Managing Pain in Patients with Substance Use Disorders: Addressing Unique Challenges and Implementing Integrated Care
Pain is a common and complex condition that affects millions of people worldwide. Pain can have physical, psychological, and social impacts on the quality of life of patients and their families. However, pain management is not a one-size-fits-all approach. Patients with substance use disorders (SUDs) face unique challenges and barriers to accessing effective and safe pain treatment. SUDs are chronic, relapsing conditions that involve compulsive use of substances despite negative consequences. SUDs can interfere with pain perception, increase the risk of opioid misuse and overdose, and complicate the use of non-opioid analgesics. Therefore, pain management in patients with SUDs requires a comprehensive and multidisciplinary approach that addresses both the pain and the underlying addiction.
Integrated care is a model of health care delivery that aims to provide coordinated, patient-centered, and evidence-based services for patients with complex needs. Integrated care can improve the quality and outcomes of pain management in patients with SUDs by addressing the biopsychosocial aspects of pain, reducing stigma and discrimination, enhancing communication and collaboration among providers, and facilitating access to appropriate resources and referrals. Integrated care can also prevent or reduce the harms associated with substance use, such as overdose, infection, withdrawal, and relapse.
There are several components of integrated care that can be applied to pain management in patients with SUDs. These include:
– Screening and assessment: Patients with pain should be screened for SUDs using validated tools, such as the Alcohol Use Disorders Identification Test (AUDIT), the Drug Abuse Screening Test (DAST), or the Opioid Risk Tool (ORT). Patients with SUDs should be assessed for pain using standardized measures, such as the Numeric Rating Scale (NRS), the Brief Pain Inventory (BPI), or the McGill Pain Questionnaire (MPQ). The screening and assessment process should also include a comprehensive evaluation of the patient’s medical history, physical examination, psychosocial factors, functional status, and treatment preferences.
– Treatment planning: Patients with pain and SUDs should be involved in the development of an individualized treatment plan that addresses both conditions. The treatment plan should include realistic and measurable goals, strategies to monitor progress and outcomes, and contingency plans for potential challenges or crises. The treatment plan should also specify the roles and responsibilities of each provider involved in the patient’s care, as well as the frequency and mode of communication among them.
– Pharmacological interventions: Patients with pain and SUDs may benefit from pharmacological interventions that target both pain and addiction. However, these interventions should be used with caution and under close supervision, as they may pose risks of misuse, dependence, tolerance, withdrawal, or overdose. Opioids are potent analgesics that can relieve moderate to severe pain, but they can also cause euphoria, sedation, respiratory depression, constipation, nausea, and itching. Opioids should be prescribed only when other analgesics are ineffective or contraindicated, and only in the lowest effective dose and for the shortest duration possible. Opioids should be combined with non-opioid analgesics, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or anticonvulsants, to enhance their efficacy and reduce their adverse effects. Opioids should also be co-prescribed with naloxone, an opioid antagonist that can reverse opioid overdose, and patients should be educated on how to use it in case of emergency. Patients who are prescribed opioids should be monitored regularly for signs of misuse, abuse, diversion, or overdose using tools such as urine drug testing (UDT), prescription drug monitoring programs (PDMPs), or pill counts.
Patients with pain and opioid use disorder (OUD) may benefit from medication-assisted treatment (MAT), which combines opioid agonists or antagonists with behavioral therapies to treat both pain and addiction. MAT can reduce opioid cravings
