Substance misuse: acute pain management

Inadequate acute pain management increases likelihood of: 

• delayed recovery
• relapse to addiction
• recourse to illicit drug use

Risks to acute pain management in current opioid addicts include:

• Self-discharge because of poor analgesia
• Self-medication
• Sedation/overdose when tolerance to opioids is uncertain and when patients are using additional centrally active medications
• Diversion and misuse of drugs prescribed for acute pain

Principles of good pain management are underpinned by: 

• Empathic communication with the patient and reassurance that pain will be managed optimally
• Comprehensive assessment including physical and emotional comorbidities
• Liaison with other healthcare providers and those supporting the patient
• Objective confirmation of substance misuse
• Prompt provision of appropriate opioid therapy to avoid withdrawal
• Assessment and management of anxiety
• Use of multimodal analgesia including analgesic drugs of different classes, local anaesthesia and general measures to minimise pain
• Clear plan for dose tapering as acute pain subsides

Acute pain management in patients receiving opioid substitution therapy (OST)

• Patients need on-going reassurance that their pain will be assessed and managed appropriately
• OST used to attenuate opioid withdrawal does not provide analgesia for acute pain
• The existing opioid substitution regimen should be continued
• Opioids for analgesia need to be prescribe in addition to the patient’s maintenance regimen
• The patient on substitution therapy is likely to be tolerant to the effects of opioids so may need larger than usual doses
• Patients may have increased pain sensitivity associated with their prolonged exposure to opioids
• Communication with other members of healthcare team including drug services and the patient’s GP must be maintained

For patients on methadone: 

• Split the dose and administer twice or three times daily
• Titrate additional analgesia to effect

For patients on buprenorphine: 

• Split the dose and administer twice or three times daily
• Titrate additional analgesia or
• Discontinue and provide alternative analgesia
• Change to methadone

Acute pain management in patients in recovery from opioid addiction: important considerations

• Risk of relapse may occur both with use of opioids AND under-treatment of pain
• Use non-opioid interventions where possible
• Careful explanation of the risks and benefits of the proposed treatment plan should be discussed with the patient
• Anxiety should be assessed and managed, if necessary with medication
• Patients may have strongly held beliefs regarding opioid therapy and these should be respected