How do you manage a patient with chronic pain and a history of opioid use disorder (OUD) who reports severe pain and requests opioids?

Managing Chronic Pain in Patients with Opioid Use Disorder Requesting Opioids

Prioritize non-opioid and non-pharmacologic therapies first, and if opioids are necessary, continue or initiate medication for opioid use disorder (MOUD) while adding short-acting opioids at higher doses and shorter intervals than typically prescribed, rather than increasing baseline MOUD doses or prescribing opioids alone. 1, 2

Initial Assessment and Risk Stratification

Distinguish Pain Etiology and Drug-Seeking Behaviors

• Carefully assess for objective evidence of pain through physical examination findings, functional limitations, and consistency of presentation 1
• Recognize that requests for opioids may represent pseudoaddiction (inadequate pain control driving medication-seeking), therapeutic dependence (fear of pain or withdrawal reemergence), or pseudo-opioid resistance (reporting persistent pain to prevent dose reduction) rather than active addiction 1, 2
• Reports of acute pain with objective findings are less likely to be manipulative than vague chronic pain presentations 1
• Check the prescription drug monitoring program (PDMP) to identify concurrent prescriptions and assess overdose risk 1

Address Patient Anxiety and Establish Trust

• Explicitly reassure the patient that their history of opioid use disorder will not prevent adequate pain management 1, 2
• Acknowledge that patients with OUD often distrust the medical system due to prior stigmatization and fears of undertreatment 1
• Explain the pain management plan clearly and non-judgmentally to reduce anxiety that can complicate pain relief 1

First-Line Treatment Strategy: Non-Opioid Multimodal Approach

Prioritize Non-Opioid Therapies

• Non-pharmacologic and non-opioid pharmacologic therapies are the preferred treatment for chronic pain, even in patients with OUD 1, 3
• Aggressively implement NSAIDs, acetaminophen, and adjuvant analgesics (such as tricyclic antidepressants) that enhance pain control 1, 2
• Consider non-pharmacologic interventions including physical therapy, cognitive-behavioral therapy, and other evidence-based behavioral treatments 1, 4, 5

When Opioids Are Necessary: MOUD-Based Strategy

For Patients Not Currently on MOUD

• Offer or arrange medication treatment for opioid use disorder as the foundation of pain management 1
• Initiate methadone or buprenorphine to address baseline opioid requirements before attempting analgesia 1, 2
• Once stabilized on MOUD, add short-acting opioid analgesics if pain persists despite non-opioid therapies 2, 6

For Patients Already on Methadone Maintenance

• Continue the usual methadone maintenance dose without interruption - verify with the patient's provider or program 1, 2, 6
• Consider split-dosing the methadone into 6-8 hour intervals rather than once daily, as methadone's analgesic effect lasts only 6-8 hours despite its 30-hour half-life 2, 3, 6
• Add 5-10% of the current dose for afternoon and evening doses (resulting in 10-20% total daily increase) if split-dosing for analgesia 3, 6
• Obtain baseline EKG to assess QTc interval before any methadone adjustment, as methadone can prolong QTc and cause arrhythmias 3, 7
• Add short-acting opioids (morphine, hydromorphone, oxycodone) at higher doses and shorter intervals (every 3-4 hours) than used for opioid-naïve patients due to cross-tolerance 1, 2, 6

For Patients on Buprenorphine Maintenance

• Continue buprenorphine at the current dose and add short-acting full opioid agonists at higher-than-usual doses with scheduled dosing 6, 8
• For severe acute pain, consider temporarily discontinuing buprenorphine and using full opioid agonists, then converting back when acute pain resolves 6
• Notify the buprenorphine prescriber about additional opioids prescribed, as they will appear on urine drug screening 6
• Patients on buprenorphine maintenance therapy receive treatment doses that block most euphoric effects of co-administered opioids, theoretically decreasing abuse likelihood 1

Critical Prescribing Principles

Dosing Strategy

• Use scheduled (continuous) dosing rather than as-needed dosing to prevent pain reemergence, which causes unnecessary suffering and increases patient-provider tension 1, 2, 6
• Patients with OUD have developed significant opioid tolerance and increased pain sensitivity, requiring higher doses at shorter intervals 1, 2, 6
• Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they will precipitate acute withdrawal syndrome 1, 2, 6
• Avoid fixed-dose combination products containing acetaminophen for patients requiring high opioid doses due to hepatotoxicity risk 6

Monitoring and Safety

• Prescribe naloxone given the patient's history of substance use disorder, which is a risk factor for opioid overdose 1, 3
• Frequently monitor level of consciousness and respiratory rate when adding opioids to MOUD 2, 6
• Use caution with benzodiazepines or other CNS depressants, which significantly increase overdose risk 1, 9, 7
• Review PDMP data before prescribing and periodically (ranging from every prescription to every 3 months) 1, 3
• Consider urine drug testing to assess for prescribed medications and illicit substances 1, 3

Follow-Up and Reassessment

• Evaluate benefits and harms within 1-4 weeks of starting or changing opioid therapy 1, 3
• Reassess every 3 months or more frequently for patients at higher risk 1
• Establish clear treatment goals for both pain reduction and functional improvement, not just pain scores 1, 3
• If benefits do not outweigh harms, optimize non-opioid therapies and work with the patient to taper opioids 1

Common Pitfalls to Avoid

• Do not undertreate pain due to fears of addiction relapse or "opiophobia" - undertreating pain can lead to decreased opioid responsiveness and more difficult subsequent pain control 1, 2, 6
• Do not confuse drug-seeking behaviors with active addiction when they may represent legitimate attempts to obtain relief from uncontrolled pain 1, 2, 6
• Do not allow pain to reemerge before administering the next dose, as this causes unnecessary suffering and increases tension 1, 6
• Do not discontinue or alter MOUD without coordination with the patient's addiction treatment provider 1, 6
• Do not assume that MOUD provides analgesia for acute or chronic pain - it addresses baseline opioid requirements but does not treat pain 1, 2

Coordination of Care

• Notify the patient's methadone clinic or buprenorphine prescriber about hospitalization, discharge, and any controlled substances prescribed 1, 6
• Inform addiction treatment programs that additional opioids will appear on routine urine drug screening 1, 6
• Ensure other healthcare providers are aware of the patient's MOUD treatment to coordinate care and minimize risks 1, 9

When Opioid Therapy Should Be Reconsidered

• Consider opioid therapy only if expected benefits for both pain and function outweigh risks 1, 3
• If signs of active opioid use disorder are present, address concerns with the patient and offer or arrange medication treatment before prescribing additional opioids 1
• Avoid increasing opioid dosages to ≥90 morphine milligram equivalents (MME) per day or carefully justify such increases based on individualized assessment 1
• At dosages ≥50 MME per day, implement additional precautions including increased follow-up frequency and naloxone provision 1