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 History

Opioids should not be prescribed for chronic pain in patients with a history of opioid use disorder (OUD), and if the patient is already on opioids from another provider, these should be tapered and discontinued while implementing comprehensive multimodal pain management strategies. 1

Initial Clinical Assessment

Distinguish Pain Type and Context

• Assess for objective evidence of pain through physical examination findings, imaging, or other diagnostic tests, as reports of chronic pain with vague presentations are more likely to represent drug-seeking behavior than acute pain with objective findings 1
• Evaluate for narcotic bowel syndrome, which occurs in approximately 6% of patients on long-term opioids and presents as paradoxically worsening abdominal pain despite continued or escalating opioid doses 1
• Screen for pain catastrophizing, defined as overestimating the seriousness of pain coupled with feelings of helplessness, which is associated with higher healthcare utilization and opioid misuse 1

Verify Current Opioid Status

• If the patient reports being on medication-assisted treatment (MAT) with methadone or buprenorphine, verify the maintenance dose directly with their clinic or prescribing physician before any intervention 2, 3
• Check the prescription drug monitoring program (PDMP) for concurrent controlled substances from other prescribers 4

Management Strategy for Chronic Pain

Primary Approach: Non-Opioid Multimodal Analgesia

The evidence strongly supports avoiding opioids for chronic pain in this population due to ineffectiveness and potential harm. 1

• Implement aggressive non-opioid pharmacologic interventions:

  • NSAIDs for musculoskeletal pain (with caution for bleeding risk) 1
  • Gabapentinoids for neuropathic pain 1
  • Tricyclic antidepressants as adjuvant analgesics 2
  • Acetaminophen for adjunctive analgesia 2

• Initiate non-pharmacologic interventions:

  • Physical therapy, which is associated with an 18% decreased risk of OUD and represents a relatively accessible and safe pain management strategy 5
  • Cognitive-behavioral therapy specifically designed for comorbid pain and OUD, which shows significant functional improvement and decreased pain severity 6

If Patient is Already on Opioids from Another Provider

Collaborate with the patient on a tapering plan rather than abrupt discontinuation, as stopping opioids suddenly is contraindicated and potentially dangerous. 1, 4

• Prescribe opioids responsibly via multidisciplinary collaboration until they can be discontinued 1
• Increase follow-up frequency to monthly or more often for patients at greater risk, including those with history of OUD 1, 4
• Provide naloxone and overdose prevention education immediately 4
• Optimize other therapies while working with the patient to taper opioids to lower dosages or discontinue 1

Special Considerations for Patients on Medication-Assisted Treatment

If Patient is on Methadone or Buprenorphine for OUD

Continue the full maintenance dose without interruption—this is for addiction treatment, not analgesia. 1, 2, 3

• Methadone maintenance doses are given once daily for OUD treatment but provide only 6-8 hours of analgesia, so the maintenance dose alone will not control chronic pain 1, 2
• For chronic pain in methadone-maintained patients, consider split-dosing the methadone (dividing into 6-8 hour intervals) by adding 5-10% of the current dose as afternoon and evening doses, resulting in a 10-20% total increase 1, 2
• If split-dosing is not feasible (due to clinic policy, high baseline dose, prolonged QTc, or high diversion risk), add non-opioid adjuvant medications based on pain etiology rather than additional opioids 1

Addressing the Opioid Request Directly

Reframe Drug-Seeking Behaviors

Recognize that requests for opioids may represent pseudoaddiction (inadequate pain relief), therapeutic dependence (fear of pain or withdrawal reemergence), or pseudo-opioid resistance (fear of dose reduction), rather than true addiction. 1, 2

• Explicitly reassure the patient that their addiction history will not prevent adequate pain management, but explain that opioids are ineffective for chronic pain and potentially harmful 1, 2
• Avoid engaging in pain catastrophizing by using language that validates their pain while avoiding statements like "you shouldn't be in so much pain" or continuing to order tests to find a "cause" 1
• Build trust through open and collaborative patient-provider relationship, as patients with OUD history often distrust the medical community due to concerns about stigmatization and undertreatment 1

Document the Clinical Decision

• Document the discussion about opioid risks and benefits, including the specific reasons opioids are not being prescribed for chronic pain 1
• Include risk-benefit analysis, alternative treatments offered, and the enhanced monitoring plan 4

Critical Pitfalls to Avoid

• Do not dismiss the patient from care based on their opioid request, as this could have adverse consequences for patient safety and miss opportunities to facilitate treatment 4
• Do not prescribe opioids for chronic gastrointestinal pain in patients with disorders of gut-brain interaction, as this is ineffective and can lead to narcotic bowel syndrome 1
• Do not co-prescribe opioids with benzodiazepines or gabapentin if opioids are unavoidable, as this substantially increases OUD risk by 37-45% 5
• Do not use mixed agonist-antagonists (pentazocine, nalbuphine, butorphanol) as they can precipitate acute withdrawal syndrome 2, 3
• Do not confuse the need for chronic pain management with acute pain management, as the evidence and recommendations differ substantially between these contexts 1

Monitoring Requirements if Opioids Cannot Be Avoided

• Evaluate benefits and harms within 1-4 weeks of starting or dose escalation, and every 3 months thereafter 1
• If opioid dosage reaches or exceeds 50 MME per day, implement additional precautions including increased follow-up frequency 1, 4
• Avoid increasing dosages to 90 MME or more per day, or carefully justify based on individualized assessment showing incremental benefits outweigh harms 1
• If patients do not experience improvement in pain and function at 90 MME or more per day, discuss other approaches and consider tapering 1