What are the guidelines for prescribing opioids to patients with chronic pain, especially those with a history of substance abuse?

Opioid Prescribing for Chronic Pain in Patients with Substance Abuse History

Nonpharmacologic and nonopioid pharmacologic therapies are strongly preferred over opioids for chronic pain, and patients with a history of substance abuse represent a particularly high-risk population requiring intensive risk mitigation strategies if opioids are considered at all. 1

Initial Decision Framework

Opioids should not be first-line therapy for chronic pain outside of active cancer, palliative, and end-of-life care. 1 The evidence shows only small to moderate short-term benefits with uncertain long-term benefits, while risks are substantial—particularly in patients with substance abuse history. 1

When to Avoid Opioids Entirely

• History of substance use disorder is a documented risk factor for opioid-related harms, including overdose and death. 1
• Certain pain conditions (headache, fibromyalgia) show minimal expected benefit regardless of prior treatments, making opioids inappropriate. 1
• Active or recent alcohol/substance abuse, uncontrolled psychiatric instability, and active diversion are relative to absolute contraindications. 2

When Opioids May Be Considered Despite Substance Abuse History

If expected benefits for both pain AND function clearly outweigh risks, opioids may be initiated—but only with comprehensive risk mitigation strategies in place. 1 This requires:

• Mental health comorbidities and substance use disorders must be actively treated, not just documented. 1
• Patient demonstrates high motivation and agrees to intensive monitoring. 3
• Nonpharmacologic therapy (exercise, cognitive behavioral therapy) and nonopioid medications (NSAIDs, acetaminophen, anticonvulsants, SNRIs) have been optimized. 1

Prescribing Protocol for High-Risk Patients

Starting Dosage and Formulation

• Always initiate with immediate-release opioids, never extended-release/long-acting formulations. 1
• Start with the lowest effective dosage—up to 40 mg morphine milligram equivalents (MME) per day is considered low dose. 2
• Prescribe no greater quantity than needed; 3 days or less is often sufficient for acute pain, rarely more than 7 days. 1

Dose Escalation Thresholds

The relationship between opioid dose and overdose risk is dose-dependent and dramatic: 1

• At 50-100 MME/day: overdose risk increases 1.9 to 4.6-fold compared to <20 MME/day. 1
• At ≥100 MME/day: overdose risk increases 2.0 to 8.9-fold. 1
• Carefully reassess when considering doses ≥50 MME/day; avoid or carefully justify doses ≥90 MME/day. 1

Mandatory Risk Mitigation Strategies

For patients with substance abuse history, the following are non-negotiable: 1

1. Check prescription drug monitoring program (PDMP) data before initiating therapy and periodically during treatment (every prescription to every 3 months). 1 This identifies doctor shopping and dangerous drug combinations. 1

2. Perform urine drug testing before starting opioids and at least annually thereafter. 1 This assesses for prescribed medications, other controlled substances, and illicit drugs. 1

3. Avoid co-prescribing benzodiazepines—this combination dramatically increases fatal overdose risk. 1

4. Prescribe naloxone when risk factors are present: history of overdose, substance use disorder, doses ≥50 MME/day, or concurrent benzodiazepine use. 1

5. Use a robust opioid treatment agreement that all parties follow—this reduces overuse, misuse, abuse, and diversion. 2

Monitoring Schedule

• Evaluate benefits and harms within 1-4 weeks of starting therapy or dose escalation. 1
• Reassess every 3 months or more frequently, documenting pain relief, functional improvement, and adverse effects. 1
• If benefits do not outweigh harms at any point, discontinue or taper. 1

Special Medication Considerations

Methadone

Methadone should only be used in late stages after failure of other opioids and only by clinicians with specific training. 2 It carries disproportionate overdose death risk. 1 An electrocardiogram should be obtained before initiation, at 30 days, and yearly. 2

Alternative: Buprenorphine for Opioid Use Disorder

If the patient develops opioid use disorder during treatment, offer medication-assisted treatment with buprenorphine or methadone combined with behavioral therapies. 1 This approach increases treatment retention and decreases illicit opioid use more effectively than naltrexone alone. 1 Effectiveness is enhanced when psychosocial treatments are used in conjunction. 1

Common Pitfalls to Avoid

• Do not require patients to sequentially "fail" all nonopioid therapies before considering opioids—instead, weigh expected benefits against risks in the specific clinical context. 1
• Do not ignore mental health comorbidities—these increase risk and must be actively managed. 1
• Do not prescribe without checking PDMP data—this misses dangerous drug combinations and doctor shopping. 1
• Do not use extended-release formulations as initial therapy—immediate-release opioids allow better dose titration and carry lower risk. 1
• Do not continue therapy without documented functional improvement—pain relief alone is insufficient justification. 2