How to manage opioid use for pain control in wound care, including wound packing, in a patient with a history of Substance Use Disorder (SUD)?

Managing Opioid Use for Pain Control During Wound Care in Patients with SUD

For patients with a history of substance use disorder (SUD) requiring pain management during wound packing, a multimodal approach using both non-opioid and carefully monitored opioid therapies should be implemented, with buprenorphine as the preferred opioid option when appropriate. 1

Risk Assessment and Stratification

Before initiating pain control for wound care in patients with SUD history:

• Use validated screening tools to assess current risk of opioid misuse:

  • Single-question drug screen: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" (100% sensitivity, 73.5% specificity) 2
  • ASSIST, AUDIT, DAST, or CAGE-AID for more comprehensive screening 2

• Identify risk factors for opioid misuse:

  • Younger age
  • Family history of substance use disorders
  • Childhood trauma
  • Personal/family psychiatric history
  • History of motor vehicle collisions 2

Pain Management Algorithm for Wound Care

First-Line Approach (Mild to Moderate Pain)

1. Non-opioid analgesics:

   • NSAIDs (if no contraindications)
   • Acetaminophen (up to 3000mg/day)
   • Topical anesthetics (lidocaine gel/spray applied 15-20 minutes before wound care)

2. Non-pharmacological interventions:

   • Timing wound care to coincide with peak effect of regular pain medications
   • Distraction techniques
   • Relaxation breathing
   • Adequate pre-procedural explanation

Second-Line Approach (Moderate to Severe Pain)

1. For patients already on buprenorphine maintenance:

   • Continue scheduled buprenorphine doses (never withhold as this can worsen pain and trigger withdrawal) 1
   • Consider increasing buprenorphine dose in divided doses (4-16mg daily) 1
   • Add non-opioid analgesics as adjuncts 1

2. For patients not on maintenance therapy:

   • Consider short-term buprenorphine for pain control (4-8mg sublingually) 1
   • Monitor closely for sedation, especially when combining with other CNS depressants 1, 3

Third-Line Approach (Severe Pain)

1. When maximum buprenorphine dose is reached or ineffective:
   • Add high-potency opioids like fentanyl or hydromorphone 1
   • Use the lowest effective dose and shortest duration possible
   • Implement strict monitoring protocols including:
     • Frequent vital sign checks
     • Sedation assessment
     • Respiratory monitoring

Special Considerations

• Risk-benefit framework: A patient's history of addiction is not an absolute contraindication to receiving controlled substances for pain management 2

• Communication strategy: Discuss pain management plan openly and non-judgmentally as a safety issue 2

• Documentation requirements:

  • Obtain signed release for information exchange between providers if patient is in an opioid treatment program 2
  • Document risk assessment, treatment plan, and monitoring strategy

• Monitoring for concerning behaviors:

  • Differentiate between pseudo-addiction (behaviors due to undertreated pain that resolve with effective pain management) and true addiction behaviors 2
  • Monitor for signs of opioid-induced hyperalgesia, which may paradoxically increase pain sensitivity 3

Pitfalls to Avoid

1. Undertreatment of pain due to stigma can lead to:

   • Poor wound healing
   • Increased patient distress
   • Damaged therapeutic relationship
   • Potential for patients to seek illicit substances for relief 1

2. Abrupt discontinuation of opioids in physically dependent patients can trigger withdrawal, characterized by:

   • Restlessness, lacrimation, rhinorrhea, perspiration
   • Irritability, anxiety, backache, joint pain
   • Abdominal cramps, insomnia, nausea, vomiting 3

3. Overreliance on opioids without utilizing multimodal approaches

4. Failure to coordinate care with addiction treatment providers when applicable

By implementing this structured approach to pain management during wound care for patients with SUD history, clinicians can effectively control pain while minimizing risks of opioid misuse, withdrawal, and inadequate analgesia.