Managing acute pain in patients with opioid-use disorder
When managing acute pain in patients with opioid-use disorder, seek early advice from a specialist pain or addiction medicine physician or an acute pain service, and liaise closely with the patient’s usual care provider.
Patients with opioid-use disorder are likely to be opioid tolerant and the aims of treatment are similar—to provide effective analgesia and to prevent opioid withdrawal (see Overview of managing acute pain in opioid-tolerant patients for further advice). Acute pain management of patients with opioid-use disorder may be further complicated by:
- psychological and behavioural characteristics of opioid-use disorder
- complex psychological comorbidities
- concurrent use of illicit opioids
- concurrent medications for substance-use disorder (eg buprenorphine, methadone); see also Overview of management of disorders of opioid use
- sequelae of substance abuse (eg organ impairment, infectious diseases)
- misuse of other substances (eg amfetamines, alcohol, benzodiazepines, cocaine, cannabis)
- pejorative attitudes of some staff towards the patient with opioid-use disorder.
Identifying patients with opioid-use disorder can be problematic, and an accurate history can be difficult to obtain. In a nonjudgemental way, ask the patient about all drugs and illicit substances they are currently using. Always consider nonopioid analgesics (eg nonpharmacological techniques, NSAIDs, local anaesthetics) before initiating opioids.
In emergency situations (eg severe trauma, surgical emergency) or in other situations where the total daily dose of opioid cannot be verified from an independent source, opioid administration via patient-controlled analgesia (PCA) may be preferable. Ideally, opioids should be administered in an inpatient setting under the supervision of a specialist pain or addiction medicine physician or an acute pain service.
In addition to acute pain management, associated affective disorders and behavioural disturbances need to be managed. Beware of drug diversion tactics and the use of illicit drugs while in hospital—medications should be administered in a secure environment.
When possible, avoid prescribing opioids on discharge for ongoing management of acute pain. Some patients may elect to enter an opioid substitution program while they are still in hospital. If this is not possible, and an opioid is required upon discharge, only prescribe or dispense small quantities.