Opioid use disorders as an emerging disability

Abstract

BACKGROUND:

The rates of opioid use disorders have notably increased over the years. Initially opioid pain medications were reserved for individuals who experienced chronic pain associated with cancer (malignant) or pain post-surgery, but because of their effectiveness in alleviating pain, the widespread use of these medications resulted. In 2014 alone, American pharmacies distributed 245 million opioid prescriptions, and consequently, the United States now accounts for nearly 100% of the world’s hydrocodone and 81% of the world’s oxycodone use.

OBJECTIVE:

In this article, the authors explore how opioid use disorders develop and those at most risk of developing opioid use disorders by discussing the unique pharmacology of opioids and how they increase the propensity of addiction. Terms of treatment – such as types of treatment, recovery-oriented services, and alternative or complementary forms of treatment – are discussed as well as considerations for addressing some of the challenges of working with these individuals.

CONCLUSION:

Implications for vocational rehabilitation professionals, such as suggestions for screening, making referrals to specialists for those with chronic pain conditions, and the need for continuing education are included.

Keywords

Opioid use disorder rehabilitation counseling pain medication

1 Introduction

Derived from the milky fluid of the poppy plant, Papaver somniferum, opium was initially cultivated by the Sumerians in Mesopotamia around 3400 BC; they called it Hul Gil, or the “joy plant,” because it produced feelings of euphoria and reduced pain (Booth, 1986). In 1803, Friedrich Sertuner isolated morphine from this fluid and it was found it to be 10 times more potent than the plant itself. While the poppy plant contains a number of substances that produce similar experiences of pain relief and euphoria, those that occur in the largest concentrations are morphine, narcotine, codeine, thebaine, papaverine, and marceine. Morphine is the primary component of opium “both in amount and in medical importance” (United Nations Office on Drugs and Crime, 2017, para. 4). The discovery of morphine increased the capacity to better treat pain symptoms or induce feelings of euphoria. Prior to the development of the hypodermic needle by Charles Wood in 1853, individuals were only able to ingest morphine orally (e.g., plant chewed and swallowed, fluid blended with liquids and drunk). This made the potential for abuse and addiction relatively low because of the plant’s bitter taste and the extended time it took (20-30 minutes) for the desired effects of the drug to become noticeable (Inaba & Cohen, 2014). The hypodermic needle allowed for the injection of morphine directly into the bloodstream making the experience of pain relief and euphoria available within a matter of seconds. Because individuals received the desired effects much more quickly and intensely, the development of addictive symptoms increased dramatically (Inaba & Cohen; Volkow & McLellan, 2016). In an effort to thwart this problem, researchers touted the use of diacetylmorphine (heroin), which was once legally marketed and sold by the pharmaceutical company Bayer, as the cure for morphine addiction.

The active ingredients in opium are known as alkaloids, which are defined as “any of numerous usually colorless, complex, and bitter organic bases (such as morphine or caffeine) containing nitrogen and usually oxygen that occur especially in seed plants and are typically physiologically active” (Merriam-Webster Online, n.d.). Semi-synthetic opioids are made from opium alkaloids combined with other chemicals. For example, heroin is derived from morphine, hydrocodone is synthesized utilizing codeine, and oxycodone is made from thebaine (Boerner, Abbott, & Roe, 1975; Rinner & Hudlicky, 2012). Fully synthetic opiates are manufactured using chemicals that are not sourced from original opium alkaloids; these chemicals, however, have a structure that is similar to that of the naturally occurring opium alkaloids (Morrison & Hergenrother, 2013). Examples of synthetic opiates include methadone, naltrexone, meperidine (Demerol^®), and fentanyl.

Endorphins, enkephalins, and dynorphins are endogenous opioids (produced by the body) and serve as a first line of defense against painful stimuli (Basbaum & Fields, 1984). Opioids have the ability to cause their characteristic effects by mimicking these naturally occurring chemicals and by interacting with a number of receptors, such as mu, kappa and delta, which are located in the reward system of the brain, spinal cord, and digestive track (Feng et al., 2012). Mu receptors play a role in the experiences of pain and euphoria and are deemed central in the development of addiction to drugs in this category (Contet, Kieffer, & Befort, 2004; Trescot, Datta, Lee, & Hansen, 2008). These same receptors are also carefully considered in the production of medications developed to treat pain, the development of opioid use disorders (OUD), and the medications used to treat them.

Approximately 20.5 million Americans aged 12 and older had substance use disorders in 2015 (Center for Behavioral Health Statistics and Quality, 2016). Among those, 2 million had substance use disorders that involved prescription opioid pain relievers (e.g., oxycodone, hydrocodone, codeine, morphine, fentanyl, tramadol, and methadone), and 591,000 had substance use disorders that involved the illicit opioid heroin (Center for Behavioral Health Statistics and Quality). America’s rise in prescription overdoses is primarily due to the increased amount of prescriptions for opioid pain relievers. As the largest global consumer of opioids, the United States accounts for nearly 100% of the world’s hydrocodone and 81% of the world’s oxycodone (United Nations, 2009). In 2014 alone, American pharmacies distributed 245 million opioid prescriptions (Levy, Paulozzi, Mack, & Jones, 2015; National Institute on Drug Abuse [NIDA], 2015a). Moreover, nearly one in five individuals with an acute or chronic pain diagnosis are prescribed opioids in office-based settings in the United States between 2000 and 2010 (Daubresse et al., 2013). Some of the highest prescribing rates are found in the specialized fields of surgery, pain medicine, and physical medicine or rehabilitation; however, primary care providers are responsible for prescribing nearly half of opioid pain relievers (Daubresse et al.).

2 Characteristics of those most at risk for developing an OUD

Volkow and McLellan (2016) note that physical dependence and addiction are different concepts although they are oftentimes seen as one in the same. They state physical dependence, and the eventual development of tolerance, is inevitable especially as it relates to opioids. These conditions can develop after one dose in some instances, but are most surely to result when taking opioid medications repeatedly. These conditions are generally rapidly resolve after use is discontinued. Addiction, however, is different and separate from physical dependence and tolerance. These researchers posit that addiction develops much more slowly compared to physical dependence, is a chronic condition in and of itself, does not terminate at the cessation of drug use, carries a high risk of relapse, lasts for years, and requires a separate treatment regimen. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) the American Psychiatric Association (APA; 2013) indicates that a severe substance use disorder is synonymous with addiction (Volkow, Koob, & McLellan, 2016). For the purposes of this article, OUDs are one and the same with addiction.

It is important to note that the majority of individuals who use opioid medications for the treatment of chronic pain do not develop an OUD. Fields (2011) writes, “opiate addicts and pain patients are largely separate populations and...opiate addiction due to appropriate medical management of pain is rare” (p. 593). There is still, however, a small percentage of individuals who do become addicted thus placing the onus on physicians and other healthcare providers to recognize them and develop treatment plans accordingly. In response, researchers have identified “particular demographic variables that place individuals at higher risk for the development of” opioid abuse and addiction (Cochran et al., 2014, p. 204) such as long-term use, higher daily doses, prior diagnosis of mood disorders, prior history of substance use disorders, age, genetics, and divergent use.

Volkow and McLellan (2016) note that prescribing a long-term regimen of opioid medications sometimes requires increasing the dose in order to offset the development of physical dependence and tolerance and maintain the drugs’ therapeutic effects. “Patients can become tolerant to opioids whether or not they ever become addicted to opioids” (Institute for Chronic Pain, 2016, para. 5). As such, the combination of long-standing use coupled with higher doses is considered one such factor that increases the likelihood of overdosing and/or developing an OUD (Edlund et al., 2010; Hossack & Durmin-Goodman, 2013; Weimer, Hartung, Ahmed, & Nicolaidis, 2016). Conversely, some individuals with noncancer pain are able to experience continued pain relief with only a modest need for dose increase (Portenoy et al., 2007). Another factor that contributes to the increased probability of developing an OUD is having a diagnosis of a psychiatric disability such as depression, anxiety, and bipolar disorder and/or having a prior history of substance-related disorders (Edlund et al., 2010; Gros, Malanak, Brady, & Back, 2013; Roncero et al., 2016). Martins, Fenton, Keyes, and Blanco (2011) do report, however, that issues such as self-medication for an untreated psychiatric disability and a shared genetic vulnerability between mood disorders and substance use disorders contribute to higher rates of OUDs as well.

Numerous studies point to age as a factor associated with the misuse of opioid medications and the eventual development of an OUD noting that rates are highest among individuals ranging from 15 to 29 years old (Kolodny et al., 2015; Volkow & McLellan, 2016; Wu, Woody, Yang, & Blazer, 2011). Factors associated with changes in the brain’s circuitry related to control and regulation, reward and motivation, and harm-avoidance, coupled with stress, may make adolescents more vulnerable to the development of OUDs (Hammond, Mayes, & Potenza, 2014). NIDA (2014) points out that areas of the brain related to reward and pain mature during childhood; areas associated with making decisions, solving problems, and controlling impulses are not matured until the mid-20s.

Genetic predisposition is another risk factor associated with the development of OUDs. Volkow and McLellan (2016) found that genetic predispositions account for approximately 35-40% of the risk associated with the development of substance-related disorders, while NIDA (2008) proposed that genetics account for upwards of 45-50% of opioid addiction. Research has also identified sites on chromosome 17 thought to be associated with opioid addiction. One site is specifically correlated with opioid addiction among African Americans and European American; this same site, interestingly enough, is not correlated with addiction to any other drugs (Gelernter et al., 2006; NIDA). Sites on other chromosomes have been indicated in opioid addiction, but most research and consistent findings were connected to chromosome 17.

Opioid diversion “involves the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace, and can occur along all points in the drug delivery process - from the original manufacturing site, to the wholesale distributor, the physician’s office, the retail pharmacy, or the patient” (Inciardi, Surratt, Lugo, & Cicero, 2007, p. 127). Diversion most commonly takes place between individuals with legitimate prescriptions for opioid pain medications and a friend or family member self-medicating for a “generic pain” (Volkow & McLellan, 2016, p. 1258). Oxycodone and hydrocodone make up 67% of diverted opioids (NIDA, 2017a) and over 50% of people who misuse drugs in this fashion got them from a family member or friend for free (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016a). Diverted opioids taken for their euphoric properties are much more likely to be injected as this increases the rate of reward (Volkow & McLellan). Taking opioids in this way not only leads to a more intense rush, but they are more likely to be taken at larger doses, which can lead to higher rates of overdose, abuse, and addiction (Dart et al., 2016; Fields; 2011; Hahn, 2011; Rosenblum et al., 2007). Drugs taken in this manner may also lead to individuals seeking out less expensive substitutes that are especially risky such as heroin (SAMHSA).

Chang and Compton (2013) stress the need to understand the correlation between chronic pain and OUDs noting that if one disorder goes untreated it is impossible to treat the other; this has the potential to lead to inadequate treatment for both pain and the addiction. Undertreated pain is considered a public health and human rights issue by many (Bell & Salmon, 2009; Goldberg & McGee, 2011) because there are a number of resulting ramifications such as continued pain for the patient and the increased risk of seeking out other ways to alleviate said pain. The under-treatment of co-occurring chronic pain and OUDs is problematic because it presents a risk for heroin use (Potter et al., 2010; Tsui et al., 2013). The illicit opioid heroin is primarily injected intravenously; therefore, it is also associated with the contraction of blood-borne diseases, including sexually transmitted infections (STIs), hepatitis (predominantly Hepatitis C), and human immunodeficiency virus (HIV) (NIDA, 2014). It is common for individuals with HIV to use unhealthy pain management strategies, which can result in worse health outcomes (Merlin et al., 2015). For example, using heroin or other illicit substances to self-medicate chronic pain can promote accidents, injuries, addiction, and overdose, all of which are associated with decreased adherence to antiretroviral therapy and lower retention in HIV treatment (Celentano & Lucas, 2007). Not only are individuals with co-occurring HIV and chronic pain (including pain that is untreated or under-treated) less likely to continue HIV treatment, they are also 10 times more likely to experience functional impairments (Merlin et al., 2013).

3 The paradox of opioids

Initially the long-term use of opioids for pain was discouraged and physicians worked to wean their patients off these drugs after treatment for short-term acute problems; however, in the early 1990s, this trend began to change. It was noted that “aggressive opioid prescribing” was highly successful in treating pain associated with cancer and as a result, it was surmised that this form of treatment would be beneficial in addressing other types of pain, such as chronic non-cancer or nonmalignant pain (Burgess, Siddiqui, & Burgess, 2014, p. 25). “The type of pain and pain history of the patients do not predict reliably the chance of long term success or risks of complications from opioid therapy” (Breivik, 2005, p. 127) thus creating a quagmire of conflicting research findings. For example, it has been found that these medications are indeed effective in treating some forms of chronic pain, but a small percentage of individuals develop opioid-induced hyperalgesia (OIH). OIH is defined as “a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli” (Lee, Silverman, Hansen, Patel, & Manchikanti, 2011, p. 145).

Other inconsistencies center on the reduction of symptoms associated with pain (e.g., sleep dysregulation, inflammation) and improved quality of life. Turk and Cohen (2010) report that opioids, when prescribed for pain, can increase one’s quality of sleep; however, others found that opioid treatment can actually exacerbate sleep problems (Correa et al., 2015; Moore & Kelz, 2009; Robertson et al., 2016). Opioids may help to alleviate pain-associated inflammation (Stein & Küchler, 2012), but other researchers report some opioids can affect the immune system by decreasing the production key cells such as lymphocytes, which mature into T-cells, B-cells, and natural killer cells (Liang et al., 2016). These cells play a major role in fighting off bacteria and viruses such as those associated with cancer and HIV/AIDS (Martin, Charboneau, Barke, & Roy, 2010). Although some studies report that opioids can reduce pain, increase functionality, and improve overall quality of life for individuals with moderate to severe pain, other studies note that individuals prescribed high doses of opioids may have poorer overall functioning and lower quality of life compared to those taking moderate to low doses of opioids or none at all (Frank et al., 2017; Griffin et al., 2015).

Over 40% of older adults in America are diagnosed with chronic pain (Johannes et al., 2010), and despite the fact that opioids rapidly relieve pain and improve functioning, the benefits of prescribing them for chronic nonmalignant pain needs to be balanced with the associated risks (Stacy & Wiers, 2010). Opioid pain medications are associated with negative symptoms such as dizziness, nausea and vomiting, respiratory depression, somnolence and chronic constipation (Beyamin et al., 2008; Manchikanti, Fellows, Ailinani, & Pampati, 2010; Volkow & McLellan, 2016). Many of these symptoms, however, are temporary and abate with the continuation of the medication or with switching to a new medication. Studies report more serious problems such as an increased likelihood of overdose and death, the development of tolerance, drug misuse and diversion, physical dependence, and addiction (Chou & Ray, 2016; Ray et al., 2016; Simmonds et al., 2015; Tournebize, Gibaja, Muszczak, & Kahn, 2015). Even given these risks, some individual’s use of prescribed opioids may mean the difference between being severely incapacitated and living an active, fulfilling life. When working with consumers who may have or actually present with OUDs, vocational rehabilitation (VR) professionals must be knowledgeable of the unique needs of these individuals and how to best address them. For consumers who do not have an actual diagnosis but potential symptoms have been identified by the VR professional, he or she must understand how to make referrals to physicians knowledgeable in the areas of assessing, diagnosing, and treating OUDs. Not every physician has the appropriate training, approval, or accreditation credentials required to treat this disorder, however (SAMHSA, 2015). Rehabilitation professionals should also be mindful of the complications associated with an OUD itself, but also of the risk and benefits associated with treating these disorders. Treatment options for individuals with OUDs are unique in that specific medications can be used as part of a comprehensive program. The challenge for VR professionals is to balance the rights of individuals who can benefit from this form of therapy with the need to respond to the opioid crisis through services that are tailored to each unique consumer.

4 CDC guidelines for prescribing opioid medications

In an effort to promote the safety and well-being of individuals who may or are already taking prescription opioid medications and to address the extensive opioid crisis, the Center for Disease Control and Prevention (CDC) developed recommendations for prescribing these medications, which were released in 2016. The recommendations are as follows:

Determining when to initiate or continue opioids for chronic pain

Opioids are not first-line therapy – non-pharmacologic therapy (e.g., pain management techniques) and non-opioid pharmacologic therapy should be considered first line; if opioids are used, they should be combined with other forms of therapy as appropriate;

Establish goals for pain and function – as part to the individual’s treatment plan also include information on how opioid treatment will be tapered and eventually discontinued;

Discuss risks and benefits – physicians should be sure to engage in a dialogue with their clients about the pros and cons of opioid medications as well as the responsibilities of both parties;

Opioid selection, dosage, duration, follow-up, and discontinuation

Use immediate-release opioids when starting – immediate release opioids are faster acting with a shorter pain alleviation timeframe;

Use the lowest effective dose – physicians should always “start low and go slow”;

Prescribe short durations for acute pain – physicians should only prescribe enough of the medication needed for the expected extent of the acute pain condition;

Evaluate benefits and harm frequently – it is recommended that physicians evaluate individuals within 1 to 4 weeks of starting a new opioid medication and should follow up every three months, or more frequently if deemed necessary;

Assessing risk and addressing harms

Use strategies to mitigate risk – physicians should continually evaluate the individuals for potential harm such as offering medications that offset potential problems;

Review Prescription Drug Monitoring Programs (PDMP) – this program allows physicians to review an individual’s history of controlled substance prescriptions and allows them to determine if individuals are receiving other opioid prescriptions or taking medications that could place them in danger of an overdose;

Use urine drug testing – testing allows physicians to determine if individuals are using other controlled substances or illicit drugs;

Avoid concurrent opioid and benzodiazepine prescribing – benzodiazepines are classified as depressants; its combination with opioids can seriously depress breathing and respiration rate; and

Offer treatment for opioid use disorder – evidence-based treatment services should be made available for individuals with OUDs. (CDC, n.d.)

The development of these recommendations serve as a major catalyst in addressing the many issues surrounding chronic pain and its treatment and especially the millions of individuals with OUDs. Treatment cannot and should not occur in isolation: it involves the interaction and intersection of myriad individuals and services. As such, treatment options ranging from behavioral approaches to medication-assistance have been developed to address the needs of those with OUDs.

5 Terms of treatment and recovery

As previously mentioned, there is a distinct difference between physical dependence and addiction. Volkow and McLellan (2016) point out that through the repeated administration of opioid medications one might develop tolerance and physical dependence, but these symptoms are quickly resolved upon the cessation of the medication. OUD, or an addiction, however, is a chronic, relapsing condition that does not end with the discontinuation of opioids; proper treatment is required. Approximately 80% of individuals with an OUD do not receive appropriate treatment (NIDA, 2017b) causing many of them to succumb to the perils brought on by the disorder. A number of factors contribute to this staggering statistic including a lack of access to insurance or problems with insurance coverage and reimbursement; the underutilization of treatment services by state Medicaid programs; and a lack of specialized treatment providers (American Society of Addiction Medicine [ASAM], 2013; Jones, Campopiano, Baldwin, & McCance-Katz, 2015; NIDA, 2016). Utilizing pharmacological treatment while incorporating recovery-oriented services and pain management services are considered crucial for long-term, sustained treatment and recovery success. It is important to ensure that treatment is all encompassing as offering services in isolation does little to combat the underlying problem and others that ensue as a result. Addressing all areas of a person’s life (e.g., social, psychological, biological, spiritual, vocational) and not just the substance use disorder serves to increase the likelihood of treatment retention and completion. Medication-assisted treatment has proven to be one of the most effective forms of treatment for individuals with OUDs especially when coupled with programs that address the co-occurring biopsychosocial-spiritual needs as well.

5.1 Medication-assisted treatment

Numerous studies tout the importance of providing the right type of care for individuals with OUDs such as pharmacological or medication-assisted treatment (MAT). MAT involves the use of specific medications combined with cognitive and behavioral therapies and other programs that support psychosocial functioning. MAT for individuals with OUDs includes methadone, buprenorphine, naltrexone, and naloxone. Medications used to treat co-occurring physical and psychiatric disabilities are generally included as well. It is important to note that MAT is not a form of drug substitution; many incorrectly believe that these medications only serve to replace another drug making it one of the primary reasons many may reject this form of treatment. The potential for treatment success is dramatically increased when MAT is utilized; this is especially true when clients remain in treatment for the recommended amount of time. SAMHSA (2010) recommends that individuals engage in all parts of MAT for at least one year, but also notes that rates of relapse continue to exponentially decline for those who continue to receive treatment for at least three years.

5.1.1 Methadone

Methadone (Dolophine ^®, Methadose^®) was the first medication approved by the Food and Drug Administration (FDA) to treat OUDs. Methadone is primarily used during the detoxification period and for maintenance during and after completing treatment as it helps to reduce withdrawal symptoms and cravings and it blocks the euphoric effects of opioids; it is also safe for women who are pregnant or breastfeeding (SAMHSA, 2015). This medication is taken daily and can be administered “orally as a liquid concentrate, tablet, or oral solution of diskette or powder” (SAMHSA, para. 4). Methadone can be used as a way to manage pain, and any licensed doctor can prescribe methadone for this reason; however, federal policies mandate that methadone prescribed to treat OUDs can only be dispensed through an Opioid Treatment Programs (OTP) approved by SAMHSA. Because of this mandate, individuals taking this medication for an OUD must do so under the close supervision of a physician consequently requiring they report to the OTP each day; home doses may be allowed after establishing progress, compliance, and stability (SAMHSA). Because methadone is addictive, it is imperative patients take it as prescribed. To find information on opioid treatment programs in your state, visit http://dpt2.samhsa.gov/treatment/directory.aspx

5.1.2 Buprenorphine

Buprenorphine (Subutex^®, Suboxone^®, Zubsolv^®) was approved for the treatment of OUDs by the Food and Drug Administration (FDA) in 2002, and it works by reducing symptoms of withdrawal and cravings, and while it produces some of the same effects of opioids themselves (i.e., euphoria), these effects are diminished. Other benefits associated with buprenorphine is its “ceiling effect,” which lowers the potential for misuse, dependency, and side-effects and that it can be used on a daily or “less than daily basis” (SAMHSA, 2010, p. 30). Motov and Ast (2008) define ceiling effect as “the dose beyond which there is no additional analgesic effect (para. 1). Because higher doses of buprenorphine do not lead to an increased high or increased pain relief, patients are less likely to abuse it.

In spite of the numerous benefits associated with the use of this medication, it is generally underutilized as a form of treatment. In 2013, each state averaged only eight physicians who held the appropriate credentials to prescribe buprenorphine per 100,000 residents; these numbers varied, however, in that states with greater access to health care and substance abuse treatment facilities tended to have a larger number of approved physicians (Knudsen, 2015). Huhn and Dunn (2017) echo these findings by noting that many “physicians do not have the waiver to prescribe buprenorphine, and a large portion of physicians that are waivered do not prescribe to capacity” (p. 1). Buprenorphine combined with naloxone (Suboxone^®), another medication used to treat OUDs, is used for detoxification and maintenance and has been found beneficial to patients with co-occurring depression (NIDA, 2015b). Buprenorphine combined with hydrochloride is the preferred treatment for women who are pregnant, those with kidney or liver impairments, and for individuals transferring to methadone (SAMHSA, 2016c). To locate buprenorphine treatment practitioners in your area, visit https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator

5.1.3 Naltrexone

Naltrexone (Depade^®, ReVia^®, Vivitrol^®) also works by decreasing cravings, and it completely blocks the euphoric effects experienced by opioid users (SAMHSA, 2010). Any physician or other health care provider (e.g., physician assistant, nurse practitioner) can prescribe and administer this medication thus increasing its access to those in need. Naltrexone comes as an extended-release injectable, which is administered to patients once a month. Unlike methadone and buprenorphine, naltrexone is not recommended for use during pregnancy or while breastfeeding because it has been shown to promote tumor growth and cause other serious side-effects to nursing infants (SAMHSA, 2016d). Naltrexone is also used to treat alcohol use disorders.

5.1.4 Naloxone

Nalaxone (Narcan®) is a medication used to counteract an overdose of opioids (SAMHSA, 2016e). It can be administered as an intranasal spray, directly into the muscle or vein, or subcutaneously. Individuals at risk for an opioid overdose are prime candidates for naloxone; other candidates include those who: (a) take high doses of opioids for long-term management of chronic pain, (b) receive rotating opioid medication regimens, (c) have been discharged from emergency medical care following opioid poisoning or intoxication, (d) take certain extended-release or long-acting opioid medications, and (e) are completing mandatory opioid detoxification or abstinence programs (SAMHSA). Naloxone is safe for pregnant women and the patient, family member, caretakers, health care providers, police officers, or others can carry automatic injection devices or nasal spray for emergency administration.

5.2 Recovery-oriented systems of care

When working with individuals with OUDs, it is important to utilize a recovery-oriented approach. These systems of care are “networks of organizations, agencies, and community members that coordinate a wide spectrum of services to prevent, intervene in, and treat substance use problems and disorders” (SAMHSA, 2009, p. 6). One must recognize that recovery is a personalized and individualized process, it is not linear, and there are multiple ways in which one may reach this destination. NIDA (2012; paras. 1-13) developed 13 guiding principles that should undergird recovery-oriented systems of care; they are:

Addiction is a complex but treatable disease that affects brain function and behavior;

No single treatment is appropriate for all individuals;

Treatment needs to be readily available;

Effective treatment attends to the multiple needs of the individual, not just his or her drug use;

Remaining in treatment for an adequate period of time is critical;

Behavioral therapies-including individual, family, or group counseling-are the most commonly used forms of drug abuse treatment;

Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies;

An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs;

Many drug-addicted individuals also have other mental disorders;

Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse;

Treatment does not need to be voluntary to be effective;

Drug use during treatment must be monitored continuously, as lapses during treatment do occur; and

Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

6 Complementary nonpharmacological therapies for OUDs and pain

Busse et al. (2017) recommends the use of “nonopioid pharmacotherapy and nonpharmacological therapy” for individuals with chronic, noncancer pain (p. E659). Chang, Fillingim, Hurley, & Schmidt (2015) state that nonpharmacological therapies can be “classified as behavioral, cognitive, integrative, and physical” (p. 21). Examples include cognitive behavioral therapy; application of heat and ice; massage, stretching, and yoga; transcutaneous electrical nerve and spinal cord stimulation; hypnosis and guided imagery; deep breathing and muscle relaxation; mindful-based therapies; acupuncture; physical, manual, and manipulation therapy; and animal-assisted therapy (American Physical Therapy Association, 2014;Cameron, 2004; Chang et al, 2015; Jones & Johnson, 2009; Ziegler, 2009). However, VR professionals must keep in mind that if these therapies are ineffective, opioid therapy is still a viable alternative for those with moderate to severe chronic pain. These therapies can also be used in conjunction with opioid therapy to further alleviate pain.

7 Overcoming challenges

Challenges related to opioid dependence and treatment center around several factors such as co-occurring disorders, pain management, and policies governing access. Other concerns revolve around identifying those who might have an increased likelihood of developing an OUD. SAMHSA (2004) reports on a number of differences between individuals being treated for pain and those who have a true opioid use disorder. Some of the distinguishing characteristics of those with an OUD include (a) compulsive drug use; (b) craving the drug even when not in pain; (c) purchasing the drug from nonmedical sources; (d) obtaining the drug through illegal means; (e) increasing dosage of opioid medication without consent from the prescribing doctor; (f) supplementing with other opioid drugs (e.g., heroin); (g) requesting a specific type of opioid medication; (h) not being able to stop use; and (i) utilizing an alternative form of administration (e.g., intravenous injection as opposed to taking medication orally) (SAMHSA). It is imperative that VR professionals are able to distinguish between an actual OUD and the legitimate use of opioid medications; additional training and an understanding of the criteria outlined in the DSM-5 can assist with this. In working with consumers who may require treatment for an OUD or have a current diagnosis of such, VR professionals must balance the rights of these individuals to receive the most effective treatment available without the stigma that comes along with being labeled an addict. They are to advocate for evidence-based treatments of any and all conditions that co-occur with the OUD whether it is a psychiatric disability, physical disability, chronic pain, etc.

7.1 Considerations for co-occurring complications

Individuals with co-occurring chronic pain and OUDs are more likely to experience psychological and social problems compared to those who only have chronic pain (Kouyanou, Pither, & Wessely, 1997) and those who only have substance use disorders (Potter, Shiffman, & Weiss, 2008). For example, they are 1.77 times more likely to have psychiatric disorders (Cheatle & Gallagher, 2006) such as depression, irritability, anxiety, and negative emotions and self-concept (Grattan et al., 2012; Hawker et al., 2011; Jamison et al., 2013; Ligthart, Gerrits, Boomsma, & Pennix, 2013). Other studies denote that between 50% and 80% of individuals with chronic pain who receive specialized pain treatment display symptoms of psychopathology; therefore, psychiatric issues are the most common co-occurring complication among these individuals (Boersma & Linton, 2005; Celestin, Edwards, & Jamison, 2009; Edwards et al., 2007). Furthermore, individuals with chronic pain and co-occurring psychopathology are more likely to disclose higher pain severity, greater disability due to intense pain, and significant emotional distress resulting from high pain levels (Breckenridge & Clark, 2003). Research also illustrates that while the majority of individuals prescribed opioids to treat chronic pain do not abuse their medications, some individuals experiencing substantial negative emotions are two to three times more likely to abuse their opioid prescriptions (Becker et al., 2008; Grattan et al., 2012; Wasan et al., 2007) occasionally to mitigate their psychiatric symptoms (Hasin et al., 2002). More specifically, co-occurring chronic pain and depression and/or anxiety is correlated with elevated opioid abuse, even if there is no prior history of substance abuse (Wasan et al., 2007).

7.2 Managing pain

It is relatively common to underestimate and under-treat chronic pain (Mehta & Langford, 2006), but the increasing rates of opioid misuse and diversion complicate how chronic pain might be managed. Both methadone and buprenorphine are established forms of treatment for both OUDs and chronic pain, however, their ability to address each condition varies. Methadone and buprenorphine are effective in alleviating withdrawal symptoms associated with the OUD for 24 to 48 hours, but their ability to suppress pain lasts only 4 to 8 hours (Ballantyne & LaForge, 2007). Buprenorphine is effective in treating mild to moderate pain but is limited in its ability to suppress severe pain; it may, however, be the best option for treating chronic pain in those with or at risk for an addiction (Furlan, Sandoval, Mailis-Gagnon, & Tunks, 2006).

7.3 Policy

Provider, policy, and legal factors create another type of challenge for those with OUDs. Provider related issues stem around factors such as who can prescribe and where. Unlike methadone, buprenorphine can be prescribed and dispensed in primary care doctors’ offices thus increasing its access (SAMHSA, 2016b); however, there are limits to the number of patients any one physician can treat. Physicians were initially limited to the treatment of 30 patients at any given time; this limit was raised to 100 patients in 2006. Per SAMHSA (2016c), physicians who have prescribed buprenorphine to 100 patients for at least one year can apply to increase their patient load to 275. Volkow, Frieden, Hyde, & Cha (2014) points out some challenges created by insurance policies such as the limits on the number of doses/prescriptions (annual and lifetime), requirements for prior authorization and reauthorization, and the “fail first” rule (p. 2065), which requires an individual to seek out other forms to treatment and fail before being allowed access to MAT. It is important to note that the Affordable Care Act (ACA) has helped to increase access to treatment for all substance use disorders by requiring coverage at the same level as general medical treatment, but there are still problems surrounding access.

8 Vocational rehabilitation considerations

The primary goal of vocational rehabilitation (VR) professionals is to help individuals return to their optimal functioning, which includes obtaining competitive employment; however, OUDs can place seemingly unconquerable restrictions on the rehabilitation process (Harden, 2008). Individuals with these disorders may encounter some of the same barriers those with other forms of substance used disorders experience such as low levels of education, lack of skill development, lack of “soft” skills, lack of motivation and stamina, poor self-esteem, and low self-efficacy (Hollar, McAweeney, & Moore, 2008; SAMHSA, 2000; Sigurdsson, Ring, O’Reilly, & Silverman, 2012; Walls, Batiste, Moore, & Loy, 2009). Several news outlets (e.g., New York Post, US News and World Report) as well as Krueger (2017) express concern about the loss of “prime age” (25-54; Bureau of Labor Statistics, 2017) workers, especially men, due to the increased rate of opioid abuse and addiction. Krueger goes on to note that “nearly half of prime age NLF [not in the labor force] men take pain medication on a daily basis, and in nearly two-thirds of these cases they take prescription pain medication” (p. 3). Other employment barriers experienced by those who use opioid pain medications (even as prescribed) can result in problems such as increased work-related injuries, decreased productivity, and failed drug tests (CDC, 2016). SAMHSA (2000) notes that while treatment for substance use disorders is an absolute necessity, it is often not enough in and of itself to overcome barriers to employment. As such, SAMHSA recommends the implementation of vocational rehabilitation services.

While challenges may exist, it is important to note that several studies found that employment rates increase among individuals receiving treatment for these disorders (ASAM, 2013; NIDA, 2017c; Richardson, Wood, Montaner, & Kerr, 2012). There are a number of considerations rehabilitation professionals should make when working with these individuals including, but not limited to, considerations and referrals for treatment. VR professionals have a responsibility to refer these consumers to appropriately trained specialists – who follow guidelines such as those recommended by the CDC – to determine if they are likely to benefit from opioid treatment. Prior to treatment, physicians should discuss the consequences of using opioid pain medications regardless of the reason, but specifically for those with chronic, nonmalignant pain. This discussion should also include providing information on options for alternative and nonpharmacological forms of pain relief. VR professionals should also consider training on how to complete brief screenings for substance use disorders (e.g., Rapid Opioid Dependence Screen (RODS), Brief Risk Questionnaire (BRQ)). While VR professionals are not generally trained to conduct in depth assessments for OUDs, utilizing brief screening tools may help to identify early problems hence allowing for early intervention and referral to an appropriate source. Having a working understanding of chronic pain conditions and their many accompanying complicating factors – increased potential for addiction, lack of treatment access and participation, and co-occurring psychiatric conditions – allows VR professionals to inform and guide the consumer in making decisions that best meet his or her needs. Considering this, rehabilitation professionals then have the capacity to work with consumers on identifying the most tangible and appropriate employment options.

Conflict of interest

None to report.

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