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