Patients with substance misuse: general considerations
Considerations when prescribing for patients with a current or past history of substance misuse/in recovery from addiction
- 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