Substance misuse: chronic pain management

General considerations when managing chronic pain in the opioid addicted patient

• Pain management is underpinned by good communication with the patient and reassurance that pain will be managed optimally
• Medications should be part of a wider plan to support self management
• Mental health diagnoses and emotional difficulties need to be identified and managed
• Physical rehabilitation, exercise and psychological treatments are essential to support chronic pain management
• Close collaboration with drug services and the patient’s GP is mandatory (including confirmation of substance misuse)

Long-term opioid prescribing in the opioid addicted patient: important considerations

• Patient selection
  • Patients with addiction are more likely to be prescribed opioids than non-addicted patients
  • Addiction is a risk factor for prescription opioid misuse/problematic use

• Untreated addiction is a barrier to chronic pain management
• Opioids prescribed for pain may be in whole or in part acting as maintenance treatment for opioid addiction
• Opioids may be used by a patient to attenuate unpleasant thoughts and feelings
• Opioids are poorly effective in chronic pain
• Close collaboration between primary care, secondary care and with drug addiction and recovery services is mandatory
• The risks of misuse and diversion should be assessed and monitored
• A structured approach to care is important including clear agreement regarding dose, short duration of prescriptions and frequent follow up

Chronic pain management in the patient receiving opioid substitution therapy: 

• Medications should be part of a wider plan to support self management
• Mental health diagnoses and emotional difficulties need to be identified and managed
• Physical rehabilitation, exercise and psychological treatments are essential to support chronic pain management
• Close collaboration with drug services and the patient’s GP is mandatory
• Regimens should avoid prescription of multiple opioids

For patients on methadone

• Split dose and give 12 hourly

For patients on Buprenorphine

• Split dose and give 8-12 hourly

Chronic pain management for patients in recovery from addiction: 

• 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

Opioid prescribing for patients in recovery from addiction: 

• Agree the treatment plan with the patient and other healthcare providers
• Agree the outcomes of treatment
• Consider a short trial of opioid eg, two weeks
• Assess risk to determine frequency of review
• For long-term prescribing use sustained release preparations eg, MXL 30 mg daily
• Do not exceed 120 mg/day morphine equivalent
• If opioids do not work STOP THEM!