Patients with substance misuse

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 such as trauma, surgery etc.
  • Pain and opioid addiction have neurobiological commonality.
  • A patient receiving maintenance opioid therapy with methadone or buprenorphine will not derive analgesia from their maintenance dose 1.
  • 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 and patients at a higher risk of opioid misuse may experience more subjective pain 2.
  • The patient may have previously self-medicated to remove pain and psychological distress.
  • Although patients may have poor acceptance of non-pharmacological interventions for pain control, there is some evidence that psychological therapies can aid in reducing both pain interference and opioid misuse in those who are using opioids in a harmful manner 3,4.
  • Frequent episodes of intoxication/withdrawal may alter the intensity of the pain experience.
  • Addiction is associated with sleep disturbance which may exacerbate chronic pain 5.
  • Depression and anxiety commonly co-occur with addiction 6. 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. I.e., are at high risk from physical problems that require analgesia.

 

References:

  1. Krčevski Škvarč, N, Morlion, B, Vowles, KE, et al. European clinical practice recommendations on opioids for chronic noncancer pain – Part 2: Special situations. Eur J Pain. 2021; 25: 969–985.
  2. Robert N. Jamison, Carol L. Link, Lisa D. Marceau, Do Pain Patients at High Risk for Substance Misuse Experience More Pain? A Longitudinal Outcomes Study, Pain Medicine, Volume 10, Issue 6, September 2009. 1084–1094.
  3. Vowles KE, Witkiewitz K, Cusack KJ, Gilliam WP, Cardon KE, Bowen S, Edwards KA, McEntee ML, Bailey RW. Integrated Behavioral Treatment for Veterans with Co-Morbid Chronic Pain and Hazardous Opioid Use: A Randomized Controlled Pilot Trial. J Pain. 2020 Jul-Aug;21(7-8):798-807.
  4. Garland EL, Brintz CE, Hanley AW, et al. Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2020;180(1):91–105.
  5. Hartwell EE, Pfeifer JG, McCauley JL, Moran-Santa Maria M, Back SE. Sleep disturbances and pain among individuals with prescription opioid dependence. Addict Behav. 2014 Oct;39(10):1537-42.
  6. Sullivan, M. D. (2018). Depression effects on long-term prescription opioid use, abuse, and addiction. The Clinical journal of pain, 34(9), 878-884.

Other resources in this section

Opioids Aware homepage