Review Article of International Journal of Addiction Research and Therapy
Reexamining opioid addiction as a co-occurring disorder: A clinical perspective on the “Chronic Pain Paradox”
Dalia Chowdhury Ph.D., CRC, Stephen Fauss MS
Department of Rehabilitation and Health Services University of North Texas
The use of opioids as an anodyne for chronic pain was not prevalent before the 1980s1. Students in medical schools had learnt to avoid prescribing opioids, considered highly addictive for treatment of non-malignant chronic pain1. Yet, from the early 1990s, prescription opioids emerged as a widely accepted method of treating chronic pain and palliative care2. Previously, chronic pain was treated in multidisciplinary clinics with coordinated care which included physical exams, medication management, biopsychosocial evaluation, cognitive behavioral treatment, physical therapy, and occupational therapy2. Starting in the early 1990’s, under dubious antecedence, opioid analgesics were promoted as the proprietary remedy for chronic pain and received endorsement and support from care providers across the United States3. Non-cancerous chronic pain, as a phenomenon, was thus elevated to an ailment or a medical condition by its own right from its erstwhile status as a corollary to another medical condition. This led to an increase in opioid analgesic prescriptions, followed by a wide-ranging abuse by patients, converting opioid use disorder (OUD) to a problem of epidemic proportions4.
Apart from the legal course of action initiated against Perdue Pharma, in 2020, the maker and distributor of Oxycontin that resulted in a $3.8 billion lawsuit settlement, in which Perdue Pharma pleaded guilty; since the recognition of this problem, new measures have been adopted to counter the opioid epidemic by clinicians. There has been a significant shift towards circumvention by physicians prescribing opioids for non-cancerous chronic pain. In a few instances, providers have resorted to putting a temporary moratorium on prescribing opioids to all non-cancerous chronic pain cases5.
The Center for Disease Control (CDC) and various state agencies have passed protocols, installed prescription monitoring programs (PMPs), and created taskforces to rein in flagrant prescription practices by medical providers. Mental health counseling and alternative, non-prescriptive pain management procedures have been reintroduced in treatment as a new way of approaching the problem6,7. The Substance Abuse and Mental Health Administration (SAMHSA) have suggested hybrid programs such as medically assisted treatment (MAT) which utilizes the medical approach of prescribing slow releasing drugs with concomitant counseling for patients, as one of the best practices to intervene with opioid use disorders8. An integrated healthcare approach brought primary care physicians, nurses, and physician’s assistants together with addiction counselors and social workers to coordinate and implement treatment for opioid misuse9,10.
These new approaches are laudable and effective, yet we argue, in this paper, for ascertaining the treatment of chronic pain as a co-occurring disorder to addiction. While acknowledging the two original transgressions of the opioid epidemic: a) the delineation and decontextualization of chronic pain as an independent medical phenomenon, and b) the over-prescription of opioid analgesics to treat chronic pain; we argue that recognizing chronic pain as a co-occurring disorder with addiction and psychological trauma could help providers contextualize it better, leading to an improved treatment protocol.
Over last two decades, persistent over-prescribing has set forth a culture of righteous demand among patients to obtain opioids and receive instant pharmacological sedation as an antidote to chronic pain. This culture, which may have taken roots, could cause resistance among chronic pain patients towards any change to alternative treatment plans. This could frustrate medical providers and reformers as they usher in the new treatment procedures promulgated by SAMHSA and the CDC. Thus, a co-occurring diagnostic framework could provide a pathway to better understand this treatment dilemma. The co-occurring disorder lens of diagnosis could provide a pathway to understand this treatment dilemma.
In this paper, we do a critical, non-systematic review of existing literature that explores the intersection of chronic pain and OUD to make a case that these issues should be treated as co-occurring disorders and not as disconnected, independent phenomenon. We review the scope of the problem and provide an analysis of the complex relationship between chronic pain and usage of opioids from both pharmacological and psychological viewpoints and explore the challenges to treatment. We take an ecological and exchange theory perspective to understand the co-occurrence of pain and opioids addiction from a trauma-informed lens to unpack the complexity that OUD poses in juxtaposition to chronic pain. Furthermore, we explore the strategies to develop an integrated healthcare workforce from a co-occurring disorder perspective. Furthermore, we explain the context of co-occurring pain, addiction, and psychological trauma and identify the pertinent questions that such co-occurrences pose for treatment protocols. We draw our argument from a critical review of the literature as well as the incidence and prevalence of OUD.
Keywords: Reexamining opioid addiction; co-occurring disorder; clinical perspective; Chronic Pain Paradox
How to cite this article:
Dalia Chowdhury, Stephen Fauss. Reexamining opioid addiction as a co-occurring disorder: A clinical perspective on the “Chronic Pain Paradox”.International Journal of Addiction Research and Therapy, 2021, 4:26. DOI: 10.28933/ijart-2021-06-1005
1. Rummans TA, Burton MC, Dawson NL. How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis. Mayo Clin Proc. 2018;93(3):344-350. doi:10.1016/j.mayocp.2017.12.020
2. Alam A, Juurlink DN. The prescription opioid epidemic: an overview for anesthesiologists. Can J Anaesth. 2016;63(1):61-68. doi:10.1007/s12630-015-0520-y
3. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008;16(5):405-416. doi:10.1037/a0013628
4. Centers for Disease Control and Prevention. Opioid Overdose. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed April 13, 2021.
5. Ebbert JO, Philpot LM, Clements CM, et al. Attitudes, Beliefs, Practices, and Concerns Among Clinicians Prescribing Opioids in a Large Academic Institution. Pain Med. 2018;19(9):1790-1798. doi:10.1093/pm/pnx14
6. Shepherd J. Combating the prescription painkiller epidemic: a national prescription drug reporting program. Am J Law Med. 2014;40(1):85-112. doi:10.1177/009885881404000103
7. Lin HC, Wang Z, Boyd C, Simoni-Wastila L, Buu A. Associations between statewide prescription drug monitoring program (PDMP) requirement and physician patterns of prescribing opioid analgesics for patients with non-cancer chronic pain. Addict Behav. 2018;76:348-354. doi:10.1016/j.addbeh.2017.08.032
8. Knopf A. SAMHSA budget would eliminate ATR, encourage MAT and fund naloxone. Alcohol Drug Abuse Wkly. 2015; 27:1–3
9. Brose SW, Schneck H, Bourbeau DJ. An Interdisciplinary Approach to Reducing Opioid Prescriptions to Patients with Chronic Pain in a Spinal Cord Injury Center. PM R. 2019;11(2):135-141. doi:10.1016/j.pmrj.2018.09.030
10. Kidorf M, Brooner RK, Gandotra N, et al. Reinforcing integrated psychiatric service attendance in an opioid-agonist program: a randomized and controlled trial. Drug Alcohol Depend. 2013;133(1):30-36. doi:10.1016/j.drugalcdep.2013.06.005
11. Robinson KT, Bergeron CD, Mingo CA, et al. Factors Associated With Pain Frequency Among Adults With Chronic Conditions. J Pain Symptom Manage. 2017;54(5):619-627.doi:10.1016/j.jpainsymman.2017.07.043
12. Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain. 1986;25(2):171-186. doi:10.1016/0304-3959(86)90091-6
13. Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health. 2009;99(2):221-227. doi:10.2105/AJPH.2007.131714
14. Walid MS, Donahue SN, Darmohray DM, Hyer LA Jr, Robinson JS Jr. The fifth vital sign–what does it mean? [retracted in: Pain Pract. 2009 May-Jun;9(3):245]. Pain Pract. 2008;8(6):417-422. doi:10.1111/j.1533-2500.2008.00222.x
15. Scher C, Meador L, Van Cleave JH, Reid MC. Moving Beyond Pain as the Fifth Vital Sign and Patient Satisfaction Scores to Improve Pain Care in the 21st Century. Pain Manag Nurs. 2018;19(2):125-129. doi:10.1016/j.pmn.2017.10.010
16. Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559-574. doi:10.1146/annurev-publhealth-031914-122957
17. Poitras G. OxyContin, prescription opioid abuse and economic medicalization. Medicolegal and Bioethics. 2012; 2:31-43. https://doi.org/10.2147/MB.S32040
18. Hadland SE, Rivera-Aguirre A, Marshall BDL, Cerdá M. Association of Pharmaceutical Industry Marketing of Opioid Products With Mortality From Opioid-Related Overdoses [published correction appears in JAMA Netw Open. 2019 Mar 1;2(3):e191625]. JAMA Netw Open. 2019;2(1): e186007. Published 2019 Jan 4. doi:10.1001/jamanetworkopen.2018.6007
19. Hadland SE, Krieger MS, Marshall BDL. Industry Payments to Physicians for Opioid Products, 2013-2015. Am J Public Health. 2017;107(9):1493-1495. doi:10.2105/AJPH.2017.303982
20. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006;21(6):607-612. doi:10.1111/j.1525-1497.2006.00415.x
21. Ventola CL. Direct-to-Consumer Pharmaceutical Advertising: Therapeutic or Toxic?. P T. 2011;36(10):669-684.
22. Dyer O. OxyContin maker stops marketing opioids, as report details payments to advocacy groups. BMJ. 2018;360:k791. Published 2018 Feb 19. doi:10.1136/bmj.k79
23. National Institute on Drug Abuse. Opioid Overdose Crisis. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis. Accessed March 26, 2021.
24. Rosenblum A, Joseph H, Fong C, Kipnis S, Cleland C, Portenoy RK. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. JAMA. 2003;289(18):2370-2378. doi:10.1001/jama.289.18.2370
25. Rosenblum A, Parrino M, Schnoll SH, et al. Prescription opioid abuse among enrollees into methadone maintenance treatment. Drug Alcohol Depend. 2007;90(1):64-71. doi:10.1016/j.drugalcdep.2007.02.012
26. Whitehead AJ, Dobscha SK, Morasco BJ, Ruimy S, Bussell C, Hauser P. Pain, substance use disorders and opioid analgesic prescription patterns in veterans with hepatitis C. J Pain Symptom Manage. 2008;36(1):39-45. doi:10.1016/j.jpainsymman.2007.08.013
27. Griffin ML, McDermott KA, McHugh RK, Fitzmaurice GM, Jamison RN, Weiss RD. Longitudinal association between pain severity and subsequent opioid use in prescription opioid dependent patients with chronic pain. Drug Alcohol Depend. 2016;163:216-221. doi:10.1016/j.drugalcdep.2016.04.023
28. Mularski RA. Pain management in the intensive care unit. Crit Care Clin. 2004;20(3):381-viii. doi:10.1016/j.ccc.2004.03.010
29. Krebs EE, Carey TS, Weinberger M. Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern Med. 2007;22(10):1453-1458. doi:10.1007/s11606-007-0321-2
30. van Boekel RLM, Vissers KCP, van der Sande R, Bronkhorst E, Lerou JGC, Steegers MAH. Moving beyond pain scores: Multidimensional pain assessment is essential for adequate pain management after surgery. PLoS One. 2017;12(5):e0177345. Published 2017 May 10. doi:10.1371/journal.pone.0177345
31. Levy N, Sturgess J, Mills P. “Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: Why?. Br J Anaesth. 2018;120(3):435-438. doi:10.1016/j.bja.2017.11.098
32. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl. 1986;3: S1-S226.
33. Pergolizzi JV Jr, Raffa RB, Taylor R Jr. Treating acute pain in light of the chronification of pain. Pain Manag Nurs. 2014;15(1):380-390. doi:10.1016/j.pmn.2012.07.004
34. Corder G, Castro DC, Bruchas MR, Scherrer G. Endogenous and Exogenous Opioids in Pain. Annu Rev Neurosci. 2018;41:453-473. doi:10.1146/annurev-neuro-080317-061522
35. Zagon IS, McLaughlin PJ. Endogenous Opioids in the Etiology and Treatment of Multiple Sclerosis. In: Zagon IS, McLaughlin PJ, eds. Multiple Sclerosis: Perspectives in Treatment and Pathogenesis. Brisbane (AU): Codon Publications; November 27, 2017.
36. Ahmad AH, Abdul Aziz CB. The brain in pain. Malays J Med Sci. 2014;21(Spec Issue):46-54.
37. Loeser JD, Melzack R. Pain: an overview. Lancet. 1999;353(9164):1607-1609. doi:10.1016/S0140-6736(99)01311-2
38. Garland EL, Froeliger B, Zeidan F, Partin K, Howard MO. The downward spiral of chronic pain, prescription opioid misuse, and addiction: cognitive, affective, and neuropsychopharmacologic pathways. Neurosci Biobehav Rev. 2013;37(10 Pt 2):2597-2607. doi:10.1016/j.neubiorev.2013.08.006
39. Contet C, Kieffer BL, Befort K. Mu opioid receptor: a gateway to drug addiction. Curr Opin Neurobiol. 2004;14(3):370-378. doi:10.1016/j.conb.2004.05.00
40. Contet C, Kieffer BL, Befort K. Mu opioid receptor: a gateway to drug addiction. Curr Opin Neurobiol. 2004;14(3):370-378. doi:10.1016/j.conb.2004.05.005
41. Sederer LI, Marino LA. Ending the Opioid Epidemic by Changing the Culture. Psychiatr Q. 2018;89(4):891-895. doi:10.1007/s11126-018-9589-0
42. Castro DC, Berridge KC. Opioid hedonic hotspot in nucleus accumbens shell: mu, delta, and kappa maps for enhancement of sweetness “liking” and “wanting”. J Neurosci. 2014;34(12):4239-4250. doi:10.1523/JNEUROSCI.4458-13.2014
43. Kai Y, Li Y, Sun T, et al. A medial prefrontal cortex-nucleus acumens corticotropin-releasing factor circuitry for neuropathic pain-increased susceptibility to opioid reward. Transl Psychiatry. 2018;8(1):100. Published 2018 May 21. doi:10.1038/s41398-018-0152-4
44. Veinante P, Yalcin I, Barrot M. The amygdala between sensation and affect: a role in pain. J Mol Psychiatry. 2013;1(1):9. Published 2013 Jun 5. doi:10.1186/2049-9256-1-9
45. Youd J. Self-harm. Nurs Stand. 2013; 28(3): 16. doi: 10.7748/ns2013.09.28.3.16.s25
46. Alford DP, German JS, Samet JH, Cheng DM, Lloyd-Travaglini CA, Saitz R. Primary Care Patients with Drug Use Report Chronic Pain and Self-Medicate with Alcohol and Other Drugs. J Gen Intern Med. 2016;31(5):486-491. doi:10.1007/s11606-016-3586-5
47. Paice JA. Cancer pain management and the opioid crisis in America: How to preserve hard-earned gains in improving the quality of cancer pain management. Cancer. 2018;124(12):2491-2497. doi:10.1002/cncr.31303
48. Becker WC, Merlin JS, Manhapra A, Edens EL. Management of patients with issues related to opioid safety, efficacy and/or misuse: a case series from an integrated, interdisciplinary clinic. Addict Sci Clin Pract. 2016;11(1):3. Published 2016 Jan 28. doi:10.1186/s13722-016-0050-0
49. Bisaga A, Mannelli P, Sullivan MA, et al. Antagonists in the medical management of opioid use disorders: Historical and existing treatment strategies. Am J Addict. 2018;27(3):177-187. doi:10.1111/ajad.12711
50. Buono FD, Grau LE, Sprong ME, Morford KL, Johnson KJ, Gutmann DH. Pain symptomology, functional impact, and treatment of people with Neurofibromatosis type 1. J Pain Res. 2019;12:2555-2561. Published 2019 Aug 22. doi:10.2147/JPR.S209540
51. Cahill CM, Taylor AM. Neuroinflammation-a co-occurring phenomenon linking chronic pain and opioid dependence. Curr Opin Behav Sci. 2017;13:171-177. doi:10.1016/j.cobeha.2016.12.003
52. Guy GP Jr, Zhang K, Bohm MK, et al. Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):697-704. Published 2017 Jul 7. doi:10.15585/mmwr.mm6626a4
53. Dayer LE, Painter JT, McCain K, King J, Cullen J, Foster HR. A recent history of opioid use in the US: Three decades of change. Subst Use Misuse. 2019;54(2):331-339. doi:10.1080/10826084.2018.1517175
54. Tompkins DA, Hobelmann JG, Compton P. Providing chronic pain management in the “Fifth Vital Sign” Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug Alcohol Depend. 2017;173 Suppl 1(Suppl 1):S11-S21. doi:10.1016/j.drugalcdep.2016.12.002
55. Bolton JM, Robinson J, Sareen J. Self-medication of mood disorders with alcohol and drugs in the National Epidemiologic Survey on Alcohol and Related Conditions. J Affect Disord. 2009;115(3):367-375. doi:10.1016/j.jad.2008.10.003
56. Garland EL, Pettus-Davis C, Howard MO. Self-medication among traumatized youth: structural equation modeling of pathways between trauma history, substance misuse, and psychological distress. J Behav Med. 2013;36(2):175-185. doi:10.1007/s10865-012-9413-5
57. Smoski MJ, Salsman N, Wang L, et al. Functional imaging of emotion reactivity in opiate-dependent borderline personality disorder. Personal Disord. 2011;2(3):230-241. doi:10.1037/a0022228
58. Clay SW. Risk factors for addiction. Osteopath Fam Physician. 2010;2:41-5. 3
59. De Bellis MD. Developmental traumatology: a contributory mechanism for alcohol and substance use disorders. Psychoneuroendocrinology. 2002;27(1-2):155-170. doi:10.1016/s0306-4530(01)00042-7
60. Dunn KE, Brooner RK, Clark MR. Severity and interference of chronic pain in methadone-maintained outpatients. Pain Med. 2014;15(9):1540-1548. doi:10.1111/pme.12430
61. McCarthy JJ, Leamon MH, Finnegan LP, Fassbender C. Opioid dependence and pregnancy: minimizing stress on the fetal brain. Am J Obstet Gynecol. 2017;216(3):226-231. doi:10.1016/j.ajog.2016.10.003
62. Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, Roland CL. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Med. 2011;12(4):657-667. doi:10.1111/j.1526-4637.2011.01075.x
63. Dineen KK, DuBois JM. Between a rock and a hard place: Can physicians prescribe opioids to treat pain adequately while avoiding legal sanction? Am J Law Med. 2016;42(1):7-52. doi:10.1177/0098858816644712
64. Jamison RN, Scanlan E, Matthews ML, Jurcik DC, Ross EL. Attitudes of Primary Care Practitioners in Managing Chronic Pain Patients Prescribed Opioids for Pain: A Prospective Longitudinal Controlled Trial. Pain Med. 2016;17(1):99-113. doi:10.1111/pme.12871
65. Rothstein MA. The Opioid Crisis and the Need for Compassion in Pain Management. Am J Public Health. 2017;107(8):1253-1254. doi:10.2105/AJPH.2017.303906
66. Brands B, Blake J, Sproule B, Gourlay D, Busto U. Prescription opioid abuse in patients presenting for methadone maintenance treatment. Drug Alcohol Depend. 2004;73(2):199-207. doi:10.1016/j.drugalcdep.2003.10.012
67. National Institute on Drug Abuse. Overdose Death Rates. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.Accessed September 16th, 2020.
68. Wachholtz A, Ziedonis D, Gonzalez G. Comorbid pain and opioid addiction: psychosocial and pharmacological treatments. Subst Use Misuse. 2011;46(12):1536-1552. doi:10.3109/10826084.2011.559606
69. Pearson AC, Moman RN, Moeschler SM, Eldrige JS, Hooten WM. Provider confidence in opioid prescribing and chronic pain management: results of the Opioid Therapy Provider Survey. J Pain Res. 2017;10:1395-1400. Published 2017 Jun 7. doi:10.2147/JPR.S136478
70. Tompkins DA, Hobelmann JG, Compton P. Providing chronic pain management in the “Fifth Vital Sign” Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug Alcohol Depend. 2017;173 Suppl 1(Suppl 1):S11-S21. doi:10.1016/j.drugalcdep.2016.12.002
71. Murthy V, Sibbritt DW, Adams J. An integrative review of complementary and alternative medicine use for back pain: a focus on prevalence, reasons for use, influential factors, self-perceived effectiveness, and communication. Spine J. 2015;15(8):1870-1883. doi:10.1016/j.spinee.2015.04.049
72. Dunn KE, Brooner RK, Clark MR. Severity and interference of chronic pain in methadone-maintained outpatients. Pain Med. 2014;15(9):1540-1548. doi:10.1111/pme.12430
73. McCarthy DM, Cameron KA, Courtney DM, Adams JG, Engel KG. Communication about opioid versus nonopioid analgesics in the emergency department. J Opioid Manag.2015;11(3):229-236. doi:10.5055/jom.2015.0271
74. Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med. 2017;167(5):293-301. doi:10.7326/M17-0865
75. McCauley JL, Mercer MA, Barth KS, Brady KT, Back SE. Pain management perceptions among prescription opioid dependent individuals. Drug Alcohol Depend. 2014;142:354-358. doi:10.1016/j.drugalcdep.2014.06.024
76. Green TC, Bowman S, Davis C, Los C, McHugh K, Friedmann PD. Discrepancies in addressing overdose prevention through prescription monitoring programs. Drug Alcohol Depend. 2015;153:355-358. doi:10.1016/j.drugalcdep.2015.05.000
77. Ayres I, Jalal A. The Impact of Prescription Drug Monitoring Programs on U.S. Opioid Prescriptions. J Law Med Ethics. 2018;46(2):387-403. doi:10.1177/1073110518782948
78. Kosten TR, Baxter LE. Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment. Am J Addict. 2019;28(2):55-62.doi:10.1111/ajad.12862
79. Azevedo RT, Macaluso E, Avenanti A, Santangelo V, Cazzato V, Aglioti SM. Their pain is not our pain: brain and autonomic correlates of empathic resonance with the pain of same and different race individuals. Hum Brain Mapp. 2013;34(12):3168-3181. doi:10.1002/hbm.22133
80. Alter TH, Ilyas AM. A Prospective Randomized Study Analyzing Preoperative Opioid Counseling in Pain Management After Carpal Tunnel Release Surgery. J Hand Surg Am. 2017;42(10):810-815. doi:10.1016/j.jhsa.2017.07.003
81. Barry DT, Beitel M, Cutter CJ, et al. An evaluation of the feasibility, acceptability, and preliminary efficacy of cognitive-behavioral therapy for opioid use disorder and chronic pain. Drug Alcohol Depend. 2019;194:460-467. doi:10.1016/j.drugalcdep.2018.10.015
82. Fiellin DA, Pantalon MV, Chawarski MC, et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med. 2006;355(4):365-374. doi:10.1056/NEJMoa055255
83. Weiss RD, Griffin ML, Potter JS, et al. Who benefits from additional drug counseling among prescription opioid-dependent patients receiving buprenorphine-naloxone and standard medical management?. Drug Alcohol Depend. 2014;140:118-122. doi:10.1016/j.drugalcdep.2014.04.005
84. Substance Abuse and Mental Health Services Administration. Medication and Counseling Treatment. 2015. https://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat. Accessed August 3, 2020.
85. Collins AB, Bluthenthal RN, Boyd J, McNeil R. Harnessing the language of overdose prevention to advance evidence-based responses to the opioid crisis. Int J Drug Policy. 2018;55:77-79. doi:10.1016/j.drugpo.2018.02.013
86. Ling W, Mooney L, Hillhouse M. Prescription opioid abuse, pain and addiction: clinical issues and implications. Drug Alcohol Rev. 2011;30(3):300-305. doi:10.1111/j.1465-3362.2010.00271.x
87. Adesoye A, Duncan N. Acute pain management in patients with opioid tolerance. US Pharmacist. 2017;42(3):28-32.
88. Sehgal N, Smith HS, Manchikanti L. Peripherally acting opioids and clinical implications for pain control. Pain Physician. 2011;14(3):249-258.
89. Kennedy-Hendricks A, Barry CL, Gollust SE, Ensminger ME, Chisolm MS, McGinty EE. Social Stigma Toward Persons With Prescription Opioid Use Disorder: Associations With Public Support for Punitive and Public Health-Oriented Policies. Psychiatr Serv. 2017;68(5):462-469. doi:10.1176/appi.ps.201600056
90. Barry CL, Kennedy-Hendricks A, Gollust SE, et al. Understanding Americans’ views on opioid pain reliever abuse. Addiction. 2016;111(1):85-93. doi:10.1111/add.13077
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