Patients With Pain  

Anything that is worth having is worth asking for. Some say yes and some say no. ---Dr. Melba Colgrove

Patients Being Treated For Pain Who Become Dependent On Opioids

Patients who need treatment for pain but not for addiction should be treated within the context of their regular medical or surgical setting. They should not be transferred to an opioid maintenance treatment program simply because they are being prescribed opioids and have become physically dependent on the opioids in the course of their medical treatment.

It can be difficult to distinguish between the legitimate desire to use opioids for pain relief and the desire to procure them for purposes of obtaining a high. This may be especially true in patients who have become physically dependent on opioids in the course of the treatment of a pain condition when that pain has been undertreated and inadequately relieved.

Clinical Features Distinguishing Opioid Use In Patients With Pain Versus Patients Who Are Addicted To Opioids

Clinical FeaturesPatients With PainPatients Who Are Addicted to Opioids

Compulsive drug useRareCommon
Crave drug (when not in pain)RareCommon
Obtain or purchase drugs from nonmedical sourcesRareCommon
Procure drugs through illegal activitiesAbsentCommon
Escalate opioid dose without medical instructionRareCommon
Supplement with other opioid drugsUnusualFrequent
Demand specific opioid agentRareCommon
Can stop use when effective alternate treatments are availableUsuallyUsually not
Prefer specific routes of administrationNoYes
Can regulate use according to supplyYesNo

Patients Who Are Addicted to Opioids and Who Require TreatmentFor Pain

Behaviors associated with drug abuse frequently result in the development of acute and chronic pain conditions. These conditions may be caused by the toxic effects of the drug itself, as well as by trauma and infection.

Patients receiving addiction treatment also may experience pain due to illness or injury unrelated to drug use. Physicians must manage this pain efficiently and appropriately.

Opioids are among the most effective available options for managing pain, but they are often not prescribed to patients receiving treatment for addiction out of fear of “feeding the addiction” or of triggering relapse in currently abstinent patients.

 State laws governing the prescription of opioids to known substance abusers may place prescribing physicians at risk for prosecution unless the medical record clearly distinguishes between treatment of the addiction and treatment of the pain condition.

Treatment Approach

Little clinical experience is documented regarding the treatment of pain in patients receiving buprenorphine. Pain in patients receiving buprenorphine treatment initially should be treated with nonopioid analgesics when appropriate. Although buprenorphine itself has powerful analgesic properties, the once-daily administration of buprenorphine, as used for the treatment of opioid addiction, often does not provide sufficiently sustained relief of pain.

Additionally, the onset of action of analgesia with buprenorphine may not be adequate for the treatment of acute pain. In a study of the use of buprenorphine for acute analgesia (Nikoda et al. 1998), the high analgesic activity of buprenorphine was comparable to that of morphine, but the onset of action was found to be inadequate for urgent care.

Patients maintained on buprenorphine whose acute pain is not relieved by nonopioid medications should receive the usual aggressive pain management, which may include the use of short-acting opioid pain relievers. While patients are taking opioid pain medications, the administration of buprenorphine generally should be discontinued.

 Note that, until buprenorphine clears the body,and higher doses of short-acting opioids may be required. It may be difficult to achieve analgesia with short-acting opioids in patients who have been maintained on buprenorphine

 Noncombination opioid analgesics are generally preferred to avoid the risk of acetaminophen or salycilate toxicity when combination products are used at the doses that are likely to be required for pain control in patients who have been maintained on buprenorphine. Analgesic dose requirements should be expected to decrease as buprenorphine clears the body.

When restarting buprenorphine administration, physicians should
refer to induction procedures. 
 To prevent the precipitation of withdrawal, buprenorphine should not be restarted until an appropriate period after the last dose of the opioid analgesic, depending on the half-life of the opioid analgesic used.

Patients who are receiving opioids for chronic severe pain may not be good candidates for buprenorphine treatment because of the ceiling effect on buprenorphine's analgesic properties.

This rationale also would be applicable to terminally ill patients. In patients who are maintained on buprenorphine and require end-of-life opioid analgesia, buprenorphine administration should be discontinued, unless the buprenorphine provides adequate analgesia or the patient prefers buprenorphine for some other reason.

 In patients who are opioid addicted and who have severe chronic pain methadone several times per day or other “round the clock” (rather than as required) long-acting, full-agonist medications may be the best alternative for treatment. This form of treatment is often best undertaken in conjunction with an Opioid Treatment Program (OTP).

However, if the physician is (1) otherwise qualified to treat the condition causing the pain and (2) careful to document that the primary purpose of the opioid pharmacotherapy is the management of that pain condition, then it may be acceptable to treat that patient in the office setting without further referral.

As long as this type of patient remains compliant and is not abusing the pain medication or other drugs, there is no legal need for the patient to be treated in an OTP or with buprenorphine for the preexisting or concurrent addictive disorder.

However, the Drug Enforcement Administration (DEA) frowns on the use of this as a rationale to treat the “pain of withdrawal” or spurious and ill-defined pain conditions to justify unsanctioned opioid maintenance.

Patients who are on chronic opioids for pain management and who have a history of drug abuse or addiction can be referred to a 12-Step program or other self-help group to help them maintain their level of recovery. Random drug screening also can reassure the physician that both physician and patient are staying within lawful bounds.

Because all pharmacological treatment with opioids is highly regulated, physicians who desire to use opioids to treat chronic pain in patients who are at risk for opioid addiction or relapse are advised to consult with a colleague knowledgeable in opioid maintenance pharmacology.

Reference: (1)  Clinical Guidelines For  The  Use  of   Buprenophine  In  The
                                Treatment Of Opioid Addiction (TIP 40) Chapter 5 pp.73-75

Written And Compiled:  Deborah Shrira             Dated:  12 June 2007