Collaboration between a pain specialist and outpatient psychiatrist in the care of a patient with addiction

Since ancient times, opioids have had an irreplaceable role in treating pain. Their comprehensive effect covers a wide range ofsymptoms accompanying painful conditions. Patients with both acute and chronic, particularly non-tumour-related, pain havea potential for developing an addiction. According to pain management standards, it is not the pain aetiology, but its intensitythat is the indication for opioid administration. Addiction to opioid-based pain medications is a relatively common and, whatis more, much-feared complication in patients treated for chronic non-tumour-related pain. It is a major burden for the patient,the health care system, and the whole society. Long-term exposure to opioids leads to the processes of neuroadaptation in theCNS – the development of tolerance (desirable – sedation, nausea, vomiting vs. undesirable – analgesic effect). From a clinicalviewpoint, a distinction has to be made between physical tolerance to opioids and psychological dependence on opioids.Physical tolerance involves a physiological adaptation to the continuous presence of a certain substance in the human bodythe subsequent omission of which results in the development of withdrawal syndrome. By contrast, psychological dependenceis a comprehensive biopsychosocial phenomenon with a specific pattern of behaviour (a compulsive feeling and pathologicalcraving to take a given dose in spite of negative health, psychosocial, and existential consequences – with a loss of control over the use of the drug). As a result, opioid use occurs not because of pain relief, but for a specific euphorizing effect. There typicallyoccurs an addiction triangle – exposure to a risk substance + susceptible individual + typical social context. Accordingly, a painfreecondition is a high-risk factor for developing psychological dependence! Dependence is not the case when the patient oftenrepeatedly and aggressivelyrequests treatment adjustment and intensification because of insufficient analgesia, and when,after dosage adjustment and obtaining relief, behaviour modification occurs. In the clinical practice, it is possible to encountertherapeutic dependence manifested by insisting on a treatment modality that was helpful in the past. The collaboration of thepain management specialist, outpatient psychiatrist, and addicted patient is essential in the treatment. An addicted patient canbe encountered anywhere; however, under current legislation, a pain management specialist cannot diagnose addiction andindicate replacement therapy. Rather than hundreds or dozens of patients, we are talking about individual patient cases thatrequire our assistance.

Keywords: pain, opioid addiction, physical tolerance