Posts Tagged ‘pain meds in addicts’

Treatment of Pain in Patients with Addiction

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Recently I was discussing the finer points of management of pain with a colleague, and it occurred to me I hadn’t done a recent post on the management of pain in opioid addicts.

I think about pain in two categories: acute and chronic. While there are some conditions that defy this handy concept, most types of pain fall into one of the two types.

This post will address only about acute pain; I will do another post about chronic pain in future posts.

To reiterate, I’m not talking about pain from chronic conditions like arthritis, chronic back pain, pelvic pain, fibromyalgia, and the like. In contrast, acute pain examples include broken bones, surgery, physical trauma from an accident, and other conditions that begin suddenly, and resolve over a period of weeks to months.

Just because a person has the disease of opioid addiction does NOT mean she needs to suffer through acutely painful conditions without the blessed relief opioids can bring. Obviously, any time a person with opioid addiction is given a bottle of opioids, pain or no, we worry about the risk of relapse. And we know relapse can be serious, even life-threatening. However, safeguards can be put into place to defend against a relapse.

Acute severe pain is more difficult to manage if the patient is taking buprenorphine than methadone, but pain relief can still be achieved.

Many patients in recovery from opioid addiction are surprised to discover that mild to moderate acute pain can often be treated with non-opioid pain medication like anti-inflammatories such as ibuprofen or acetaminophen. While in active addiction, many of my patients never even tried such measures, and are happy to find that they can be effective. Other options like massage, heat, ice, or elevation can also help.

But moderate to severe acute pain usually requires opioid pain medications.

For patients on methadone, the standard approach is to continue the methadone at the patient’s usual dose, and add short-acting opioids. Best results for the patient are seen when the opioid treatment program doctor communicates with the doctor treating the condition causing the acute pain.

When I collaborate with other doctors, I tell them to prescribe whatever they would prescribe for any other patient, except my patients will probably need about fifteen to twenty percent higher dose, to make up for their existing tolerance to opioids.

I don’t worry about a relapse while the patient is in the hospital. While hospitalized, the patient’s response to opioid medication can be controlled and adjusted. It would be difficult for the patient to abuse the opioids they are being given while hospitalized.

The greater risk occurs after the patient leaves the hospital. I suggest the patient give their bottle to a dependable non-addict who can dispense one dose at a time, or at least one day’s dose at a time. So long as someone else controls the opioid medication, my patient will be safer. I also recommend prescribing smaller amounts of opioids with more frequent follow-up, but that’s not always possible.

With buprenorphine, it gets tricky. Some patients on buprenorphine get pain relief from short-acting opioid prescribed in addition to the usual buprenorphine daily dose, but I’ve had plenty of patients tell me they could not get pain relief from opioids until after buprenorphine was stopped for several days. To be on the safe side, if a patient has a surgery scheduled, I’ll ask my patient to stop dosing the day prior to the surgery, and stay off buprenorphine until after the pain resolves enough to get by without short-acting opioids.

For patients who were more fragile in their recovery, I’ve used an approach that I learned from other doctors at addiction medicine conferences: I reduce the usual maintenance dose of buprenorphine down to 2 mg sublingual daily, starting the day before surgery. Theoretically, this low dose of buprenorphine prevents euphoria from short-acting opioids, while not blocking the analgesic (anti-pain) effect of these opioids.

For a planned surgery, I prefer to work out details of pain control with the other doctor prior to the surgery. Duh. I hate getting post-operative calls from the nurses of surgeons telling me I am expected to manage the patient’s pain, since the patient has addiction and Dr. Surgeon does not “believe” in prescribing opioids for opioid addicts.

Oh no. That does not work for me at all.

I’m not a surgeon, so I don’t know how long patients usually need opioids after this type of surgery. I also won’t know when the degree of pain may indicate some complication from surgery. Not to mention that I wasn’t the one who got paid for doing the surgery, and was not consulted pre-operatively.

I’m happy to collaborate with the surgeon, and of course prefer to do this prior to the surgery. I tell the surgeon I prescribe methadone/buprenorphine to treat addiction, not pain, and that the usual maintenance dose of either will not help with acute pain. I give the doctor some guidance regarding my patients’ opioid tolerance. I tell her our opioid treatment program will watch our shared patient more closely for signs of relapse, and that the counselor will work with the patient to get a dependable non-addict to handle the bottle of pills. I tell the surgeon that we are happy to do pill counts when needed, for additional accountability.

My patients tell me they hate to tell a surgeon or other new doctor about being in medication-assisted recovery. They say when they tell a new doctor about being prescribed methadone or buprenorphine, they sometimes detect a change in attitude, like judgment, increased brusqueness, or even hostility. They fear they will not be believed if they report pain.

I can’t blame them for being worried, because even when I call other physicians, I sometimes detect a bit of insolence from the physician on the other end of the phone. I often feel my legitimacy as a physician is being questioned, even though, ironically, I have more data to support what I do now as a doctor than I ever had as a primary care physician. I often sense a real reluctance for surgeons and other doctors to go along with what I’m recommending, and that’s a shame, because I have evidence-based information they can use.

My goal when talking with another physician is primarily to make sure my patient gets appropriate care including pain control. It’s a bonus if I can educate that doctor about medication-assisted treatment, and try to give them a better understanding of addiction and recovery.