What are the guidelines for pain management in patients with a history of addiction?

Pain Management in Patients with Known Addiction

Patients with a history of addiction require aggressive, multimodal pain treatment that addresses their baseline opioid requirements first, followed by additional analgesia using scheduled short-acting opioids at higher doses and shorter intervals than opioid-naïve patients, while avoiding the common pitfall of undertreatment due to unfounded fears of precipitating relapse. 1, 2

Critical Understanding: Pain and Addiction Interact

• Patients with addiction have a "syndrome of pain facilitation" where their pain experience is worsened by subtle withdrawal syndromes, intoxication, withdrawal-related sympathetic arousal, sleep disturbances, and affective changes 1
• Patients with opioid use disorder demonstrate lower pain tolerance than peers in remission 1
• The presence of acute pain decreases the euphoric qualities of opioids, making therapeutic use less likely to trigger relapse 2
• Undertreating pain can lead to decreased responsiveness to opioid analgesics, making subsequent pain control more difficult 2

Four Common Misconceptions Leading to Undertreatment

Healthcare providers must recognize and reject these dangerous myths 1:

1. Maintenance opioids (methadone/buprenorphine) provide analgesia - They do not; methadone's analgesic effect lasts only 6-8 hours despite its 30-hour half-life for addiction treatment 2, 3
2. Using opioids for analgesia will cause addiction relapse - This fear is exaggerated and leads to harmful undertreatment 1
3. Adding opioids to maintenance therapy causes respiratory depression - While monitoring is required, this fear should not prevent adequate pain control 1
4. Pain complaints are manipulation to obtain drugs - "Drug-seeking" may actually represent pseudoaddiction (seeking relief from uncontrolled pain) or therapeutic dependence (fear of pain or withdrawal) 2, 3

Recommended Treatment Algorithm

For Patients on Opioid Agonist Therapy (Methadone/Buprenorphine)

Step 1: Verify and Continue Maintenance Therapy

• Confirm the patient's current maintenance dose with their provider or program before initiating pain management 2
• Reassure patients that their addiction treatment will continue and that pain will be aggressively treated to decrease anxiety 2

Step 2: Optimize Maintenance Dosing for Analgesia

• Consider splitting daily methadone into 6-8 hour intervals (three times daily) rather than once daily to leverage its shorter analgesic duration 2, 3
• Add 5-10% of the current dose for afternoon and evening doses 3
• Obtain baseline EKG to assess QTc interval before any methadone adjustment 3

Step 3: Add Short-Acting Opioids

• Use scheduled (not as-needed) dosing of short-acting opioid analgesics at higher doses and shorter intervals than typically used for opioid-naïve patients 2
• Appropriate options include morphine, hydromorphone, and oxycodone 2
• Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they precipitate acute withdrawal 2

Step 4: Implement Aggressive Non-Opioid Interventions

• Add NSAIDs and acetaminophen 2
• Consider adjuvant analgesics that enhance opioid effects (e.g., tricyclic antidepressants) 2

For Patients NOT on Maintenance Therapy

Step 1: Initiate Methadone Maintenance

• Establish methadone maintenance therapy to address baseline opioid requirements before attempting to achieve analgesia 2
• Once stabilized, add short-acting opioid analgesics for pain control 2

Step 2: Follow Steps 3-4 Above

For Chronic Pain Management

Prioritize non-opioid approaches first 3:

• Non-pharmacologic therapies (physical therapy, cognitive behavioral therapy)
• Non-opioid pharmacologic therapies (NSAIDs, acetaminophen, gabapentinoids, antidepressants)
• Only consider additional opioid therapy if non-opioid multimodal therapy has been optimized and failed 3

Essential Monitoring and Safety Measures

Establish Clear Treatment Agreements 2:

• Document the number of pills dispensed, frequency of use, and expected duration of treatment
• Set clear functional goals for pain and function, not just pain reduction 3

Intensive Monitoring Requirements 2, 3:

• Monitor level of consciousness and respiration frequently when adding opioids to methadone therapy
• Evaluate benefits and harms within 1-4 weeks of any dose change, and every 3 months thereafter 3
• Review prescription drug monitoring program (PDMP) data before changes and periodically 3
• Consider urine drug testing to assess for prescribed medications and illicit substances 3

Prescribe Naloxone 3:

• All patients with substance use disorder history should receive naloxone given their increased overdose risk

Use the "Four A's" for Treatment Monitoring 1:

• Analgesia (pain relief)
• Activities of daily living (psychosocial functioning)
• Adverse effects (side-effects)
• Aberrant drug taking (addiction-related outcomes)

Multidisciplinary Team Approach

Engage integrated care teams for patients with co-occurring substance use disorders 1:

• Consultation with addiction specialists when available
• Behavioral health specialists (social workers, psychologists) to address life events impacting pain management 1
• Palliative care specialists for complex pain management 1
• Frequent communication between patient, providers, and support system at appropriate health literacy levels 1

Critical Pitfalls to Avoid

• Never allow pain to reemerge before administering the next dose - this causes unnecessary suffering and increases tension between patient and treatment team 2
• Do not confuse physical dependence and tolerance with addiction - these are predictable physiologic consequences of opioid exposure and do not indicate maladaptive behavior 1
• Avoid "opiophobia" - the exaggerated tendency to undermedicate patients with opioid analgesics due to unfounded fears 1
• Do not abruptly discontinue opioids in physically-dependent patients; taper by 25-50% every 2-4 days while monitoring for withdrawal 4

Special Considerations for Hospitalized Patients

• Patient-controlled analgesia (PCA) may be considered to minimize anxiety about pain management 2
• Verify maintenance dose before surgery or procedures 2
• Continue maintenance therapy throughout hospitalization 2