Abstract
Definitions
SUD: a maladaptive pattern of substance use leading to clinically significant impairment or distress.
Aberrant drug behaviors: medication-related behaviors that depart from strict adherence to the prescribed therapeutic plan of care.
Addiction: overwhelming involvement with the acquisition and use of a drug, characterized by loss of control, compulsive drug use, and use despite harm (see Fast Facts #68, 69).
Diversion: the illegal transfer of a pharmaceutical controlled substance from the person it was prescribed to another person for use. Patients with SUDs are at higher risk for diversion of opioids.
Risks of Opioid Therapy in Patients with a History of SUD
• Inability to achieve effective analgesia due to opioid tolerance.
• Adverse opioid effects when higher doses are used.
• Aberrant drug behaviors including drug diversion.
Patient Selection
The goal of analgesic therapy is to ensure that opioid prescribing is safe, effective, and does not contribute to worsening of an SUD. Opioids for acute severe pain (such as hospitalization for a broken bone) can be used in a closely monitored setting, no matter the history of SUD. Patient selection for opioid use in moderate-to-severe chronic pain is more complex and involves the interplay of the following:
• Prognosis of the serious illness. • Status of the SUD: in recovery versus active substance abuse. • Pain severity/risk of adverse opioid effects.
Except those with a limited prognosis (e.g., <2 months) or with an acute pain problem (e.g., bone fracture), we do not recommend starting opioids for patients who are actively using drugs to maintain an SUD (heroin, cocaine, methamphetamine, alcohol, and prescription drugs). Marijuana use should be evaluated on a case-by-case basis. Patients with a more distant history of SUD, those who are established in a substance abuse treatment program, and those with aberrant drug behaviors without evidence of an SUD should be evaluated carefully in terms of risk. Long-term opioids for selected nonlife-threatening conditions are potentially harmful (e.g., chronic headaches, fibromyalgia, chronic lower back pain, and osteoarthritis). 1 The risks of initiating opioid therapy in these patients may outweigh the benefits, especially if the patient has a longer prognosis and/or is exhibiting aberrant drug behaviors. Other pain relieving methods such as physical therapy and non-opioid analgesics should be used first.
Initial Pain Assessment
The initial assessment is similar to patients without previously identified SUDs, in which a comprehensive identification of the type of pain and its etiology is pivotal. Clinicians should:
• Perform a careful history of past, present, and quantity of tobacco, alcohol, recreational drug use, and prescription drug misuse. Use a validated screening tool to stratify risk of opioid misuse (Fast Fact #244). • Differentiate active substance use, at-risk behaviors, recovery, and enrollment in a treatment program. • Evaluate for potentially treatable psychiatric disorders such as depression and anxiety, which are common in both chronic pain and those with SUDs. • Assess for current use of sedatives (like muscle relaxants and benzodiazepines).
Initial Opioid Management
• Describe treatment expectations. Opioids will not completely eradicate pain, and their effect on both pain and function may only be short term. 1
• Although access can be limited, ideally patients with an active SUD and chronic pain should be referred to an addiction medicine specialist. 1 Multidisciplinary teams engaging social workers and mental health professionals can enhance treatment adherence and social support. 2 See Fast Fact #127.
• Use an opioid agreement at initiation of therapy to delineate safe practices and when opioids would be discontinued. Specify the consequences related to the presence of illicit drugs on a urine drug screen, requests for early refills, or attempts to obtain controlled substances from other clinicians.
• For patients on maintenance therapy for opioid addiction such as buprenorphine or methadone, discuss the care plan with the addiction treatment program. If opioids are agreed to be appropriate, be prepared that higher doses may be needed to achieve therapeutic expectations.3,4
• Published data and expert opinion on the use of long acting opioids in SUDs offer conflicting advice.1,2,5 One study has shown a higher rate of unintentional overdose with long-acting opioids, most pronounced in the first two weeks after initiation. 6 This may suggest that clinicians have a difficult time identifying patients who misuse long-acting opioids.
• A one-to-two-week course of short-acting opioids with a follow-up date less than two weeks may be the safest initial regimen. If available, offer a rescue naloxone prescription and opioid overdose education.
• Combination opioid agonist/antagonist therapy (e.g., oxycodone/naloxone, buprenorphine/naloxone) under the guidance of a pain specialist has shown promise in the treatment of patients with SUD.