How to manage a patient with chronic pain who has developed opioid use disorder (OUD) and is experiencing withdrawal after being discharged from a pain management practice due to medication overuse?

From the Guidelines

For a patient with chronic pain who has become addicted to pain medication and is experiencing withdrawal after being discharged from their pain practice, immediate intervention with medication-assisted therapy (MAT) and a multidisciplinary approach is necessary to manage both withdrawal and pain, as recommended by the CDC guideline for prescribing opioids for chronic pain 1.

Key Considerations

• The patient should be helped to find a new healthcare provider who specializes in both pain management and addiction medicine.
• While arranging this care, consider referring them to an emergency department if withdrawal symptoms are severe.
• Treatment typically involves MAT with buprenorphine (starting at 4-8mg sublingually, titrated as needed) or methadone (30-40mg initially) to manage both withdrawal and pain, as supported by evidence from studies on opioid use disorder treatment 1.

Managing Withdrawal Symptoms

• Clonidine (0.1-0.2mg every 6 hours), loperamide (4mg initially, then 2mg after each loose stool), and ondansetron (4-8mg every 8 hours) can help manage specific withdrawal symptoms.
• A multidisciplinary approach is crucial, incorporating behavioral therapy, physical therapy, and non-opioid pain management strategies like NSAIDs, acetaminophen, gabapentinoids, and antidepressants.

Importance of Comprehensive Approach

• This comprehensive approach addresses both the physical dependence and underlying pain condition, recognizing that abrupt discontinuation of opioids can worsen pain and lead to dangerous withdrawal, while proper treatment can help restore function and quality of life, as emphasized in recent studies on ensuring patient protections when tapering opioids 1.
• The treatment plan should be tailored to the individual patient's needs, taking into account their medical history, current symptoms, and treatment goals, as recommended by experts in pain management and addiction medicine 1.

From the FDA Drug Label

1. 1 Addiction, Abuse, and Misuse Buprenorphine Sublingual Tablets contain buprenorphine, a Schedule III controlled substance that can be abused in a manner similar to other opioids, legal or illicit. Clinical monitoring appropriate to the patient’s level of stability is essential.
2. 5 Neonatal Opioid Withdrawal Syndrome Neonatal opioid withdrawal syndrome (NOWS) is an expected and treatable outcome of prolonged use of opioids during pregnancy, whether that use is medically-authorized or illicit. Unlike opioid withdrawal syndrome in adults, NOWS may be life-threatening if not recognized and treated in the neonate Healthcare professionals should observe newborns for signs of NOWS and manage accordingly

The patient is experiencing withdrawal symptoms from opioid overuse, and the pain doctor has discharged him from the practice. Key considerations:

• The patient requires immediate medical attention to manage withdrawal symptoms and prevent potential complications.
• Buprenorphine or methadone may be considered for managing opioid withdrawal, but this should be done under the guidance of a healthcare professional.
• Close monitoring is essential to ensure the patient's safety and adjust treatment as needed.
• Alternative pain management options should be explored to address the patient's chronic pain.
• Coordination of care is crucial to ensure the patient receives comprehensive treatment and support. 2 2 3

From the Research

Managing Patient Withdrawal

To manage a patient with chronic pain who has become addicted to pain medication and is experiencing withdrawal, several strategies can be employed:

• Gradual tapering of the opioid dose to minimize withdrawal symptoms
• Use of medications such as clonidine, buprenorphine, or naltrexone to alleviate withdrawal symptoms 4, 5, 6, 7, 8
• Close monitoring of the patient's vital signs and withdrawal symptoms to adjust the treatment plan as needed

Detoxification Protocols

Different detoxification protocols can be used, including:

• Methadone substitution/detoxification
• Codeine or other opiate substitution/detoxification
• Opiate of choice detoxification
• Buprenorphine substitution/detoxification 4
• Clonidine-based protocols, which have been shown to be effective in reducing withdrawal symptoms 6, 8
• Naltrexone-based protocols, which can be used to induce opioid blockade and prevent relapse 7, 8

Medication Options

Various medications can be used to manage withdrawal symptoms, including:

• Buprenorphine, which has been shown to be effective in reducing withdrawal symptoms and improving treatment outcomes 5, 6, 8
• Clonidine, which can be used to alleviate withdrawal symptoms and reduce the risk of relapse 4, 6, 8
• Naltrexone, which can be used to induce opioid blockade and prevent relapse 7, 8
• Methadone, which can be used as a substitute for other opioids and to reduce withdrawal symptoms 4