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