Psychiatric Pharmacy Essentials: Pain Management in Patients with Substance Use Disorder(s)

Management of pain in patients with comorbid substance use disorders can be challenging. Providers may be hesitant to use opioid analgesics in patients with a history of substance misuse or those currently receiving substance use disorder treatment. However, these patients may still experience pain and should have their pain adequately treated.

  • How does one treat pain in the setting of comorbid substance use disorders?1-9
  • What are the consequences of suboptimal pain control in the presence of substance use disorder treatment?10-12
  • How to manage pain in the perioperative and postoperative setting for those on medication assisted treatment for opioid use disorder?12-19

Reviewer 1: Allison Beatty, PharmD, BCPP
Reviewer 2: Austin Smith, PharmD, BCPP
2024-2025 AAPP Resident and New Practitioner Committee

References

  1. Substance Abuse and Mental Health Services Administration. Managing chronic pain in adults with or in recovery from substance use disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. [Weblink]
  2. Chang Y-P, Compton P. Management of chronic pain with chronic opioid therapy in patients with substance use disorders. Addict Sci Clin Pract. 2013;8:21. DOI: 10.1186/1940-0640-8-21. PubMed PMID: 24341916; PubMed Central PMCID: PMC3904483.
  3. Cheatle M, Comer D, Wunsch M, Skoufalos A, Reddy Y. Treating pain in addicted patients: recommendations from an expert panel. Popul Health Manag. 2014;17(2):79-89. DOI: 10.1089/pop.2013.0041. PubMed PMID: 24138341; PubMed Central PMCID: PMC3996998.
  4. Liebschutz J, Beers D, Lange A. Managing Chronic Pain in Patients with Opioid Dependence. Curr Treat Options Psychiatry. 2014;1(2):204-223. DOI: 10.1007/s40501-014-0015-4. PubMed PMID: 24892008; PubMed Central PMCID: PMC4039557.
  5. Vadivelu N, Lumermann L, Zhu R, et al. Pain control in the presence of drug addiction. Curr Pain Headache Rep. 2016;20(5):35. [PubMed]
  6. Speed TJ, Parekh V, Coe W, Antoine D. Comorbid chronic pain and opioid use disorder: literature review and potential treatment innovations. Int Rev Psychiatry. 2018;30(5):136-146. [PubMed]
  7. Potru S, Tang YL. Chronic pain, opioid use disorder, and clinical management among older adults. Focus (Am Psychiatr Publ). 2021;19(3):294-302. [PubMed]
  8. Witkiewitz K., Vowles K. Alcohol and opioid use, co-use, and chronic pain in the context of the opioid epidemic: a critical review. Alco Clin & Experi Res. 2018;42(3):478-488. [PubMed]
  9. Murphy L., Ng K., Shu V., et al. Approach to the pharmacological management of chronic pain in patients with an alcohol use disorder. J Pain Res. 2015;8: 851-857. [PubMed]
  10. Eagen K, Rabson L, Kellum R. Management of chronic pain in patients with substance us disorders. Prim Care. 2022;49(3):455-468. [PubMed]
  11. Bounes V, Palmaro A, Lepeyre-Mestre M, Roussin A. Long-term consequences of acute pain for patients under methadone or buprenorphine maintenance treatment.  Pain Physician. 2013;16(6):E739-47. [PubMed]
  12. Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med. 2015;9(5):358-67. DOI: 10.1097/ADM.0000000000000166. PubMed PMID: 26406300; PubMed Central PMCID: PMC4605275.
  13. Goel A, Azargive S, Lamba W, et al. The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes. Can J Anaesth. 2019;66(2):201-217. [PubMed]
  14. Mehta D, Thomas V, Johnson J, et al. Continuation of Buprenorphine to Facilitate Postoperative Pain Management for Patients on Buprenorphine Opioid Agonist Therapy. Pain Physician. 2020;23(2):E163-E174. [PubMed]
  15. Kohan L, Potru S, Barreveld AM, et al. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021;46(10):840-859. [PubMed]
  16. Hickey T, Abelleira A, Acampora G, et al. Perioperative buprenorphine management: a multidisciplinary approach. Med Clin North Am. 2022;106(1):169-185. [PubMed]
  17. Schuster B, Bell B, Massoll A, White S. Continuation versus discontinuation of buprenorphine in the perioperative setting: a retrospective study. Cureus. 2022;14(3):e23385. [PubMed]
  18. Cornett EM., Kline RJ., Robichaux SL., et al. Comprehensive perioperative management considerations in patients taking methadone. Curr Pain and Headache Reports. 2019;23:1-9. [PubMed]
  19. Harrison TK, Kornfeld H, Aggarwal AK, Lembke A. Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy. Anesthesiol Clin. 2018;36(3):345-359. [PubMed]