Safe Treatment of Pain in the Patient With a Substance Use Disorder

Addiction to alcohol and other drugs is a complex disorder that has been
shown to cause modifications in the structure and function of the brain's reward
system. These changes are apparent during active drug use, and they persist to
some extent for long periods after a person stops using drugs. Because of these
persistent changes, as well as established patterns of behavior, patients with
substance use disorders—whether actively using or in recovery—are vulnerable to
reactivating or complicating their addiction. They can relapse to using the
original drug of choice, or an addiction can develop to other chemicals not used
in the past. Persons addicted to opioids are at great risk for becoming
re-addicted when similar drugs are introduced to their vulnerable brains.
Nevertheless, conditions associated with severe pain can and do develop in
persons who have an active addiction or who are in remission from an addictive
disease, and these patients may require treatment for pain relief. This presents
a challenge to clinicians: how do we help patients manage pain without
exacerbating or reactivating the addictive disorder? There is little research
data on this topic, but experiential and anecdotal reports collected over the
past 3 decades indicate that there are safe and effective approaches to pain
management in these patients.^1-3
Acute pain syndromes
For acute pain syndromes such as
pain that occurs following an operation, trauma, or extensive dental work, the
use of opioids may be indicated to control severe pain and to achieve optimal
pain relief. Many but not all patients recovering from a substance use disorder
have an increased tolerance to the effects of opioid drugs and may require
higher than average doses for appropriate effect. Despite this, the treating
physician or dentist, in a well-meaning but misguided attempt to prevent
complications related to addiction, will often reduce the dosage of opioids
administered. However, this is contrary to the effective approach, which is to
give as large a dose as needed to achieve good pain control. Untreated pain is a
trigger for relapse—a trigger that can be as powerful as exposure to an
intoxicant.
Since patients with substance use disorders who are in pain often have
difficulty discriminating between the need for pain relief and the craving for
more drug, it is best to administer the analgesics on a fixed schedule rather
than on an as-needed basis. Personally controlled analgesia is not recommended
for most persons with a history of substance use addiction.
An additional recommendation for preventing problems with craving is to
designate a "medication administrator" who will hold the supply of pills and
give them to the patient on schedule. If possible, this will be a person who
cannot be manipulated easily by the patient. As soon as possible, the analgesic
should be switched from an opioid to an NSAID and/or acetaminophen. In some
cases, this may require gradual detoxification from the opioid.⁴
If the patient has an active addiction to alcohol, sedatives, or opioids at
the time when the trauma or surgery necessitates pain control, postoperative
care may be complicated by the need to manage a more complex detoxification. In
addition, clinicians should initiate a discussion about plans for further
addiction treatment following recovery. An addiction psychiatrist would be
helpful in designing a pharmacologic plan to manage pain and withdrawal symptoms
and for follow-up referrals.
If the patient is receiving agonist treatment for opioid dependence with
either methadone or buprenorphine, the physician who is prescribing the agonist
therapy should be contacted and involved in the pain-management plan.
Maintenance medication will not cover the patient's need for acute pain
control.⁵ Maintenance methadone should be continued as before, and
short-acting opioid medication should be given in addition to the maintenance
drug on a standing dosage schedule.⁶ For example, immediately after
surgery, a patient receives his or her usual dosage of methadone, 90 mg/d, and
also receives meperidine, 100 mg q4h, intramuscularly for pain. Since
buprenorphine is a partial agonist with a high affinity for the µ-receptor, it
will need to be discontinued in order for the short-acting opioid pain
medication to be effective. Once the patient no longer requires opioids for pain
management, the patient can be re-induced on buprenorphine for continued opioid
agonist treatment.^7,8
During a bout with acute pain, a patient recovering from a substance use
disorder will need increased support from his ongoing recovery program.
Strengthening the support system may make all the difference in preventing a
relapse. The abstinent patient without an ongoing program of recovery is at high
risk for relapse when exposed to opioid pain medications or sedative muscle
relaxants.

2004

Heroin Addiction and Related Clinical Problems.
2004(Dec), Vol. 6, No. 3

• Patient-Treatment Matching and Opioid Addicted Patients: Past Methods and
  Future Opportunities
  
• Methadone Patients' Sexual Dysfunctions: Clinical and Treatment Issues
  
• Unreported Double Frequency of Heroin Addicts Visiting Psychiatric Services
  and Addiction Treatment Services
  
• Evaluation of Effectiveness of Drug Treatment Programmes in the Ukraine
  
• Bad Patients or Bad Treatment?
  
• Opiate Dosage Adequacy Scale (ODAS): A Clinical Diagnostic Tool as a Guide
  to Dosing Decisions
  
• Download PDF: HeroinAdd6-3.pdf (1.20 MB, 54 pp)
  

Heroin Addiction and Related Clinical Problems.
2004(August), Vol. 6, No. 2

• Craving in Opiate, Cocaine and Alcohol Addiction
  
• Clinical Foundations for the Use of Methadone in Jail
  
• Download PDF: HeroinAdd6-2.pdf (2.24 MB, 78 pp)
  

Heroin Addiction and Related Clinical Problems.
2004(April), Vol. 6, No. 1

• Addressing Violence in Methadone Maintenance Treatment
  
• "Vedette" Study and "Tracking" Project; Their Integration and Preliminary
  Results
  
• Methadone Treatment. Safe Induction Techniques
  
• Naltrexone as Maintenance Therapy for Heroin Addiction: Predictors of
  Response
  
• Download PDF: HeroinAdd6-1.pdf (1.65 MB, 60 pp)
  

2003


Heroin Addiction and Related Clinical Problems.
2003(Dec), Vol. 5, No. 3

• Understanding the Pathogenesis of Drug Addiction in Order to Implement a
  Correct Pharmacological Intervention
  
• Structured Motivational Interventions in Methadone Maintenance Treatment
  
• Psychiatric Severity and Treatment Response in Methadone Maintenance
  Treatment Programmes: New Evidence
  
• Treatment of Prisoners Addicted to Prohibited Drugs in Institutions for
  Criminal Law Sanctions in Maribor, Slovenia
  
• -Clinical Picture and Treatment of Psycho-organic Syndrome in Drug Addicts
  
• Download PDF: HeroinAdd5-3.pdf (1.97 MB, 60 pp)
  

Heroin Addiction and Related Clinical Problems.
2003(August), Vol. 5, No. 2

• Dual Diagnosis in Heroin Addicts. The Clinical and Therapeutic Aspects
  
• Personality Disorders in Addicted Patients
  
• Mood Disorders in Addicted Patients
  
• Anxiety Disorders in Addicted Patients
  
• Aggression and Violence in Heroin Addicted Patients
  
• Alcoholism in Heroin-Addicted Patients
  
• Methadone Treatment in Dual Diagnosis Patients
  
• Download PDF: HeroinAdd5-2.pdf (2.18 MB, 108 pp)
  

Heroin Addiction and Related Clinical Problems.
2003(April), Vol. 5, No. 1

• The Impact of Methadone Substitution Therapy (MST) on Illicit Drug Use and
  Drug Abuse-Related Quality of Life: A European Study
  
• When "Enough" is Still Not "Enough". Effectiveness of High-Dose Methadone in
  the Treatment of Heroin Addiction
  
• The Impact of Continuing Terror and Stress on the Use of Psychoactive Drugs
  in Israel
  
• Reduction in Self-Reported Nicotine Dependence After Stabilization in
  Methadone Maintenance Treatment
  
• Liver Cytochrome Overexpression in Human HCV Infection
  
• Download PDF: HeroinAdd5-1.pdf (1.42 MB, 52 pp)
  

2002

Heroin Addiction and Related Clinical Problems.
2002(Dec), Vol. 4, No. 3

• Harm Reduction and Specific Treatments for Heroin Addiction. Different
  Approaches or Levels of Intervention? An Illness Centered Perspective
  
• Methadone Treatment in Croatia
  
• The Renaissance of Methadone Treatment in America
  
• Methadone and Commonplaces
  
• Methadone Maintenance and HIV Infection
  
• Breast-Feeding for a Methadone-Maintained Mother: A Case Report
  
• Methadone Maintenance Treatments in European Extra-Community Target
  
• Download PDF: HeroinAdd4-3.pdf (1.36 MB, 52 pp)
  

Heroin Addiction and Related Clinical Problems.
2002(August), Vol. 4, No. 2

• Correlation Between Hepatitis C Serostatus and Methadone Dose Requirement in
  1,163 Methadone-Maintained Patients
  
• Is Craving for Heroin and Alcohol Related to Low Methadone Dosages in
  Methadone Maintained Patients?
  
• Clinical Foundations for the Use of Methadone. Italian Consensus Panel on
  Methadone Treatment
  
• “Manifesto of Barcelona”: Care Programmes for Health Professionals with
  Mental
  
• Disorders and Addictive Behaviours in Europe
  
• Galicia Document on Problems Related to Addictive Disorders in Europe
  
• 5th Conference of The European Opiate Addiction Treatment Association and
  2002 “Chimera Award”
  
• Download PDF: HeroinAdd4-2.pdf (556 KB, 52 pp)
  

Heroin Addiction and Related Clinical Problems.
2002(April), Vol. 4, No. 1

• Mortality Among Problem Drug Users in Europe: A Project of the European
  Monitoring Centre for Drugs and Drug Addiction (EMCDD)
  
• Buprenorphine: Evidence for Effectiveness
  
• 1995-2001 Programme Evaluation of the A-Center for Treatment of Addicts
  Consuming Prohibited Drugs at Maribor, Slovenia
  
• Does Therapeutic Threshold of Methadone Concentration in Plasma Exist?
  
• Treatment Characteristics and Retention in Methadone Maintenance: High and
  Stable Retention Rates in a Swedish Two-Phase Programme
  
• Download PDF: HeroinAdd4-1.pdf (448 KB, 50 pp)
  

2001


Heroin Addiction and Related Clinical Problems.
2001(Dec), Vol. 3, No. 2

• The Problem of Drug Dependence
  
• Evaluation Survey of a Methadone Treatment Share Care Programme Between a
  Specialized Clinic and a Network of GPs
  
• Treatments of Substance Users Detainees in La Santé Prison
  
• Intensive Sport and Risk of Heroin Addiction
  
• The Differences Between Heroin Addicts With and Without Comorbidity
  
• Methadone Treatment: Italy vs USA – Methadone Treatment in Europe
  
• Download PDF: HeroinAdd3-2.pdf (1.52 MB, 52 pp)
  

Heroin Addiction and Related Clinical Problems.
2001(June), Vol. 3, No. 1

• The Promise of Opioid Receptor Antagonist Drugs in the Treatment of
  Neuropsychiatric Disorders
  
• Haematic Concentrations Versus Oral Doses of Methadone. Comparative
  Assessment of Two Reference Systems During Substitute Therapy in Opiate
  Addiction
  
• Therapeutic Effects of Paroxetine on the Cocaine Abuse in Heroin Addicts
  
• Methadone Regulations in USA: Comments, Proposal to Adopt New Regulations
  and Proposed Rule
  
• Articulation of Codeine Treatment and Methadone Maintenance Programs
  
• The Differences Between Inpatients and Outpatients with Illegal Drug Use:
  Prevalence of Comorbid Mental Disorders
  
• Download PDF: HeroinAdd3-1.pdf (1.20 MB, 48 pp)
  

2000

Heroin Addiction and Related Clinical
Problems. 2000(Dec), Vol. 2, No. 2

• Managing Benzodiazepine Withdrawal
  
• Addiction and Methadone: One American's View
  
• An Evaluation Study on Share Care Methadone Treatment Between a Specialized
  Clinic and a Network of General Practitioners
  
• Opioids and Cannabinoids Abuse Among Bipolar Patients
  
• Pregnant Addict Care in Methadone Treatment Programs
  
• Prohibitionism, a Feasible Way Forward
  
• Hepatitis C Infected Patients and Higher Doses of Methadone
  
• Introducing the European Collaborating Centres in Addiction Studies (ECCAS)
  
• Download PDF: HeroinAdd2-2.pdf (737 KB, 70 pp)
  

Heroin Addiction and Related Clinical Problems.
2000(June), Vol. 2, No. 1

• Women, Pregnancy and Methadone
  
• Sexual Dysfunction Associated with Methadone Maintenance: Treatment with
  Bromocriptine
  
• Attitudes and Beliefs Towards Methadone of Staff Working in Substance Abuse
  Treatment
  
• Is Prescribing Higher Doses of Methadone Likely to Promote Elevated Drop-out
  Rates?
  
• The Pacific Drug Policy Institute and Research Findings That Led to Its
  Founding
  
• Methadone Treatment: An Interesting Analogy
  
• Take-Home Doses and Compliance with Methadone Maintenance Treatment
  
• Methadone Dose and Retention in Treatment of Heroin Addicts with Bipolar I
  Disorder Comorbidity, Preliminary Results
  
• Discontinuation Symptoms are Not Addiction/Dependence
  
• Download PDF: HeroinAdd2-1.pdf (545 KB, 60 pp)
  

1999


Heroin Addiction and Related Clinical Problems.
1999(Dec), Vol. 1, No. 2

• Alcohol, Benzodiazepines and Other Drug Use in Heroin Addicts Treated with
  Methadone. Polyabuse or Undermedication?
  
• What Defines Switzerland’s Drug Policy? Switzerland: Drug Policy of Mountain
  Dwellers?
  
• Methadone Treatment and Spread of AIDS in Europe in the 1987-1992 Years
  
• Adolescent Narcotism in Russia
  
• The Treatment of Viral Hepatitis in Drug Addicts
  
• General Practitioners and Heroin Addiction. Chronicle of a Medical Practice
  
• Download PDF: HeroinAdd1-2.pdf (290 KB, 46 pp)
  

Heroin Addiction and Related Clinical Problems.
1999(June), Vol. 1, No. 1

• Treating Heroin Addicts, i.e. “Breaking through a Wall of Prejudices”
  
• Heroin Addiction as Normal Illness
  
• Methadone Maintenance Comes of Age
  
• Pharmacokinetics and Pharmacogenetics of Methadone: Clinical Relevance
  
• Integrating Methadone Treatment in the Slovenian Public Health System
  
• Treatment of Opiate Dependency: A Comment
  
• Methadone as a Mood Stabilizer
  
• Download PDF: HeroinAdd1-1.pdf (338 KB, 54 pp)