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.
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