What are non-addictive pro re nata (PRN) medications for individuals with addiction?

From the Guidelines

For individuals with a history of addiction, non-addictive PRN medication options such as non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, acetaminophen, and certain antidepressants like selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) should be considered as first-line treatments. These medications have been shown to be effective for pain management without the risk of addiction 1. NSAIDs, for example, have anti-inflammatory and antipyretic properties, and their use is limited to patients not at risk for coronary artery disease. Antidepressants, on the other hand, exert analgesic effects by enhancing monoaminergic neurotransmission, and there is strong evidence for their analgesic effects 1.

Some key points to consider when using these medications include:

• Following recommended dosages to minimize the risk of side effects
• Being aware of potential side effects, such as gastrointestinal and cardiovascular adverse effects with NSAIDs, and cardiovascular side effects with certain antidepressants
• Maintaining open communication with healthcare providers about effectiveness and any concerns that arise
• Considering alternative treatments, such as physical therapy, exercise, stress management, and cognitive behavioral therapy, which have also been proposed for the management of chronic pain 1

It's also important to note that the use of opioids should be initiated at the lowest possible dose to achieve acceptable analgesia and patient goals, and patients who have been taking other analgesics may continue these analgesics after opioid initiation if they provide additional analgesia and are not contraindicated 1. However, for patients with a substance use disorder, clinicians should collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management 1.

In terms of specific medications, ibuprofen (400-800mg every 6-8 hours) or naproxen (220-500mg every 12 hours) are effective options for pain management, and acetaminophen (500-1000mg every 4-6 hours, not exceeding 4000mg daily) is another safe pain reliever. For anxiety, hydroxyzine (25-50mg every 6 hours as needed) can provide relief without the risks associated with benzodiazepines. Promethazine (12.5-25mg every 4-6 hours) or ondansetron (4-8mg every 8 hours) can address nausea without addiction concerns. For insomnia, options include melatonin (3-10mg at bedtime), trazodone (25-100mg at bedtime), or diphenhydramine (25-50mg at bedtime) 1.

From the FDA Drug Label

THE POTENTIATING ACTION OF HYDROXYZINE MUST BE CONSIDERED WHEN THE DRUG IS USED IN CONJUNCTION WITH CENTRAL NERVOUS SYSTEM DEPRESSANTS SUCH AS NARCOTICS, NON-NARCOTIC ANALGESICS AND BARBITURATES. Since drowsiness may occur with use of this drug, patients should be warned of this possibility and cautioned against driving a car or operating dangerous machinery while taking hydroxyzine.

Non-addictive PRN medicines for addicts may include hydroxyzine 2, as it is not a narcotic or opioid. However, it is crucial to note that hydroxyzine can potentiate the effects of central nervous system depressants, and its use should be cautious, especially in patients with a history of addiction.

• Key considerations:
  • Dose reduction may be necessary when used with other central nervous system depressants.
  • Monitoring for signs of overdose, such as respiratory depression, is essential.
  • Patient education on the risks of combining hydroxyzine with other substances, including alcohol, is crucial. It is essential to consult a healthcare provider before prescribing any medication, especially for individuals with a history of addiction.

From the Research

Non-Addictive PRN Medicines for Addicts

• The use of PRN medications in psychiatric inpatients is a common practice, but there is a lack of published evidence supporting their use 3.
• Alternative non-pharmacological treatment options to PRN medication are effective and associated with fewer side-effects 3.
• Gabapentin and pregabalin are two medications that have been used off-label for psychiatric indications, including anxiety and insomnia, but their safety and efficacy are still being studied 4.
• Hydroxyzine is another medication that has been studied for its efficacy and safety in treating insomnia in adults, with mixed results 5.

Medication Options

• Gabapentin and pregabalin may be considered as options for treating anxiety, but their use should be justified and monitored closely 4.
• Hydroxyzine may be considered as a short-term treatment option for adults with insomnia, but more studies are needed to establish its long-term efficacy and safety 5.
• Non-pharmacological interventions, such as behavioral therapies, should also be considered as alternatives to PRN medications 3, 6.

Administration and Documentation

• The administration of PRN medications should be guided by clear protocols and documentation, including the reason for administration and the patient's response to the medication 3, 6.
• The lack of documentation surrounding PRN medication administration is a concern and should be addressed to ensure patient safety and inform best clinical practice 6.