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 medication 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?1-10
  • 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 medications for opioid use disorder?13-21

Reviewer 1: Roisin Sabol, PharmD
Reviewer 2: Austin Smith, PharmD, BCPP
2025-2026 AAPP Resident and New Practitioner Committee

  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 YP, Compton P. Management of chronic pain with chronic opioid therapy in patients with substance use disorders. Addict Sci Clin Pract. 2013;8:21. [PubMed]
  3. Liebschutz J, Beers D, Lange A. Managing chronic pain in patients with opioid dependence. Curr Treat Options Psychiatry. 2014;1(2):204-223. [PubMed]
  4. Vadivelu N, Kai AM, Kodumudi G, et al. Recommendations for substance abuse and pain control in patients with chronic pain. Curr Pain Headache Rep. 2018;22(4):25. [PubMed]
  5. 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]
  6. 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]
  7. 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]
  8. 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]
  9. Spreen LA, Dittmar EN, Quirk KC, Smith MA. Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review. Pharmacotherapy. 2022;42(5):411-427. [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. [PubMed]
  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. 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]
  18. Foglia R 3rd, Yan J, Dizdarevic A. Methadone and buprenorphine in the perioperative setting: A review of the literature. Curr Pain Headache Rep. 2024;28(11):1105-1111. [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]
  20. Smith K, Wang M, Abdukalikov R, et al. Pain management considerations in patients with opioid use disorder requiring critical care. J Clin Pharmacol. 2022;62(4):449-462. [PubMed]
  21. Buonora MJ, Mackey K, Khalid L, et al. Acute pain management in people with opioid use disorder : a systematic review. Ann Intern Med. 2025;178(4):558-570. [PubMed]