Aleksander Shalshin, MD, CCHP is the former Deputy Medical Director Correctional Health Services for the City of New York Department of Health currently in private practice. This post is based on his session “Pain Management in Patients with Substance Use Disorders” that took place at the 2015 NCCHC Spring Conference on Correctional Health Care.

Pain in some form is one of the most common symptoms that bring patients to nursing sick call. Even in traditional practice settings pain is often undertreated and many health care practitioners are particularly concerned about medicating a patient with a history of substance abuse. This is magnified in the correctional setting where substance use disorders are common in the incarcerated patient population. Yet, pain is a legitimate patient concern that we need to manage effectively.

Addiction Complicates Pain Treatment

Substance users present several challenges for pain treatment. First, use of psychoactive drugs results in the development of drug tolerance so pain medication at normal dose levels may be ineffective. Additionally, those with addictions appear to have decreased pain tolerance and, therefore, an increased perception of their pain experience.

The majority of inmates are immediately withdrawn from drugs and alcohol on entry into the criminal justice system. Withdrawal can be intensely uncomfortable, exacerbating any underlying chronic pain. Once withdrawn, practitioners can be concerned that pain treatment may contribute to a relapse.

Finally, pain is subjective, often without any objective confirming characteristics. Clinicians may not trust the patient to accurately describe the level of pain and assume ‘drug seeking’ behavior when patients with a history of substance abuse identify a need for pain treatment.

Pharmacologic Treatment Options

Opiates are the go-to drugs for pain treatment however other drug categories are underutilized and may be good options for this patient population. Nonsteroidal anti-inflammatory drugs (NSAIDs) and even tricyclic antidepressants have been helpful therapies. Depending on the source of pain, topical agents or muscle relaxants may be useful.

When opiates are necessary, they present some concerns in the correctional setting. Security of narcotics must be maintained in the medical unit and precautions against diversion during administration may need to be taken. For example, some settings crush and float narcotics so that the patient is less likely to ‘cheek’ pills for hoarding or barter on the prison black market. Liquid narcotics may also be used for the same reasons. Newer delivery methods such as the dissolving film available for buprenorphine (Suboxone) can also help assure the right patient gets the right dose.

Non Pharmacologic Treatment Options

Non pharmacologic treatments of pain are also often underutilized modalities; but, can play an important role in effectively treating chronic pain for this patient population. Depending on the resources in a particular correctional setting, physical therapy programs and exercise plans can be of benefit. Nurses can play an important role in initiating non pharmacologic treatment options for chronic pain. Treatments are discussed in more depth in this post on chronic pain and this post on managing arthritis behind bars.

Overcoming Resistance in the Correctional Setting

There can be significant resistance to pain management in the correctional setting. Officers and administration may harbor fear of diversion or manipulation in obtaining narcotics from health care staff. Even providers and nurses can have biases against pain treatment for patients with a history of a substance disorder. It takes a multidisciplinary process to be most effective. It also takes organization-wide education about pain treatment and how it is managed for this patient population. A good relationship among the disciplines of security and health care is a must.

Online Resources

American Society for Pain Management Nursing Position Statement: Pain Management in Patients with Substance Use Disorders

Pain Management in Patients with Substance-Use Disorders (American College of Clinical Pharmacology)

What have been your experiences with pain management for inmate-patients with history of a substance use disorder? Share your thoughts in the comments section of this post.

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