INDEX

    Pain Management for Patients with Opioid Use Disorder

    Substance Use, Toxicology

    Last Updated Mar 16, 2021
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    Context

    • Patients with opioid use disorder experience greater pain severity and sensitivity, and have less tolerance to pain.
    • Greater than 50% of patients on opioid agonist therapy (OAT) experience chronic pain.
    • They are less likely to divulge being on OAT due to fear of stigma in the context of acute pain episodes.
    • Inadequate pain management has been linked to decrease retention to treatment and increase rates of self-treatment through ongoing illicit use.
    • Tenants of adequate pain management for patient with opioid use disorder include (Warner et al):
      • Guiding the patient safely through the acute care episode.
      • Avoid iatrogenic harms, including immediate complications (e.g. respiratory depression) and long-term complications (e.g. relapse to opioid use in patients with OUD).
      • Treat acute pain in a manner which is both safe and effective.
      • Promote return to baseline function with discontinuation of additional opioids as rapidly as feasible.

    Recommended Treatment

    Non-pharmacotherapy

    • Create trauma-informed and safe care space.

     

    Basal Analgesia

    NSAIDs and Acetaminophen

    • Frontline use of NSAIDs and acetaminophen can reduce opioid requirements by 25-30% and leads to superior analgesia.
    • Consider if no contraindication:
      • Ibuprofen 400-600mg po and acetaminophen 1g po

    Ketamine

    • Can be used as adjunct to opioids or alone for pain management
    • Reduces opioid related hyperalgesia
    • Supported by ACEP: 1-0.3mg/kg bolus IV +/- infusion
    • Keep to lower dose range to avoid dysphoria, which is not well tolerated in this patient population
    • Consider:
      • Ketamine 10-20mg IV push dose

    Clonidine

    • Adjunct to reduce opioid requirements and pain scores
    • Side effects include bradycardia, hypotension
    • Consider:
      • Clonidine 0.1-0.2mg po

    Opioids

    • Need to address underlying withdrawal prior to successfully treating pain.
    • Immediate release opioids are more practical in the ED – more easily titratable and more rapid onset. They can easily temporize even in cases of missed OAT.
      • Oral is preferred over parental administration given longer duration of action (3-4 hours vs 1-2 hours), but IV can be used in severe cases given more rapid onset (15 min vs 90 min)
      • Avoid morphine in renal failure
      • Consider following orders (oral liquid for faster onset and minimizes cheeking)
        • Morphine oral liquid 20-30 mg po q2h PRN for cravings, withdrawal or pain. Hold if drowsy/not easily rousable
          • Increase to 30-40mg as needed
        • Hydromorphone oral liquid 4-6mg po q2h PRN
          • Can consider lower range of 2-4mg given higher affinity

    Opioid Agonist Therapy (OAT)

    • Peak effect of OAT beyond typical length of stay in ED (e.g. SROM 6-8 hours, methadone 2-4 hours)
    • Consider dosing in ED if:
      • Pharmacy is closed (prolonged stay in ED)
      • Admission
      • Missed doses that could lead dose reduction/discontinuation of prescription
    • Know your hospital’s protocol for dosing OAT and notify patient’s usual pharmacy of dose administered

    Special Scenarios

    • Injectable OAT
      • Managed in specialty clinics
      • Administration of high IV opioids doses BID or TID (either diacetylmorphine or hydromorphone)
      • Low threshold to ask for advice from addiction specialist- requires high doses of IV hydromorphone for pain/withdrawal (5-20mg IV)
    • Buprenorphine/naloxone (bup/nlx)
      • Response to IR opioids will depend on mu receptor binding – related to dose of bup and last dose administered
      • Need higher affinity opioids (fentanyl and hydromorphone) at higher doses

    Discharge Planning

    • Maintain similar pain approach as per guidelines: consider non-opioid analgesics as first line
    • If opioid prescription is required: short prescription at lowest dose, daily dispense with OAT, avoid oxycodone and provide THN
    • Ensure continuation of OAT

    Quality Of Evidence?

    Justification

    Ketamine: RCT and meta-analysis based in the ED, with one study including 25% of patients on opioids.

    NSAIDs and Acetaminophen: Good evidence some studies based in ED < but not necessarily reflective of this specific patient population.

    Moderate

    Guidance around pain management in patients with opioid use disorder is mostly expert consensus and observational studies (case reports, case series).

    Low

    Related Information

    OTHER RELEVANT INFORMATION

    Reference List

    1. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Opioids, Hatten BW, Cantrill SV, Dubin JS, Ketcham EM, Runde DP, Wall SP, Wolf SJ. Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department. Ann Emerg Med. 2020 ;76(3):e13-e39.


    2. Balzer N, McLeod SL, Walsh C, Grewal K. Low‐dose Ketamine For Acute Pain Control in the Emergency Department: A Systematic Review and Meta‐analysis. Miner J, ed. Acad Emerg Med. 2021;6:198–11.


    3. Bowers KJ, McAllister KB, Ray M, Heitz C. Ketamine as an Adjunct to Opioids for Acute Pain in the Emergency Department: A Randomized Controlled Trial. Miner J, ed. Acad Emerg Med. 2017;24(6):676-685.


    4. Chan AKM, Cheung CW, Chong YK. Alpha-2 agonists in acute pain management. Expert Opin Pharmacother. 2010;11(17):2849-2868. 


    5. Wheeler et al. Adjuvant Analgesic Use in the critically ill: a systemic review and meta-analysis. Critical Care Explorations. 2020;2(e0157):1-8.


    6. Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department. JAMA. 2017;318(17):1661-1667. 


    7. Coutens B, Derreumaux C, Labaste F, et al. Efficacy of multimodal analgesic treatment of severe traumatic acute pain in mice pretreated with chronic high dose of buprenorphine inducing mechanical allodynia. European Journal of Pharmacology. 2020;875:172884. 


    8. Dunn KE, Finan PH, Tompkins DA, Fingerhood M, Strain Characterizing pain and associated coping strategies in methadone and buprenorphine-maintained patients. Drug and Alcohol Dependence. 2015;157(C):143–149.


    9. Helander EM, Menard BL, Harmon CM, et al. Multimodal Analgesia, Current Concepts, and Acute Pain Considerations. February 2017:1-10.


    10. Horn A, Kaneshiro K, Tsui BCH. Preemptive and Preventive Pain Psychoeducation and Its Potential Application as a Multimodal Perioperative Pain Control Option. Anesthesia & Analgesia. 2020;130(3):559-573.


    11. Karlow N, Schlaepfer CH, Stoll CRT, et al. A Systematic Review and Meta‐analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department. Miner J, ed. Acad Emerg Med. 2018;25(10):1086-1097.


    12. Koller G, Schwarzer A, Halfter K, Soyka M. Pain management in opioid maintenance treatment. Expert Opin Pharmacother. 2019;20(16):1993-2005.


    13. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. JAMA. 2018;319(9):872–11.


    14. Scott G, Gong J, Kirkpatrick C, Jones P. Systematic review and meta‐analysis of oral paracetamol versuscombination oral analgesics for acute musculoskeletal injuries. Emerg Med Australas. 2020;33(1):107-113.


    15. Tucker H-R, Scaff K, McCloud T, et al. Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review. Br J Sports Med. 2020;54(11):664-664.


    16. Veazie S, Mackey K, Peterson K, Bourne D. Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review. September 2020;1-9.


    17. Voon P, Callon C, Nguyen P, Dobrer S, Montaner J, Wood E., Kerr Self-management of pain among people who inject drugs in Vancouver. Pain Management. 2014;4(1):27–35. 


    18. Wachholtz, A., & Gonzalez, G. Co-morbid pain and opioid addiction: Long term effect of opioid maintenance on acute pain. Drug and Alcohol Dependence. 2014;145:143–149. 

       


    19. Wardhan R, Chelly J. Recent advances in acute pain management: understanding the mechanisms of acute pain, the prescription of opioids, and the role of multimodal pain therapy. F1000Res. 2017;6:2065–10.


    20. Warner NS, Warner MA, Cunningham JL, Gazelka HM, Hooten WM, Kolla BP, Warner DO. A Practical Approach for the Management of the Mixed Opioid Agonist-Antagonist Buprenorphine During Acute Pain and Surgery. Mayo Clin Proc. 2020 Jun;95(6):1253-1267.


    21. Zeballos JL, Lirk P, Rathmell JP. Low-Dose Ketamine for Acute Pain Management. Regional Anesthesia and Pain Medicine. 2018;43(5):453-455.

       


    22. BC Centre on Substance Use – Opioid Use Disorder Guideline


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