What is the approach to managing pain in patients with opioid (narcotic) addiction?

From the Guidelines

Managing pain in patients with opioid addiction requires a balanced approach that addresses both pain control and addiction concerns, prioritizing non-opioid medications and involving addiction specialists when available. Start by validating the patient's pain while acknowledging their addiction history in a non-judgmental manner. Use multimodal analgesia, prioritizing non-opioid medications like acetaminophen (1000 mg every 6 hours, not exceeding 4000 mg daily), NSAIDs such as ibuprofen (400-600 mg every 6 hours) or ketorolac (30 mg IV initially, then 15-30 mg every 6 hours for short-term use), and adjuvant medications including gabapentin (300-600 mg three times daily), pregabalin (75-150 mg twice daily), or duloxetine (30-60 mg daily) 1. When opioids are necessary, continue the patient's maintenance therapy (methadone or buprenorphine) and add short-acting opioids for breakthrough pain, typically requiring higher doses due to tolerance. Monitor closely for signs of withdrawal, undertreated pain, and aberrant behaviors. Involve addiction specialists and pain management teams when available, and develop a clear treatment plan with defined boundaries. Non-pharmacological approaches like physical therapy, cognitive behavioral therapy, and relaxation techniques should be incorporated. This comprehensive strategy addresses the dual challenges of providing adequate pain relief while minimizing the risk of worsening addiction, recognizing that undertreated pain can trigger relapse in recovering patients 1.

Some key considerations include:

• The use of risk prediction instruments to assess the risk of opioid overdose, addiction, abuse, or misuse 1
• The effectiveness of risk mitigation strategies, including opioid management plans, patient education, urine drug screening, and use of prescription drug monitoring program data 1
• The importance of continued maintenance therapy with methadone or buprenorphine, and the addition of short-acting opioids for breakthrough pain 1
• The need for close monitoring and regular reassessment of treatment goals and risks 1

Overall, the goal is to provide effective pain management while minimizing the risks associated with opioid use, and to prioritize the patient's overall well-being and quality of life 1.

From the FDA Drug Label

Acute Pain Maintenance patients on a stable dose of methadone who experience physical trauma, postoperative pain or other acute pain cannot be expected to derive analgesia from their ongoing dose of methadone. Such patients should be administered analgesics, including opioids, in doses that would otherwise be indicated for non-methadone-treated patients with similar painful conditions Due to the opioid tolerance induced by methadone, when opioids are required for management of acute pain in methadone patients, somewhat higher and/or more frequent doses will often be required than would be the case for non-tolerant patients.

The approach to managing pain in patients with opioid (narcotic) addiction is to administer analgesics, including opioids, in doses that would otherwise be indicated for non-methadone-treated patients with similar painful conditions.

• Higher and/or more frequent doses of opioids may be required due to the opioid tolerance induced by methadone.
• Patients on a stable dose of methadone should not be expected to derive analgesia from their ongoing dose of methadone for acute pain. 2 2

From the Research

Approach to Managing Pain in Patients with Opioid Addiction

The approach to managing pain in patients with opioid addiction involves a combination of pharmacological and non-pharmacological interventions.

• Maintenance therapy, such as methadone and buprenorphine, is the backbone of pain management in opioid-addicted patients 3.
• Adjunctive treatments, including regional analgesia, non-opioid analgesia, antidepressants, and alternative therapies like acceptance and commitment therapy, biofeedback, and hypnosis, should be considered 3.
• Additional opioid medication may be necessary in some cases, but its use should be carefully managed to minimize the risk of relapse 3.

Chronic Pain Management

Chronic pain is a common comorbidity among individuals with opioid use disorder (OUD), but it is often not adequately managed in OUD treatment programs 4.

• A study found that two-thirds of patients with chronic pain reported that their pain was not managed through their OUD treatment program, and 47% reported worsening pain 4.
• Chronic pain was a primary factor in opioid relapse for 43.2% of patients, highlighting the need for effective pain management strategies in OUD treatment 4.

Nonpharmacological Interventions

Nonpharmacological interventions, such as acupuncture, massage, mindfulness, and relaxation techniques, may be effective in reducing acute pain in patients with opioid tolerance or opioid abuse 5.

• A scoping review identified a range of nonpharmacological interventions, including physical, psychological, and multimodal approaches, that may be used to manage acute pain in patients with opioid dependence or opioid tolerance 5.
• However, more primary research is needed to fully understand the effectiveness of these interventions 5.

Acute Pain Management

Managing acute pain in patients with OUD on medication can be complicated by patients' higher baseline pain sensitivity and need for higher opioid doses to achieve pain relief 6.

• A rapid review found that continuing methadone or buprenorphine during acute pain episodes may reduce the need for additional opioids, but the evidence is limited and more research is needed 6.
• Nonpharmacological interventions, such as those identified in the scoping review, may be useful in managing acute pain in patients with opioid tolerance or opioid abuse 5.