How do physicians manage severe pain in patients with a history of opioid use disorder?

Physical trauma such as broken bones and sprains are painful and uncomfortable experiences, but for some, they can trigger something worse: opioid relapse. For people with a history of opioid use disorder, traumatic injuries can create an impossible choice between extreme pain and relief that risks reigniting a life-threatening addiction.

With over 75,000 deaths in 2022 attributed to opioid overdoses, it's critical for health care providers to understand how to support and treat patients facing this all too common dilemma. GBH's All Things Considered host Arun Rath spoke about injuries and opioids with Dr. Peter Grinspoon, an addiction educator and instructor in medicine at Harvard Medical School.

Arun Rath: So as we understand, the scenario of being injured after a recovery from opioid addiction is something you recently have dealt with yourself. Could you share your story with us?

Dr. Peter Grinspoon: Absolutely. I do have to say, I've had 15 years in solid recovery from opiate addiction. I had a very bad opiate addiction in 2005 to prescription painkillers. I lost my medical license for three years. It was really, really bad. I had a hard time getting off the opiates. But I finally did, and I've been back to work for 15 years as a primary care doctor at MGH. Unfortunately, over the last 10 years, I've had three different surgeries: one for spinal stenosis, one for a torn quadriceps and one for, recently, I got hit by a car, and I now have a broken leg. So I feel like I'm one person who definitely has a deep background in both opiate addiction and in severe pain.

Rath: So let let let's dig right in with what you experienced recently after the car accident. You must have been in a tremendous amount of pain. How did you and your physicians approach pain management?

Grinspoon: Well, first of all, I was in so much pain right after I get hit by the car. I was in the ambulance and I'm like, "Guys, you have to give me pain control." And they give me 100 micrograms of fentanyl, which is enough for four colonoscopies. And it didn't touch the pain. Then they gave me another 100, and it still didn't touch the pain. I asked for more and they said, "Absolutely not. You're on the maximum dose."

So when someone's in severe, acute pain with a broken bone or right post surgery, I would say regardless of any history of addiction, you have an ethical and moral obligation to treat the pain. It's just inhumane and unethical to withhold pain medication. So in the acute event, treat the pain. Then as the next weeks go by and you're trying to figure out how to transition the patient off of opiates or how to taper them or how to treat them as an outpatient when they get to go home, then you start thinking about what are the safest ways we could prescribe opiates to this person who needs it without potentially triggering a relapse.

Rath: How does that process work? Because the intense pain is sustained for a while.

Grinspoon: Well, unfortunately, there's a lot of misinformation, taboo and superstition. Some very hard core people would say, "One is too many because a thousand is never enough, and you shouldn't be taking opiates." Other people think you have to treat the pain no matter what. So you treat the pain, and then you put in protections against relapse. I do have to say that during my addiction, if I had access to oxycodone, pain or not, I would have just snorted the whole bottle. But during the three surgeries I've had, it hasn't been a problem. It's very different when you're under stress, at a really unhappy part of your life, miserable and addicted versus later in life.

Once you're five, 10, 15 years in recovery, you're happier. You've dealt with all the psychological and physical triggers that were fueling your addiction, and it really hasn't been difficult for me to judiciously take the opiates. And again, 15 years ago, I would have found some excuse to take all of them, and now I actually have some left over. So your susceptibility to addiction changes as you grow and change and enter into stable recovery. You're not really the same person with the same addiction that you were 10 years ago because a lot of work, a lot of self-reflection, a lot of working with other people and peer support goes into entering into a stable recovery and it protects you from the addiction.

Rath: It sounds like it requires more direct activity from the physician. Talk about that, as you were mentioning, that that how the physician guides the patient through this process.

Grinspoon: Well, I think it's really important for the physician not to have a judgmental or stigmatized attitude towards addiction. Unfortunately, a lot of physicians do have a really stinky attitude towards addiction, and that makes it harder. But generally speaking, they need to be open about this and to talk about it, to educate people, to remind people that they are probably at higher risk. And the key is close communication with your providers and close follow up. You don't just prescribe 60 oxycodone and then say, "Okay, goodbye, have a good life." You need to check in with them, and that helps the patient and helps the doctor learn.

There are things a patient can do if they're worried about relapsing and if they have trouble not taking too many of the pills at once. Taking two pills for pain is different from snorting ten because you're addicted. One causes a lot of euphoria. The other just makes you not feel pain. But, for example, you could have your partner or significant other lock away the pills and just dispense you two pills every six to eight hours. So there are things you could do to protect yourself.

Rath: Probably goes without saying that you should make certain that your physician knows that if you have a traumatic injury and you do have a history of addiction, to share that.

Grinspoon: That's a little bit complicated because I'm virtually always in favor of being open and honest, but I've treated a lot of people with addiction, and I've helped a lot of physicians with addiction. At times, if you tell your doctor you have a history of addiction, they're going to be like, "Oh, we can't give opiates," or "Oh, we're going to cut down drastically on the opiates." And you run the risk of being severely undertreated for chronic pain unless you have a very enlightened physician. When people are undertreated for chronic pain, they do desperate things like buy opiates on the street, and that's where we're getting the overdoses from the fentanyl that's contaminating the supply.

So what I think is a smart thing to do when you're in the hospital, if you're going to be in a lot of pain, if you're going to need opiates and there's some concern about addiction and you want to be open with your doctor, ask for a pain consult. Every hospital has a pain specialty team, and they very judiciously weigh the risk of relapse, which nobody really knows what the real risk is, versus the risk of undertreating the chronic pain. So I would just get pain specialists involved in the hospital early because they're very tuned into treating pain and not torturing the patient. At the same time, they're very attuned to all the data about who is and who isn't susceptible to a relapse.

Rath: It seems a little strange that in the age of modern pharmacology that the standard we turn to for pain relief are still varients of opioids. Is there any work in the pharmaceutical world towards coming up with some other kind of pain relief that doesn't have this baggage?

Grinspoon: In biotech, there's a ferocious search for painkillers that are as effective as opiates but are not as euphorogenic, as in, they don't cause as much euphoria and consequently they don't cause as much addiction. Another thing that I do with patients and I can honestly say I did as a physician recently, is use cannabis to lower your pain. Cannabis and opiates working together can really lower the dose of opiates that you need because they work in the same receptor. Cannabis is one of my specialties, but I think cannabis is a very powerful harm reduction technique on the whole.

How many opiates do we give? How do we minimize the opiates but also maximize the pain control? I think people are going to be using cannabis more frequently because it really does help lower the dose of opiates and most of the mischief you get with opiates is based on the dose and the quantity of pills that you're given.

Rath: Dr. Grinspoon This is so fascinating and really important information. Thank you so much.

Grinspoon: Thank you guys for bringing light to this.