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Pain Management of Patients with Substance Abuse in the Ambulatory Setting

  • Other Pain (N Vadivelu and A Kaye, Section Editors)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction.

Recent Findings

Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient’s outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate NSAIDs, tricyclics, gabapentinoids, anticonvulsants, opioid tapering, and regional anesthesia can help alleviate high postoperative pain control requirements.

Summary

In conjunction with such medication management, setting realistic expectations for pain control with preoperative counseling may be highly beneficial. For postoperative pain refractory to other strategies, the use of inpatient low-dose ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated pain service.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. • Huffman KL et al. Nonopioid substance use disorders and opioid dose predict therapeutic opioid addiction. J Pain. 2015;16(2):126–34. This paper showed that a high opioid dosage requirement and the presence of substance abuse are associated with a higher risk of opioid addiction. This relates highly to our review because surgical patients are exactly the demographic who will have increased dose requirements due to postoperative pain, and those patients who are coming to surgery with a history of substance use are especially susceptible.

  2. Hall AJ et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300(22):2613–20.

    Article  CAS  PubMed  Google Scholar 

  3. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15(9):618–27.

    Article  PubMed  Google Scholar 

  4. • Dart RC et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372(3):241–8. Although clinically, an increasing trend in opioid use and substance use in our patients is obvious, it is hard to demonstrate unequivocally in data due to the difficulty of collecting such a large database of information over time, especially for current data. This paper summarizes these trends over the last 15 years, in particular, giving numbers for the large increase in opioid prescriptions since 2002 and the increase in opioid diversion and abuse since 2002.

  5. Soyka M. New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone. Subst Abuse Rehabil. 2015;6:1–14.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Degenhardt L, Whiteford H, Hall WD. The Global Burden of Disease projects: what have we learned about illicit drug use and dependence and their contribution to the global burden of disease? Drug Alcohol Rev. 2014;33(1):4–12.

    Article  PubMed  Google Scholar 

  7. Manchikanti L et al. Prevalence of opioid abuse in interventional pain medicine practice settings: a randomized clinical evaluation. Pain Physician. 2001;4(4):358–65.

    CAS  PubMed  Google Scholar 

  8. Manchikanti L et al. Prevalence of illicit drug use in patients without controlled substance abuse in interventional pain management. Pain Physician. 2003;6(2):173–8.

    PubMed  Google Scholar 

  9. Vadivelu N et al. Pain control in the presence of drug addiction. Curr Pain Headache Rep. 2016;20(5):35.

    Article  PubMed  Google Scholar 

  10. Kahan M et al. Misuse of and dependence on opioids: study of chronic pain patients. Can Fam Physician. 2006;52(9):1081–7.

    PubMed  PubMed Central  Google Scholar 

  11. Weaver M, Schnoll S. Abuse liability in opioid therapy for pain treatment in patients with an addiction history. Clin J Pain. 2002;18(4 Suppl):S61–9.

    Article  PubMed  Google Scholar 

  12. Bingham CR, Shope JT, Tang X. Drinking behavior from high school to young adulthood: differences by college education. Alcohol Clin Exp Res. 2005;29(12):2170–80.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Conroy DA et al. Marijuana use patterns and sleep among community-based young adults. J Addict Dis. 2016;35(2):135–43.

    Article  PubMed  Google Scholar 

  14. Vadivelu N et al. Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient. Best Pract Res Clin Anaesthesiol. 2014;28(1):91–101.

    Article  PubMed  Google Scholar 

  15. Ghuran A, Nolan J. Recreational drug misuse: issues for the cardiologist. Heart. 2000;83(6):627–33.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. 2012;344:e536.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Moran S, Isa J, Steinemann S. Perioperative management in the patient with substance abuse. Surg Clin North Am. 2015;95(2):417–28.

    Article  PubMed  Google Scholar 

  18. Dowling K, Storr CL, Chilcoat HD. Potential influences on initiation and persistence of extramedical prescription pain reliever use in the US population. Clin J Pain. 2006;22(9):776–83.

    Article  PubMed  Google Scholar 

  19. Whitby LG, Hertting G, Axelrod J. Effect of cocaine on the disposition of noradrenaline labelled with tritium. Nature. 1960;187:604–5.

    Article  CAS  PubMed  Google Scholar 

  20. Foltin RW et al. The effects of escalating doses of smoked cocaine in humans. Drug Alcohol Depend. 2003;70(2):149–57.

    Article  CAS  PubMed  Google Scholar 

  21. Pavarin R et al. Cocaine-related medical and trauma problems: a consecutive series of 743 patients from a multicentre study in Italy. Eur J Emerg Med. 2011;18(4):208–14.

    Article  PubMed  Google Scholar 

  22. Irwin MR, Bjurstrom MF, Olmstead R. Polysomnographic measures of sleep in cocaine dependence and alcohol dependence: implications for age-related loss of slow wave, stage 3 sleep. Addiction. 2016;111(6):1084–92.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Demaria Jr S, Weinkauf JL. Cocaine and the club drugs. Int Anesthesiol Clin. 2011;49(1):79–101.

    Article  PubMed  Google Scholar 

  24. Bart G. Maintenance medication for opiate addiction: the foundation of recovery. J Addict Dis. 2012;31(3):207–25.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Isbell H, Wikler A, et al. Tolerance and addiction liability of 6-dimethylamino-4-4-diphenylheptanone-3 (methadon). J Am Med Assoc. 1947;135(14):888–94.

    Article  CAS  PubMed  Google Scholar 

  26. Isbell H, Vogel VH. The addiction liability of methadon (amidone, dolophine, 10820) and its use in the treatment of the morphine abstinence syndrome. Am J Psychiatry. 1949;105(12):909–14.

    Article  CAS  PubMed  Google Scholar 

  27. Treatment, C.f.S.A. Methadone mortality-a reassessment. Division of Pharmacologic Therapies. Center for Substance Abuse Treatment, SAMHSA/DHHS, 2007.

  28. Strang J et al. Impact of supervision of methadone consumption on deaths related to methadone overdose (1993-2008): analyses using OD4 index in England and Scotland. BMJ. 2010;341:c4851. doi:10.1136/bmj.c4851.

  29. Bentley KW, Hardy DG. Novel analgesics and molecular rearrangements in the morphine-thebaine group. 3. Alcohols of the 6,14-endo-ethenotetrahydrooripavine series and derived analogs of N-allylnormorphine and -norcodeine. J Am Chem Soc. 1967;89(13):3281–92.

    Article  CAS  PubMed  Google Scholar 

  30. Walsh SL et al. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994;55(5):569–80.

    Article  CAS  PubMed  Google Scholar 

  31. Kintz P. Deaths involving buprenorphine: a compendium of French cases. Forensic Sci Int. 2001;121(1):65–9.

    Article  CAS  PubMed  Google Scholar 

  32. Marsch LA et al. Predictors of outcome in LAAM, buprenorphine, and methadone treatment for opioid dependence. Exp Clin Psychopharmacol. 2005;13(4):293.

    Article  PubMed  Google Scholar 

  33. Weiss RD et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011;68(12):1238–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Moore BA et al. Primary care office-based buprenorphine treatment: comparison of heroin and prescription opioid dependent patients. J Gen Intern Med. 2007;22(4):527–30.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Rosenblatt AB, Mekhail NA. Management of pain in addicted/illicit and legal substance abusing patients. Pain Pract. 2005;5(1):2–10.

    Article  PubMed  Google Scholar 

  36. Buchsbaum DG et al. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Intern Med. 1991;115(10):774–7.

    Article  CAS  PubMed  Google Scholar 

  37. Magnani B, Kwong T. Urine drug testing for pain management. Clin Lab Med. 2012;32(3):379–90.

    Article  PubMed  Google Scholar 

  38. Arthur JA et al. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer. 2016;122:3732–9.

    Article  CAS  PubMed  Google Scholar 

  39. Peace MR, Tarnai LD, Poklis A. Performance evaluation of four on-site drug-testing devices for detection of drugs of abuse in urine. J Anal Toxicol. 2000;24(7):589–94.

    Article  CAS  PubMed  Google Scholar 

  40. Shannon M, Cox MN, Baum CR. Toxicology reviews: immunoassay in detecting drugs of abuse. Pediatr Emerg Care. 1998;14(5):372&hyhen.

    Article  Google Scholar 

  41. Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66–76.

    Article  CAS  PubMed  Google Scholar 

  42. Birnbaum HG et al. Estimated costs of prescription opioid analgesic abuse in the United States in 2001: a societal perspective. Clin J Pain. 2006;22(8):667–76.

    Article  PubMed  Google Scholar 

  43. Arthur JA et al. Aberrant opioid use and urine drug testing in outpatient palliative care. J Palliat Med. 2016;19(7):778–82.

    Article  PubMed  Google Scholar 

  44. Lee M et al. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145–61.

    PubMed  Google Scholar 

  45. Doverty M et al. Methadone maintenance patients are cross-tolerant to the antinociceptive effects of morphine. Pain. 2001;93(2):155–63.

    Article  CAS  PubMed  Google Scholar 

  46. Prater CD, Zylstra RG, Miller KE. Successful pain management for the recovering addicted patient. Prim Care Companion J Clin Psychiatry. 2002;4(4):125–31.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Jamison RN et al. Beliefs and attitudes about opioid prescribing and chronic pain management: survey of primary care providers. J Opioid Manag. 2014;10(6):375–82.

    Article  PubMed  Google Scholar 

  48. Heit HA. The truth about pain management: the difference between a pain patient and an addicted patient. Eur J Pain. 2001;5(Suppl A):27–9.

    Article  PubMed  Google Scholar 

  49. Fishman SM et al. The opioid contract in the management of chronic pain. J Pain Symptom Manage. 1999;18(1):27–37.

    Article  CAS  PubMed  Google Scholar 

  50. Fishman SM, Kreis PG. The opioid contract. Clin J Pain. 2002;18(4):S70–5.

    Article  PubMed  Google Scholar 

  51. Vadivelu N et al. Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting. J Pain Res. 2016;9:425–35.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiology. 1984;61(3):276–310.

    Article  CAS  PubMed  Google Scholar 

  53. Tung AS, Tenicela R, Winter PM. Opiate withdrawal syndrome following intrathecal administration of morphine. Anesthesiology. 1980;53(4):340.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA

    Nalini Vadivelu, Richard Zhu & Roberta Hines

  2. Stony Brook University School of Medicine, Stony Brook, NY, USA

    Alice M. Kai

  3. University of Connecticut School of Medicine, Farmington, CT, USA

    Vijay Kodumudi

Authors
  1. Nalini Vadivelu
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  2. Alice M. Kai
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  3. Vijay Kodumudi
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  4. Richard Zhu
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  5. Roberta Hines
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Correspondence to Nalini Vadivelu.

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Conflict of Interest

Nalini Vadivelu, Alice Kai, Vijay Kodumudi, Richard Zhu, and Roberta Hines declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Other Pain

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Vadivelu, N., Kai, A.M., Kodumudi, V. et al. Pain Management of Patients with Substance Abuse in the Ambulatory Setting. Curr Pain Headache Rep 21, 9 (2017). https://doi.org/10.1007/s11916-017-0610-3

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  • DOI: https://doi.org/10.1007/s11916-017-0610-3

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