How do you manage an opioid-seeking patient?

Managing Opioid-Seeking Patients

The management of opioid-seeking patients requires distinguishing between legitimate pain needs and problematic drug-seeking behavior, while assessing for opioid use disorder and providing evidence-based treatment when indicated. 1

Assessment and Identification

• Conduct a careful clinical assessment for objective evidence of pain, which decreases the chance of being manipulated by drug-seeking behavior and supports appropriate use of opioid analgesics when needed 1
• Distinguish between different types of drug-seeking behaviors:
  • Pseudoaddiction: behaviors arising when patients cannot obtain tolerable pain relief 1
  • Therapeutic dependence: behaviors reflecting efforts to maintain comfort and prevent withdrawal 1
  • Pseudo-opioid resistance: reporting persistent pain to prevent reduction in effective doses 1
• Assess for opioid use disorder using DSM-5 criteria or arrange for evaluation by a substance use disorder specialist 1
• Use screening tools such as prescription monitoring programs to identify patterns of prescription usage and reduce doctor shopping 2
• Implement urine drug testing from the beginning of treatment to monitor adherence and decrease prescription drug abuse 2

Management Approach

For Patients with Legitimate Pain Needs:

• Continue the usual dose of opioid agonist therapy (OAT) if the patient is already receiving maintenance treatment 1
• Verify maintenance doses with the patient's methadone clinic or prescribing physician 1
• Reassure patients that their addiction history will not prevent adequate pain management 1
• For acute pain in patients on OAT:
  • Use conventional analgesics, including opioids when necessary 1
  • Recognize that cross-tolerance may necessitate higher opioid doses at shorter intervals 1
  • Write continuous scheduled dosing orders rather than as-needed orders 1
  • Avoid mixed agonist-antagonist opioids that may precipitate withdrawal 1

For Patients with Opioid Use Disorder:

• Offer or arrange evidence-based treatment, preferably medication-assisted treatment with buprenorphine or methadone maintenance therapy in combination with behavioral therapies 1
• Consider oral or long-acting injectable naltrexone as an alternative for non-pregnant adults 1
• For pregnant women with opioid use disorder, offer medication-assisted therapy with buprenorphine (without naloxone) or methadone 1
• Consider offering naloxone for overdose prevention 1
• For patients with problematic opioid use that doesn't meet criteria for opioid use disorder, consider tapering and discontinuing opioids 1

Special Considerations

• Recognize that patients dependent on opioids may be perceived as demanding when hospitalized with acute pain due to:
  • Distrust of the medical community
  • Concern about being stigmatized
  • Fears of undertreatment or discontinuation of OAT 1
• Address patient anxiety by discussing the pain management plan in a nonjudgmental manner 1
• Be aware that patients receiving OAT typically receive treatment doses that block most euphoric effects of additional opioids, theoretically decreasing the likelihood of opioid analgesic abuse 1
• Physicians prescribing opioids should identify treatment resources for opioid use disorder in their community and work to ensure sufficient treatment capacity 1
• Physicians not certified to provide buprenorphine should consider obtaining a waiver from SAMHSA, especially in communities with insufficient treatment capacity 1

Pitfalls to Avoid

• Avoid allowing concerns about being manipulated to cloud clinical judgment about the patient's need for pain medications 1
• Recognize that undertreating acute pain may lead to decreased responsiveness to opioid analgesics, making subsequent pain control more difficult 1
• Avoid discontinuing OAT during acute pain episodes, as this can worsen pain due to increased sensitivity associated with opioid withdrawal 1
• Don't use mixed agonist-antagonist opioids in patients on OAT as they may precipitate withdrawal 1
• Avoid assuming that all drug-seeking behaviors indicate addiction, as they may represent appropriate responses to inadequately treated pain 1

By following these guidelines, clinicians can effectively manage opioid-seeking patients while providing appropriate pain relief when needed and offering evidence-based treatment for those with opioid use disorder.