Who should manage pain medication for a patient with an overdose?

Pain Management for Patients with Overdose: Who Should Manage?

Pain management for a patient with an overdose should be managed by a specialized team including addiction medicine specialists, pain specialists, and/or palliative care specialists in collaboration with the primary care provider.

Understanding the Complexity of Pain Management Post-Overdose

Managing pain in a patient who has experienced an overdose requires specialized expertise due to several critical factors:

1. Risk Assessment: Patients with a history of overdose have demonstrated a significant mortality risk that requires specialized monitoring and intervention
2. Substance Use Evaluation: Determining whether the patient has an underlying substance use disorder that contributed to the overdose
3. Pharmacological Expertise: Understanding complex drug interactions, especially with medications used to treat opioid use disorder

Recommended Management Approach

Immediate Post-Overdose Care

• For severe respiratory depression (respiratory rate <8/min), treatment should include:
  • Stopping opioid treatment
  • Stimulating the patient
  • Oxygen therapy
  • Naloxone administration 1
  • Transfer to intensive care if necessary

Collaborative Management Team

1. Addiction Medicine/Substance Use Specialist

   • Essential for patients with suspected substance use disorders
   • Guidelines specifically recommend: "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

2. Pain Management Specialist

   • Indicated when pain is likely to be relieved with specialized interventions
   • Provides expertise in complex pain management scenarios 1
   • Can assist with opioid rotation, dose adjustments, and alternative pain management strategies

3. Palliative Care Specialist

   • Particularly valuable for complex pain management cases
   • Recommended for consultation when initiating or rotating to complex medications like methadone 1

4. Primary Care Provider

   • Maintains continuity of care
   • Coordinates with specialists
   • Manages ongoing monitoring and follow-up

Special Considerations

For Patients on Opioid Agonist Therapy (OAT)

If the patient is on methadone or buprenorphine maintenance:

• Continue the usual dose of OAT
• Verify doses with the patient's methadone clinic or prescribing physician
• Notify the addiction treatment program about hospitalization and discharge
• Use conventional analgesics, including opioids if necessary, with appropriate dosing adjustments 1

For Patients with Renal/Hepatic Impairment

• More frequent clinical observation and dose adjustment is required
• Consider rotation to medications with safer profiles in organ dysfunction
• Avoid certain opioids (morphine, meperidine, codeine, tramadol) in renal impairment 1

Monitoring and Follow-Up

• Regular reassessment at least every 3 months for patients on long-term opioid therapy
• More frequent monitoring for high-risk patients (history of overdose, mental health conditions, substance use disorders)
• Urine drug testing as appropriate to monitor adherence and identify potential misuse 1
• Naloxone rescue kit should be prescribed and patients/caregivers educated on its use 1

Common Pitfalls to Avoid

1. Abandonment of patients with concerning behaviors

   • Unexpected urine drug test results or concerning behaviors should not lead to patient discharge from practice
   • This violates the principle of non-abandonment and undermines the therapeutic relationship 1

2. Inadequate pain control in patients with substance use disorders

   • Patients with addiction history should be reassured that their history will not prevent adequate pain management
   • Higher opioid doses at shorter intervals may be needed due to cross-tolerance 1

3. Failure to provide overdose prevention education

   • Patients and caregivers should be educated about opioid overdose and naloxone use
   • Safe storage of medications away from individuals at risk of misuse 1

By implementing this collaborative approach with appropriate specialist involvement, patients with a history of overdose can receive effective pain management while minimizing risks of recurrent overdose and optimizing outcomes related to morbidity, mortality, and quality of life.