Under ordinary conditions, one person’s pain might well be another person’s small annoyance. Add in undiagnosed psychiatric disorders, substance use issues, or the lack of safe shelter for the night—or even all three—and something that was once tolerable might suddenly be unbearable.
Although some people who are experiencing homelessness and enduring physical pain will visit a doctor and get a prescription for a chronic condition, just as many choose to self-medicate. Self-medicating may stem from a desire to avoid doctors’ offices or because it is easier, or, for that matter, because they are using illicit substances. It is a worrying trend for several reasons, not least of which is the risk of problems associated with comorbid substance use.
Patient's Pain Is Not Typically Assessed
Lara Dhingra, Ph.D., director of the Health Disparities and Outcomes Research Program at the MJHS Institute for Innovation in Palliative Care and lead author of “Epidemiology of Pain Among Outpatients in Methadone Maintenance Treatment Programs,” says that the use of opioids for pain has never been a long-term adaptive strategy, and adds that, although there has not been much research done on the issue, there is plenty of clear evidence that it is happening. It is a reality, she says, that underscores the fact that “pain is prevalent in populations with substance use disorders.” However, pain is not something that is routinely recognized, assessed, and managed in substance use treatment programs.
“So even if these folks were engaged in formal programs,” says Dhingra, “they’re not likely to have their pain assessed in a comprehensive way.” For that matter, there are not really any evidence-based guidelines on how to clinically treat or manage pain in populations with substance use disorders or dual diagnoses, says Dhingra, and there is room for research on optimal strategies for pain management in such populations—especially those who are experiencing homelessness, for whom there are additional challenges. Those individuals, who by and large are not “plugged in,” might not be aware of alternative treatment options with fewer side effects and a lower frequency of addiction, including nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, adjuvant antidepressants, and other pharmacological and integrative therapies.
“If someone isn’t hooked in with a medical provider or a comprehensive medical team or a medical home,” says Dhingra, “then there’s no one really monitoring patients to determine what their needs are, what their pain syndromes might be, and what strategies—both drug and non-drug—they may benefit from.”
Identifying the Pain's Source Is Difficult
Robert Schiller, M.D., does see such patients, but he recognizes that it can sometimes be challenging to determine actual medical issues. Schiller is chair of the Alfred and Gail Engelberg Department of Family Medicine at Mount Sinai Beth Israel Medical Center and chief medical officer of the Institute for Family Health (IFH). IFH treats some 80,000-plus low-income patients in the New York City area each year, including a number of individuals through Care for the Homeless, the federally funded program, at eight shelters, drop-in centers, and food pantries around Manhattan. Schiller says the IFH sees a variety of attempts to self-medicate for pain.
“It’s very hard to tease out pain from a host of other behavioral health problems,” he says. “People are in pain from isolation, from depression, from thought disorders. The fact is, people somaticize. For people in the homeless community, so many of their conditions are undifferentiated. The social determinants of their quality of life are intertwined with the physical dimensions of their health.” There can be a simple cause and effect: Schiller has observed that many of his long-time patients who have been experiencing homelessness for a while find that if their lives are spinning out of control, their pain is worse. As a result, applying the traditional medical model to this marginalized population is not always the best approach, says Schiller.
Solutions to Stop the Self-Managed Use of Opioids
The I-STOP/Prescription Monitoring Program (PMP) Registry, instituted in August of 2013, will play an important role in minimizing the self-managed use of opioids. Although Schiller says some health professionals see it as the "Big Brother" model of care, requiring doctors to check its database before writing a prescription is meant to cut down on the over-prescription of opioids.
“There are still too many places around the country that are giving out this stuff very liberally,” says Schiller, “and people know by word of mouth where they are.”
This article was published to highlight the November 2014 theme of Drug Use. Learn about SAMSHA's efforts to address prescription drug misuse and abuse and how medication-assisted treatment (MAT) is used to help people with opioid dependency.
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