Patients with substance misuse: general considerations

Considerations when prescribing for patients with a current or past history of substance misuse/in recovery from addiction

Key Points

• Poor understanding of addiction and stigma amongst healthcare professionals can be a barrier to optimal pain management.
• Concerns expressed by healthcare professionals include

– Addiction relapse
– Dangers of drug overdose when there is uncertainty regarding patients’ illicit drug doses
– Uncertainty in identifying drug-seeking behaviours in the substance-misusing patient.

• The addicted patient can benefit from opioid therapy for moderate/severe acute pain
• Pain and opioid addiction have neurobiologic commonality
• A patient receiving maintenance opioid therapy with methadone or buprenorphine will not derive analgesia from their maintenance dose.
• Patients on maintenance opioid regimens will be tolerant to the analgesic effects of opioids and may have a degree of increased pain sensitivity.
• Detailed assessment corroborated by other professionals involved in the patient’s care is mandatory
• Comprehensive communication within the health (and social) care team supports safe management
• See also sections on diagnosis, identification and risk populations and treatment and prevention.

Pain Experience in the Opioid Addicted Patient: General Considerations

• Any drug misuse may worsen the patient’s experience of pain
• The patient may have previously self medicated to remove pain and psychological distress
• Patient’s may have poor acceptance of non-pharmacological interventions for pain control
• Frequent episodes of intoxication/withdrawal may alter the intensity of the pain experience
• Addiction is associated with sleep disturbance which may exacerbate chronic pain
• Depression and anxiety commonly co-occur with addiction. These are important influences on the pain experience and need to be identified and managed accordingly.
• Patients with addiction are more likely to suffer from accidental/non-accidental injury and medical complications related to drug use ie, are at high risk from physical problems that require analgesia