Faced with the ambiguity of managing chronic pain in patients with pre-existing addiction disorders, most providers adhered to a decision-making framework that influenced their treatment goals, perceptions of treatment risks, pain management strategies, and tolerance for ambiguity. The two frameworks we identified corresponded to widely divergent pain management practices, which led to tension between providers.
Practice variation has been documented in numerous fields23–26
, including pain treatment7
and opioid replacement therapy27,28
. Variation has been attributed to difficulty interpreting scientific evidence29,30
and incorporating it into clinical practice31
, but little is known about how different strategies for clinical decision-making lead to different practice patterns. In this study, we describe an extremely ambiguous clinical scenario and two divergent heuristics that providers used to make necessary decisions.
Currently, there are no published data to conclusively support or refute either of these decision-making frameworks. It may be that successful treatment for pain and addiction requires using aspects of both. Future empirical studies should evaluate different pain management strategies and examine outcomes of pain, illicit drug use, prescription drug abuse, and functional status among current and former drug users.
The wide practice variation among the providers we interviewed was partly explained by the perceived relationship between pain and illicit drug use. The few published studies on the association between inadequate analgesia and illicit drug use among patients on methadone maintenance therapy had inconsistent results, with some studies suggesting an association between pain and illicit drug use, particularly drugs with analgesic properties14,32
, and others suggesting no association20
. Though all providers in this study were clearly committed to delivering high quality care, opposing perceptions of the impact of pain on illicit drug use led to important differences in practice.
There are two potential avenues that may address the ambiguity faced by providers managing chronic pain in patients on methadone maintenance. The first requires establishing an evidence base for decision-making. Two central questions needing attention are: when does the provision of opioids for chronic pain management to patients with pre-existing addiction increase the risk of illicit drug use and, conversely, when does withholding opioids increase self-medication of pain with illicit drugs? Currently, the subject of chronic pain management in patients with addiction, and particularly with opioid dependence, can best be described as pre-paradigmatic33
. This concept, adopted from the philosophy of science, describes the "pre-history" phase of a discipline, during which there is wide disagreement about fundamental issues. While such a state persists, a field cannot be said to be truly scientific. Although opportunities for specialists in pain and addiction to share knowledge have recently been created34
, important clinical questions must be answered before these closely related scientific fields can be successfully integrated.
A second potential avenue to alleviate the dilemma of treating pain and co-morbid addiction requires minimizing tension between providers. Most providers we interviewed experienced difficulty coping with the ambiguity of making decisions about chronic opioid pain management. Our findings support those of Bendtsen et al., who reported that the quandary of prescribing opioids led to dissatisfaction with decisions, low self-esteem, and discontent with colleagues9
. The tension for some providers derived from awareness of differences among colleagues, which is not unexpected since providers turn most often to colleagues for guidance in situations of clinical ambiguity35
. Establishing an open forum for providers to discuss challenging scenarios might foster collaboration. Potential scenarios might include patients with documented pain syndromes and functional impairment who are actively using drugs or patients with high opioid tolerance who may need large doses of opioids for effective analgesia. Though instituting a general approach to assessing, treating, and monitoring pain might decrease tension, it may be necessary to simply acknowledge ambiguity and accept variation in practice.
Limitations to our study should be noted. Our study sample was neither random not representative, and the providers’ overall knowledge about specific pain management issues, such as opioid-induced hyperalgesia, is unclear. Further, the setting was unique, and while it does not invalidate our findings, regional or local culture may have influenced provider’s concerns. Lastly, without larger, more representative sampling, these results should not be generalized to primary care providers in other settings or to pain specialists.
In summary, in a convenience sample of providers delivering integrated primary medical care and substance abuse treatment to patients on methadone maintenance for opioid dependence, we found that clinical ambiguity was a major barrier to making diagnostic and therapeutic decisions about chronic opioid pain management. To enable consistency, most providers adhered to one of two decision-making frameworks. Differences between frameworks led to differences in strategies to assess and treat chronic pain, and the resultant wide practice variation led to tension between providers. To establish an evidence base, research addressing the clinical intersection between pain and addiction should focus on the relationship between chronic opioid pain treatment and illicit drug use. Such efforts have the potential to guide health-care providers faced with this complex high-risk scenario and to provide effective chronic pain treatment for opioid-dependent drug users.