How to manage an adult patient with a history of chronic pain and potential substance abuse who is requesting more pain medication?

Managing Patients with Chronic Pain and Potential Substance Abuse Requesting More Pain Medication

The most critical first step is to conduct a careful clinical assessment for objective evidence of pain while explicitly reassuring the patient that their pain will be aggressively treated and that concerns about addiction will not prevent adequate pain management. 1

Distinguish Between True Pain and Drug-Seeking Behavior

The key challenge is differentiating legitimate pain from manipulative drug-seeking, which requires understanding several important concepts:

• Pseudoaddiction occurs when patients exhibit drug-seeking behaviors (requesting higher doses, seeking alternate sources) because their pain is undertreated, not because of addiction—these behaviors resolve with adequate pain relief 1
• Therapeutic dependence describes patients with adequate pain control who continue requesting medication because they fear pain recurrence or withdrawal symptoms, not because of addictive disease 1
• Pseudo-opioid resistance occurs when patients with adequate pain control report persistent severe pain to prevent dose reductions of currently effective medications 1

Reports of acute pain with objective findings are less likely to be manipulative than reports of chronic pain with vague presentations. 1

Immediate Assessment Priorities

Before making any medication decisions, verify the following:

• Confirm the patient's current maintenance therapy dose with their prescribing provider or program if they are on methadone or buprenorphine, as these patients have developed significant opioid tolerance and cross-tolerance 2, 1
• Assess for objective evidence of pain including physical examination findings, vital signs, functional limitations, and correlation with known pathology 1
• Screen for concurrent CNS depressants including benzodiazepines, alcohol, cannabis, and other sedating medications, as combinations dramatically increase overdose risk 1, 3
• Check the prescription drug monitoring program (PDMP) for concurrent controlled substances from other prescribers 3

Risk Stratification for Aberrant Behaviors

Assess the patient's risk profile for prescription opioid abuse:

Lower risk patients typically have: 4

• History of alcohol abuse alone or remote polysubstance abuse
• Active participation in Alcoholics Anonymous or similar support programs
• Stable family or support system
• No recent history of oxycodone abuse specifically

Higher risk patients typically have: 1, 4

• Recent polysubstance abuse
• Prior history of oxycodone abuse
• No active participation in recovery programs
• Unstable social support
• Among people living with HIV, 37% reported aberrant opioid behavior within 90 days and 19% reported major aberrant behaviors (using to "get high," snorting, crushing, injecting, or smoking opioids) 1

Treatment Algorithm for Patients Requesting More Medication

If Pain is Undertreated (Pseudoaddiction Suspected)

Aggressively treat the pain using a multimodal approach: 1, 2

1. Continue or optimize non-opioid analgesics:

   • Acetaminophen 650 mg every 4-6 hours (maximum 4-6 grams daily) 2, 1
   • NSAIDs if not contraindicated, with baseline and q3-month monitoring of blood pressure, BUN, creatinine, liver function, CBC, and fecal occult blood 1

2. For patients on methadone maintenance: 2, 1

   • Continue the usual daily methadone dose for maintenance of opioid dependence
   • Add short-acting opioids (morphine, hydromorphone, or oxycodone) for pain control
   • Use scheduled dosing at fixed intervals rather than as-needed orders
   • Expect to need higher doses and more frequent intervals than for opioid-naïve patients due to cross-tolerance

3. For patients on buprenorphine maintenance: 2, 1

   • Continue buprenorphine maintenance therapy
   • Add short-acting full opioid agonists
   • Collaborate with palliative care, pain, and/or substance use disorder specialists

4. Critical medication avoidance: 2, 1

   • Never use mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they precipitate acute withdrawal
   • Avoid tramadol and codeine due to limitations in dose titration and potential for neurotoxicity

Undertreating pain leads to decreased responsiveness to subsequent opioid analgesics, making pain control progressively more difficult. 1, 2

If Pain is Adequately Controlled (True Drug-Seeking Suspected)

Do not immediately discontinue opioids, as abrupt discontinuation is contraindicated and potentially dangerous. 3, 5

Instead, implement enhanced monitoring and risk mitigation:

1. Establish clear treatment agreements: 1, 2

   • Specify number of pills dispensed
   • Define frequency of use and expected duration
   • Designate single provider and single pharmacy
   • Document consequences of aberrant behaviors

2. Increase monitoring frequency: 3

   • Monthly or more frequent follow-up visits
   • Additional precautions if opioid dosage ≥50 MME/day
   • Regular urine drug screening

3. Provide naloxone and overdose prevention education immediately for patients with risk factors including concurrent CNS depressant use 3, 1

4. Consider substance use disorder consultation: 1

   • Evaluation for substance use disorder
   • Assistance with establishing treatment agreements and limit setting
   • Coordination of care between pain management and addiction treatment

Common Pitfalls to Avoid

• Do not allow fear of being manipulated to cloud clinical judgment—patient anxiety about being stigmatized, undertreated, or having their maintenance therapy discontinued is profound and well-founded, which can complicate adequate pain relief 1
• Do not dismiss patients from care based solely on drug-seeking behaviors—this could have adverse consequences for patient safety and miss opportunities to facilitate treatment for substance use disorder 3, 1
• Do not abruptly discontinue opioids in physically-dependent patients—withdrawal syndrome may occur with symptoms including restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, mydriasis, irritability, anxiety, and potentially life-threatening complications 6, 5
• Do not assume signing an "opioids contract" alone predicts successful outcome—contracts must be combined with active monitoring and clinical assessment 4

Documentation Requirements

Document the following in every encounter: 3

• Discussion with patient about current pain level, functional status, and medication use
• Assessment for objective evidence of pain
• Presence or absence of overdose warning signs
• Risk-benefit analysis supporting treatment decisions
• Naloxone provision and overdose education provided
• Enhanced monitoring plan with specific follow-up intervals
• Treatment agreement reviewed or established