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Pain and Opioid Treatment

NEW YORK STATE OFFICE OF ALCOHOLISM AND SUBTANCE ABUSE SERVICES
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Addiction Medicine FYI

Pain and Opioid Treatment

Acute Pain Management For Patients Receiving Maintenance Methadone or Buprenorphine Therapy

An article in a recent Annals of Internal Medicine (2006;144:127-132) by Alford et al. highlighted an important medical situation that is increasing in frequency – how to treat acute pain in a patient who is receiving opiate agonist maintenance. (For a detailed description of agonist interaction, see ”Addiction Medicine Knowledge Workbook I”.)

This article states that “adequate treatment of acute painful conditions is an essential dimension of quality medical care and that inadequate treatment is common among a wide spectrum of patients. A further complication is that physicians may not prescribe effective opioid analgesia across all patients, but there is a particular fear in prescribing opioids in a patient with a chemical dependency problem. The other challenge is the patient who is already receiving opioid agonist therapy.”

The “syndrome of pain facilitation” complicates treatment with opioids in the opioid maintained patient. This syndrome, first described by Savage and Schofferman in 1995 is noted in a patient with addiction and pain; the pain experience is worsened by the subtle withdrawal syndrome and withdrawal related sympathetic nervous system arousal and sleep disturbances that can be seen in a maintained patient.

4 Common Misconceptions regarding the treatment of pain in the opioid maintained patients:

  1. Maintenance opioid agonists provide analgesia
  2. Use of opioids for analgesia may result in addiction relapse
  3. Addictive effects of opioid analgesia and opioid agonist therapy may cause respiratory and central nervous system depression (in the opioid maintained patients)
  4. Reporting pain is frequently a manipulation to obtain opioid medication, because of the underlying opioid addiction

Some important recommendations for treating acute pain in patients receiving opioid agonist therapy are cited :

  1. Reassure patient that addiction history will not prevent adequate pain management and discuss the plan for pain management in a nonjudgmental manner. Use conventional analgesics, including opioids, to aggressively treat the painful condition.
  2. Be aware that opioid cross-tolerance and the patient’s increased pain sensitivity will often necessitate higher opioid analgesic doses that may have to be administered at shorter intervals.
  3. Write continuous scheduled dosing orders, rather than as-needed orders.
  4. Avoid using mixed agonist and antagonist opioids as they can precipitate acute withdrawal.
  5. Continue the usual dose (or equivalent) of opioid agonist therapy.
  6. Methadone or buprenorphine maintenance doses should be verified by the clinic or prescribing physician.
  7. Notify the addiction treatment program or prescribing physician regarding the patient’s amount and time of last maintenance opioid dose.
  8. Inform the addiction treatment program or prescribing physician of any medications given to the patient, as they may show up on routine urine drug screening.

The article gives specific recommendations for treating acute pain in patients receiving opioid agonist therapy. Some of these recommendations are:

  1. The patient is receiving methadone maintenance and requires opioid analgesics:
    • continue methadone maintenance dose
    • use short acting opioid analgesics
  2. The patient is receiving buprenorphine maintenance and requires opioid analgesics:
    • continue buprenorphine maintenance therapy and titrate short acting opioid analgesics for pain of short duration only
    • divide buprenorphine dose to every 6 – 8 hours; additional opioids may be needed.
    • discontinue buprenorphine maintenance therapy and use opioid analgesics. Convert back to buprenorphine when acute pain no longer requires opioid analgesia.

A workbook entitled “Pain and the Substance User” can be found on the OASAS Addiction Medicine Free Educational Series page. 3 CASAC/CPP/CPS credit hours are available for this workbook.

02/06