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In this chapter, we address substance use, the final topic for which future clinicians will need considerable mastery in handling mental health problems in medical settings. We’ll focus mainly on prescription-based disorders where the prescribing clinician has great control. Physicians unfortunately received little clinical training in chronic pain or in using opioids when in medical school or in most residencies, just one among many factors contributing to the current opioid crisis.

The Mental Health Care Model (MHCM) from Chapter 3 provides the overarching structure for managing prescription substance problems, including chronic pain. In this chapter, we’ll address the pharmacologic and related nonpharmacologic management of patients with problematic substance use. Let’s start with the opioid crisis, the worst of the prescription drug problems.



Considerable research shows there is little, if any, clinically significant benefit for opioid use in chronic noncancer pain.1-4 The Centers for Disease Control and Prevention (CDC) has recently underscored this fact, including that opioids should be prescribed for acute pain only and for no more than 3 to 7 days.1 For the unfortunate millions of people already addicted to or otherwise dependent on chronic opioid use, the CDC advises that the safe dose is no more than 50 morphine milligram equivalents (MME) per day, and that the maximum acceptable dose is 90 MME each day; more on how to calculate MME shortly. Unfortunately, we have seen people taking as much as 2200 MME and commonly see them taking 200 to 400 MME. These are lethal amounts for someone not accustomed to this high dose. For example, if a teenager steals them from an addicted parent and takes the same dose written on the bottle for their parent, it could be lethal.

You will, we believe, be encouraged to learn that there are effective ways to manage these patients. Informed by a rich body of research from psychiatry, multidisciplinary pain management, and primary care,5-15 the authors’ research group identified an evidence-based model for medical physicians and other clinicians, the MHCM, which you’ve already learned in Chapter 3. It is designed to guide clinicians in conducting mental health care in medical settings. This model includes treating chronic pain and co-occurring mental disorders, reducing and discontinuing opioids while replacing them with something effective, and handling patients demanding more narcotics.13,14,16-20 In addition to demonstrating that it is a very effective model to care for patients, we also have shown it is easily learned.16,21


Many opioid prescriptions are “misused,” which we define as use for nonprescribed reasons such as for recreation, to satisfy an addiction, to self-treat one’s pain, to give to someone else, or to sell.22 Importantly, there is no agreed-upon definition of misuse, abuse, or addiction,23...

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