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Primary Care and Treatment of Pain and Addiction

woman in pain

Patients who suffer from chronic pain, addiction, and stress appear in all primary care settings. Despite research demonstrating that these three conditions frequently occur together and share underlying pathophysiological mechanisms, they are often addressed separately. Primary care clinicians can help these patients live better, healthier lives.

By opening their doors to patients struggling with addiction, primary care practitioners can provide the best care possible for these patients, treating their diabetes along with their addiction. 

Julian Mitton, MD

IFM’s 2019 Annual International Conference focused in these three conditions and recasts the landscape of treatment options to address these ubiquitous issues. With a diverse panel of multidisciplinary speakers, the 3-day conference explored a range of topics, including:

  • Pediatric pain and addiction (including: Elizabeth Mumper, MD, FAAP, Lonnie Zeltzer, MD, Joy Weydert, MD)
  • Emerging therapies for pain, including psychotropics, pharmacogenomics, cannabinoids, and electrical stimulation (including: Cecilia Hillard, PhD, Roland R. Griffiths, PhD, Dave Hagedorn, MD, Jeff Mogil, PhD, Heather Tick, MD)
  • Addiction medicine and behavior change (including: Arwen Podesta, MD, ABPN, FASAM, ABIHM, Stephen Loyd, MD, John Kelly, PhD, Paul Thomas, MD)
  • Stress management and resilience therapies (including: David Haase, MD, Eric L. Garland, PhD, LCSW, Wayne Jonas, MD, Dave Rakel, MD)
  • Lifestyle change and pain management for patients in the military healthcare system (including: Bryan Stepanenko, MD, MPH, Mylene Huynh, MD, Elijah Sacra, Henri Roca, MD)

Pain, stress, and addiction are linked on several levels, and different subcategories of each are related as well. For instance, behavioral and substance addictions are almost always treated by different specialists as different disorders, despite having common underlying antecedents, triggers, and mediators.1 Specialists and primary care clinicians comprise a care team for these patients,2-5 and those collaborative care teams face many challenges.3,6,7 To help these patients in primary care, a broader view is needed that addresses the core physiological imbalances. Presenters at the 2019 AIC provided the tools primary care clinicians need to make a difference for treatment of pain and addiction.

Listen to podcasts with presenters>

Pain and addiction both are characterized by alterations in underlying systems, including the brain’s reward systems.8,9 Primary care clinicians engage in the majority of care for patients with chronic pain, yet often struggle with these patient encounters.10 Patients report wanting better care coordination and increased knowledge about non-pharmacological approaches to pain management.11

Changes to hedonic homeostasis can lead to the feeling of spiraling into worse and worse pain and/or addiction. Stress is one of the many factors that affects the tuning of those systems,9,12 and so for individuals with chronic pain, any type of addiction, and ongoing stress, the health effects can be extremely challenging and difficult to unravel. Both early adverse childhood events and chronic stress also predispose patients to later-life addiction,13 highlighting the importance of stress management throughout the lifespan for long-term health.

IFM’s Executive Director of Medical Education, Robert Luby, MD, describes the role of stress in a Functional Medicine approach to pain or addiction:

Learn more about this trio of factors

References

  1. Kim HS, Hodgins DC. Component Model of Addiction Treatment: A Pragmatic Transdiagnostic Treatment Model of Behavioral and Substance Addictions. Front Psychiatry. 2018;9:406. Published 2018 Aug 31. doi:10.3389/fpsyt.2018.00406.
  2. American Psychiatric Association; Academy of Psychosomatic Medicine. Dissemination Of Integrated Care Within Adult Primary Care Setting: The Collaborative Care Model. 2016. Available from: https://med.dartmouth-hitchcock.org/documents/behavioral-health-integration-guideline.pdf. Accessed November, 2018.
  3. Watkins KE, Ober AJ, Lamp K, et al. Collaborative Care for Opioid and Alcohol Use Disorders in Primary CareThe SUMMIT Randomized Clinical Trial. JAMA Intern Med. 2017;177(10):1480–1488. doi:10.1001/jamainternmed.2017.3947.
  4. Dr. Robert Bree Collaborative. Collaborative Care for Chronic Pain Report and Recommendations. 2018. Available http://www.breecollaborative.org/wp-content/uploads/Recommendations-Chronic-Pain-Draft-18-0810.pdf Last Accessed 11/13/2018.
  5. Peterson K, Anderson J, Bourne D, et al. Evidence Brief: Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain. 2017 Jan. In: VA Evidence-based Synthesis Program Evidence Briefs [Internet]. Washington (DC): Department of Veterans Affairs (US); 2011-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK442254/
  6. Duncan M. Collaborative Care Model Effective For Addiction Treatment. Psychiatric News. 2017; Sept 14. doi:10.1176/appi.pn.2017.9b9.
  7. IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.
  8. Elman I, Borsook D. Common Brain Mechanisms of Chronic Pain and Addiction. Neuron. 2016 Jan 6;89(1):11-36. doi:10.1016/j.neuron.2015.11.027.
  9. Kwako LE, Koob GF. Neuroclinical Framework for the Role of Stress in Addiction. Chronic Stress (Thousand Oaks). 2017;1 doi:10.1177/2470547017698140.
  10. Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: providers’ perspectives. Pain Med. 2010 Nov;11(11):1688-97. doi:10.1111/j.1526-4637.2010.00980.x.
  11. Giannitrapani K, McCaa M, Haverfield M, et al. Veteran Experiences Seeking Non-pharmacologic Approaches for Pain. Mil Med. 2018 Mar 26. doi:10.1093/milmed/usy018.
  12. Koob GF, Buck CL, Cohen A, et al. Addiction as a stress surfeit disorder. Neuropharmacology. 2013;76 Pt B(0 0):370-82. doi:10.1016/j.neuropharm.2013.05.024.
  13. Chronic stress, drug use, and vulnerability to addiction. Ann N Y Acad Sci. 2008;1141:105-30. doi:10.1196/annals.1441.030.

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