K, et al. Buprenorphine added to the local anesthetic for axillary brachial plexus block prolongs postoperative analgesia. Reg Anesth Pain Med. 2002;27(2):162–7.

    Article  CAS  PubMed  Google Scholar 

  51. Karlsson M, et al. Efficacy and safety of low-dose transdermal buprenorphine patches (5, 10, and 20 micrograms/h) versus prolonged-release tramadol tablets (75, 100, 150, and 200 mg) in patients with chronic osteoarthritis pain: a 12-week, randomized, open-label, controlled, parallel-group non inferiority study. Clin Ther. 2009;31:503–13.

    Article  CAS  PubMed  Google Scholar 

  52. Heit H, et al. Dear DEA. Pain Med. 2004;5:306–7.

    Article  Google Scholar 

  53. Malinoff HL, et al. Sublingual buprenorphine is effective in the treatment of chronic pain syndrome. Am J Ther. 2005;12:379–84.

    Article  PubMed  Google Scholar 

  54. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: ED Visits Involving the Muscle Relaxant Carisoprodol. Rockville, MD, 27 October 2011.

    Google Scholar 

  55. Paemeleire et al. Practical management of medication-overuse headache. Acta Neurol. Belg. 2006;106:43–51

    Google Scholar 

  56. Baldwin DS, et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2005;19(6):567–96.

    Article  CAS  PubMed  Google Scholar 

  57. Kouyanou K et al. Medication misuse, abuse and dependence in chronic pain patients. J Psychosom Res 1997: 43:497–504.

    Google Scholar 

  58. Rickels K, et al. Long- term therapeutic use of benzodiazepines. 1. Effects of abrupt discontinuation. Arch of General. Psychiatry. 1990;47:899–907.

    CAS  Google Scholar 

  59. Lader M, Tylee A, Donoghue J. Withdrawing benzodiazepines in primary care. CNS Drugs. 2009;23(1):19–34.

    Article  CAS  PubMed  Google Scholar 

  60. Smith DE, et al. Benzodiazepine dependency discontinuation: focus on the chemical dependency detoxification setting and benzodiazepine—poly drug abuse. J Psychiatric Res. 1990;24(Suppl 2):145–56.

    Article  Google Scholar 

  61. Coupland M. CBT for pain management. Int Assoc Ind Accid Boards Comm (IAIABC). 2009;6(2):77–91.

    Google Scholar 

  62. Fordyce WE. Behavioral methods for chronic pain and illness. USA: St. Louis Mosby; 1976.

    Google Scholar 

  63. Bickel W, et al. Effects of adding behavioral treatment to opioid detoxification with buprenorphine. J Consult Clin Psychol. 1997;65(5):803–10.

    Article  CAS  PubMed  Google Scholar 

  64. Shahrokh J. Opioid-induced central sleep apnea: mechanisms and therapies. Sleep Med Clin. 2014;9(1):49–56.

    Article  Google Scholar 

  65. Dunn KM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Int Med. 2010;152(2):85–92.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Gomes T, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Int Med. 2011;171:686–91.

    CAS  Google Scholar 

  67. Bohnert AS, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305:1315–21.

    Article  CAS  PubMed  Google Scholar 

  68. Von Korff M, et al. Long-term opioid therapy reconsidered. Ann Int Med. 2011;155:325–8.

    Article  Google Scholar 

  69. Clark AK, et al. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med. 2014;8(3):153–163.

    Google Scholar 

  70. Walley AY, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. Br Med J. 2013;346:f174.

    Article  Google Scholar 

  71. Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) 1 4-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Clinical Biomedical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA

    Sanford M. Silverman

  2. Comprehensive Pain Medicine, 100 E Sample Rd, Suite 200, Pompano Beach, FL, 33064, USA

    Sanford M. Silverman

Authors
  1. Sanford M. Silverman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sanford M. Silverman .

Editor information

Editors and Affiliations

  1. Shrewsbury, New Jersey, USA

    Peter S. Staats

  2. Comprehensive Pain Medicine, Pompano Beach, Florida, USA

    Sanford M. Silverman

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Silverman, S.M. (2016). Controlled Substance Management: Exit Strategies for the Pain Practitioner. In: Staats, P., Silverman, S. (eds) Controlled Substance Management in Chronic Pain. Springer, Cham. https://doi.org/10.1007/978-3-319-30964-4_14

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-30964-4_14

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-30962-0

  • Online ISBN: 978-3-319-30964-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation