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withdrawal syndrome if use is stopped abruptly. Due to a rise in methadone-associated deaths, the
JournalofPainreleasedguidelinesonmethadonesafety(Chouetal.,2014).Theseguidelinesprovide
directionontheappropriateuseofmethadoneforchronicpainandOUDbasedontheavailableevidence.
Informationondosing,titration,andECGmonitoringareareascoveredintheguidelines.
OpioidAntagonist:Naloxone
Naloxoneisapureopioidantagonistthatcompetitivelybindstoopioidreceptorswithoutproducingan
analgesicresponse.Naloxoneisinactivatedwhengivenorallyandthereforeisgivenmainlybyinjection.
Naloxoneisindicatedfortreatingopioid-inducedrespiratorydepression.Effortsarebeingmadetomake
naloxone readily available as a response to the increasing opioid-related deaths. Many states have a
“standingorder”givingpharmaciststhefreedomtosellnaloxonetopatientsatariskofanoverdose.An
intra-nasaldosageformisapprovedforoutpatientuse.
The duration ofnaloxone’s drugactionis approximately45 minutes. In mostcases, this durationis
shorter thanthatoftheoffendingopioid,andtheoverdoseeffectfromtheopioidmayreturn,requiring
readministrationofnaloxone.Caremustbetakentoavoidprecipitationofwithdrawalinopioid-tolerant
patientswhenadministeringnaloxone.Rareadverseeffectsofnaloxoneincludetachycardia,ventricular
fibrillation, and cardiac arrest dueto the release of neurotransmitters when naloxoneis administered.
Opioidwithdrawalsyndromemayoccurinopioid-tolerantpatientswhenexcessiveorrapidreversalis
used.
SafetyofOpioids
Side effects common to all opioids include sedation, confusion, respiratory depression, itching,
nausea/vomiting,andconstipation.Opioid-inducedboweldysfunctiondevelopsduetoreducedmovement
throughthelowerGItractduetoreductionofboweltoneandmotility,increasedanalsphinctertone,and
increased absorptionof fluids.Althoughconsideredthe mostdangeroussideeffect,severe respiratory
depressionisseennotonlyinoverdosesituationsbutalsoinpatientswhoareopioidnaive.Patientswho
areatriskforrespiratorydepressionincludeolderadults,patientswhohaverespiratorycomorbidities
such as obstructive sleep apnea, andpatients with kidney/liver failure. Patients with chronic pain on
opioidsusuallydeveloptolerancetotherespiratorydepressioneffects. However,ifsubstantial opioid
doses are usedinadditiontochronic therapy,asinthecaseofa postoperative opioid-tolerantpatient,
riskforrespiratorydepressionis increased.Inpatientswithclosedheadinjuryorrecentbrainsurgery,
opioidsshouldbeusedwithcautionbecausehemodynamiceffects(e.g.,hypotension,orthostasis)maybe
exaggerated.
Careshouldbetakenwhenadministeringopioidstoolderadultsorinpatientswithrenalfailure,liver
failure,andrespiratorydiseases.Inpatientswithrenalfailure,morphineshouldbeusedwithcautiondue
toaccumulationofneurotoxicmetabolites.Opioid-inducedhyperalgesiacanresult,aphenomenonwhere
rapidupwardtitrationofopioiddosesormetaboliteaccumulationcancausepaintoescalate.Myoclonus
canbetheinitialtelltalesignthathyperalgesiaispresent.Inpatientswithend-stageliverdisease,lower
doses andextendeddosing intervals are recommendeddue to decreases inopioid metabolism.Lower
dosesshouldbeinitiatedinthesepatientsandtitratedslowlybasedonresponse.Utilizingcoanalgesicsas
monotherapyorincombinationwithopioidsmaybeeffectiveinchronicpaintreatmentandmaydecrease
opioidrequirements.
BowelRegimenforthePreventionofConstipation
Toleranceusuallydevelopswithinafewdaystomostoftheadversereactionsassociatedwithopioids,
except for constipation. Constipation prevention is needed in patients receiving opioids. The general
approachforpatientsonopioidtherapyistoinstituteaprophylacticbowelregimenconsistingofamild
stimulantorosmoticagentplus/minusastoolsoftener.Thedoseofthestimulantcanbetitratedbasedon
patientresponse.Initialdosingwouldconsistofsenna2tabletsdailyortwicedaily.Polyethyleneglycol
(PEG) powder packetsused dailyis another effective alternative. PEG is usuallydosed initially at 1
packet(17g)daily.Upto4packetsperdosedailycanbeutilized.Docusatesodium100mgtwicedaily
is often used when stool softening is needed. However, a 2013 study comparing senna alone to
senna/docusate showed nodifference intheefficacyofdocusate versus placebowhen added to senna
(Tarumietal.,2013).Ifthereisnobowelmovementproducedin48hours,considerusinganadditional
agent (e.g., bisacodyl suppository, lactulose, sorbitol, additional PEG) to stimulate peristalsis. If
interventions continue to be ineffective, assess for impaction. If no impaction is present, utilizing an
additional method (e.g., enema) is recommended. Once the patient has a bowel movement, titrate the
dosageofthecurrentregimentoaneffectivedose.(Upto8tabletssennaperdayortheliquidequivalent
has beenused in the hospice andpalliative care population.) Docusate sodiumshould not be titrated
aggressivelybecausesodiumsaltmayaffectsodiumlevels.
Use of bulk-forming laxatives in patients receiving opioids is not recommended. Due to slower
peristalsisinpatientsreceivingopioidsandpotentialinadequatefluidintake,themedicationmaylodgein
thecolon,causingbowelobstruction.
New novel agents are now available to treat refractoryconstipationdue to opioids by specifically
targeting the mu receptors in the gut. These medications were developed by altering the structure of
naltrexone and naloxone, making them unable to cross the blood–brain barrier, thereby preventing
reversalofanalgesia.Methylnaltrexoneisavailableasaninjectableandoralformulationwitheffectseen
withinminutestoafewhourswiththeinjectableproduct.Naloxegolisanoralagentwithatimetoeffect
ofapproximately12hours.
OpioidTolerance,Dependence,Pseudo-Addiction,andAddiction
Opioid tolerance develops when chronic use of opioids causes the need for upward dose titrationto
maintain analgesia. Opioid dependence isdefinedasanemergence ofwithdrawal symptomswhenthe
drugisabruptlydiscontinuedorwhenthedoseisrapidlydecreased.Toleranceandphysicaldependence
ofopioids candevelop quickly. Apparentdependence and/or tolerance in a patient with chronic pain
should not impede titrationof therapy to an effective dose. However, if no pain control is seen with
increasingdoses,analternateopioidshouldbeconsidered.
Patients taking opioids for as briefly as 2 or 3 days may become dependent and can experience
withdrawalsymptomsupondiscontinuation.Withdrawalsymptomsrangefrommildtremorstosweating
andfeverandmimicflu-likesymptoms.Severewithdrawalsymptomsinopioid-dependentpatientsmay
consist of increased respiratory rate, perspiration, lacrimation, mydriasis, hot and cold flashes, and
anorexia.
Patients with pain may demonstrate signs of maladaptive behavior, which may be a result of
undertreated pain or worsening pain due to disease progression, rather than active SUD. Pseudoaddiction,definedas drug-seekingbehaviorsduetoinadequatepainmanagement,canbedifferentiated
fromtrueaddictionbecause“pseudo-addictive”behaviorswillresolveonceadequatepainmanagement
isachieved.
Addictionis definedas“a treatable, chronic medicaldisease involvingcomplexinteractionsamong
braincircuits,genetics,theenvironment,andanindividual’slifeexperiences.Peoplewithaddictionuse
substances or engage in behaviors that become compulsive and often continue despite harmful
consequences”(AmericanSocietyofAddictionMedicine[ASAM]2019).Thetermaddiction hasbeen
replacedbythetermSUDduetothenegative connotationsassociatedwiththeformer.SevereSUDis
characterized by behaviors thatinclude 6 of 11 criteria set by the American Psychiatric Association.
Criteria include impaired control over drug use, compulsive use, continued use despite harm, and
cravings.In2016,anestimated2.1millionAmericanswerereportedtobesufferingfromanopioiduse
disorder(SubstanceAbuseandMentalHealthServicesAdministration[SAMHSA]2017).Opioidabuse
hasbeenreportedinpatientswithchronicpainwithpsychologicalcomorbiditieswhouseopioidstotreat
painresultingfromdepressionoranxiety.Theconceptofsubstanceabusewithrespecttoopioidsisan
important consideration in patients presenting with uncontrolled pain but is beyond the scope of this
chapter.Forfurtherinformation,seeChapters10and43.
Co-analgesics
Severalmedicationshavebeenevaluatedforuseeitheraloneorinconjunctionwithotheranalgesicsto
treat many persistentpain conditions. The most benefit is seen in chronic pain, neuropathic pain, and
sensitizedpainsyndromes.
Antidepressants
Antidepressants, including tricyclic antidepressants (TCAs) and selective norepinephrine reuptake
inhibitors(SNRIs),exhibitanalgesiceffectsbyprimarilyblockingthereuptakeofnorepinephrine,thereby
increasingpain-modulatingpathwayactivity. TCAsalso blockperipheral sodiumchannels, whichmay
also helpreducepain.TCAsandSNRIshavebeenusefulinneuropathicpainresultingfrom canceror
cancer therapies and chronic noncancer, neuropathic pain syndromes (i.e., diabetic or postherpetic
neuropathy, chronic low back pain, and fibromyalgia). Several TCAs have beneficial effects in
neuropathic pain, including amitriptyline, desipramine, and nortriptyline. Common adverse reactions
includedrymouth,weightgain,dizziness,urinaryretention,confusion,andsedation.DosingofTCAsis
initiatedat10to25 mgnightlyandtitratedweeklytoaneffective dose of75to100 mgeachevening.
Therapywith TCAs should be initiated withcautionin older adults duetoanincreased incidence of
confusionandsedationduetoanticholinergicactivity,whichmayleadtofalls.TCAsshouldnotbeused
as a first-line agent and should be reserved for treatment failures to other agents in the older adult
population. Amitriptyline is the most studied TCA. The second-generation agents nortriptyline and
desipraminemaybebettertoleratedthanamitriptylinebecauseoflesscholinergicandsedativeeffects.
TheSNRIsduloxetineandvenlafaxinemaybesaferalternativesforthetreatmentofneuropathicpain
conditions.Duloxetinedosingisinitiatedat20 to30 mg/d toa targetdose of60 mg/d. Dosingcanbe
titratedto120mg/difindicated.Venlafaxinedoseisinitiatedat75mg/dandtitratedtoamaximumdose
of 225 mg/d either once daily or divided twice daily based on dosage form (SR vs. IR) These
medications are better tolerated than the TCAs because no cholinergic side effects are seen. GI
disturbances,sedation,insomnia,sweating,andconfusionmaybeseenwithSNRIuse.Venlafaxinehas
alsobeenassociatedwithincreasesinbloodpressure.
Abrupt discontinuation of TCAs and SNRIs may precipitate withdrawal symptoms. Patients can
experienceflu-likesymptoms,insomnia,nausea,andanxiety.Thephenomenonisseenmorewhenshortactingagentsarestoppedwithoutanappropriatetaper.Symptomsaregenerallynotseriousbutcanbe
severeinsomepatients.Restartingthemedications,transitioningtoalong-actingantidepressantpriorto
decreasingthedose,orslowingthetapercanhelpwithreducingthesymptomsofwithdrawal.
Anticonvulsants
Another groupofagentscommonly prescribed for neuropathic painconditions are theanticonvulsants.
The most common agents used in this class are the gabapentinoids, which include gabapentin and
pregabalin.Theanticonvulsantscarbamazepineandoxcarbazepinearespecificallyusedforpaindueto
trigeminalneuralgia.Gabapentinhashistoricallybeenthefirst-lineanticonvulsantagentrecommendedfor
paintreatment.Pregabalinisstructurallysimilartogabapentinandhasthesamemechanismofaction.The
mechanismofactionisnottotallyunderstood,butitispostulatedtobeduetotheeffectsofbindingtothe
alpha-2-delta subunit of voltage-dependent calcium channels, resulting in a reduction of the influx of
calciumintothedorsalhorn.Thisresultsinadecreasedreleaseofglutamate,causingloweractivationof
thesecond-order neurons responsible for transmissionofthepain signal to thebrain.Gabapentinand
pregabalinaregenerallywell tolerated. Mostcommonside effectsincludenausea,sedation,dizziness,
weightgain,andataxia.Peripheraledemahasbeenassociatedwithpregabalinuse.Gabapentinoidshave
been shown to be effective for many neuropathic pain conditions, including diabetic neuropathy,
trigeminal neuralgia, restless leg syndrome, phantom limb pain, and pain after a stroke. Generally,
gabapentindosesarestartedat100to300mgdailyandtitratedupto1,800to3,600mgdailyinthreeto
fourdivideddailydoses.ASRformulationisalsoavailablewithalowermaximumdoseof1,800mg/d.
TheSRandIRproductsarenotinterchangeable.
Pregabalinisbetterabsorbedthangabapentin,andefficacyisseeninapproximately1week,compared
to4to6weekswithgabapentin.Thedoseshouldbestartedlowandtitrated.Initialdosesare50mgtwo
tothreetimesdaily,titratedtoaneffectivedose.Themaximumdoseofpregabalinis600mg/d.Ageneric
formulation of pregabalin has recently been released. Side effects are similar to those of gabapentin.
Dosingofgabapentinandpregabalinshouldbereducedinpatientswithrenalimpairment.
Carbamazepineandoxcarbazepineareconsideredthedrugsofchoicefortrigeminalneuralgia.Other
anticonvulsants including topiramate, lamotrigine, and divalproex may be tried for neuropathic pain
treatmentifothermodalitieshavefailed.
SodiumChannelBlockers(LocalAnesthetics)
Thisclassofmedicationsexertsitsanalgesiceffectsbyblockingsodiumchannels,therebyslowingpain
transmission and increasing the firing threshold of the second-order neurons. Several routes of
administrationexistandare chosenbased on the indicationfor use. Topical applications help control
localizedneuropathicpainwithminimalabsorption.LidocainepatchesandEMLA(R)cream(mixtureof
lidocaineandprilocaine)areavailablefortopicaluse.Lidocainepatchesareindicatedforpostherpetic
neuralgia, but efficacy is reported in painful conditions such as diabetic peripheral neuropathy and
osteoarthritis.Patchesmaybecut,anduptothreepatchesmaybeused.Applicationisusually12hourson
and 12 hours off daily. Systemic absorption is minimal. The safety and tolerability of 24-hour
administrationweredemonstratedinastudypublishedintheAnnalsofPharmacotherapyin2002,which
compared safety of 24-hour administration to the recommended 12-hour application (Gammaitoni &
Alvarez,2002).Pharmacokinetic dataon24-houradministrationreportedinthestudyshowedsystemic
absorptionmarkedlybelowthelevel neededfortoxicityandwaswelltolerated.Lidocainepatchesare
nowavailableoverthecounter.
Localinjectionsofanestheticscanbeutilizedasregionalanesthesia,injectedintotissueortheepidural
space. Epidural analgesia is commonly utilized in managing obstetric or postoperative pain. Rarely,
lidocaine has been administered intravenously to control refractory pain conditions in subanesthetic
dosages.Intravenousinfusionsmustbe administeredina monitoredsettingbecauseofthepotentialfor
severeadversedrugreactionswithpossibleexceptionsintheend-of-lifepopulation.Evidencehasshown
that the use of lidocaine as a palliative measure for refractory pain may be efficacious when other
methodshavefailed.
N-Methyl-D-AspartateReceptorAntagonists
Evidence is emerging in the use of the NMDA antagonists, specifically ketamine, for both acute and
chronic pain. Ketamine, an anesthetic agent, is used as a bolus dose or an intravenous infusion for
treatmentofavarietyofpainconditions,suchaspostoperativepain,chronicrefractorypain,andacute
painintheemergencydepartment.Dosesforanalgesiaarelowerthandosesusedforanesthesia.Cancer
andnoncancer pain refractoryto other treatmentsmaybenefitfromtheadditionof ketamine to opioid
therapy. Better pain control andanopioid-sparing effect have beendemonstratedin studies using this
combination. Ketamine reduces firing of the NMDA receptor, thereby decreasing sensitivity to pain
impulses.Ketamine,bytheoralandtopicalroutes,alsoshowspromiseforthetreatmentofpain.Adverse
effectsare dose relatedandincreasedinpatientswhohaveahistoryofpsychiatric comorbidities.The
most common side effects with ketamine are vivid dreams and sedation. Delirium, dysphoria,
hallucinations,hypotension,hypertension,andincreasedintracranialpressurehavealsobeenassociated
with its use. Other NMDA antagonists, such as dextromethorphan, memantine, amantadine, and
magnesium,havenotshownpromiseforpainreductioninstudiesrelatedtouseasanalgesics.
Anupsurgeofketamineusagefor a varietyofconditionshasprompted therelease ofguidelinesfor
both acute (Schwenk et al., 2018) and chronic (Cohenet al., 2018) pain management. The consensus
guidelines were developed by three pain organizations to address the use of ketamine for acute and
chronicpain.Foracutepain,theguidelinesproviderecommendationsonindications,contraindications,
useasanadjunctiveagenttoopioids,useofnon-parenteraldosageforms,andtheappropriateanalgesic
dosing range. Chronic pain guidelines suggest possible efficacy for use in CRPS for up to 12 weeks
(moderateevidence) andpossibleshort-termimprovementofspinal cord injurypain(weakevidence).
Contraindications include pregnancy, active psychosis, uncontrolled cardiovascular disease, severe
hepaticdiseaseandelevatedintracranial/intraocularpressure.Ketamineshouldbeadministeredbyhealth
carepersonnelcertifiedinadvancedlifesupportwithclinicalexperienceandtraininginadministration
ofmoderatesedationtoensurepatientsafety.
SkeletalMuscleRelaxants
Inthepast,skeletalmusclerelaxantswereoneofthemostextensivelyprescribedagentsfortreatmentof
musculoskeletal disorders, suchas low backpain,musclesprains,or athleticinjury.Currently, muscle
relaxantsare recommendedfortheshort-term treatmentofacutemusculoskeletalconditions.Long-term
useisnotrecommended.Twocategoriesofskeletalmusclerelaxantsexist:antispasmodicagentsusedfor
musculoskeletal conditions and antispastic agents for central spasticity in conditions such as multiple
sclerosisandcerebralpalsy.
AntispasmodicSkeletalMuscleRelaxants
Skeletal muscle relaxantsare often used in the treatment of acute low back pain. Themost benefitis
usually demonstrated within the first few days of treatment. Adverse effects such as drowsiness and
dizzinessarecommonlyseen,andsomeagentsinthisclasshavepotentialforabuse.Ifamusclerelaxant
isindicated,choiceshouldbebasedonadverseeffectprofile,druginteractionpotential,andidentified
riskofabuse.
Cyclobenzaprinehasbeenthemoststudiedskeletalmusclerelaxant.Themanufacturer’srecommended
dose of cyclobenzaprine is 10 mg. However, a 5-mg dose has been shown to be effective with less
toxicity. Its anticholinergic properties must be taken into account if used in older adults. Tizanidine
(Zanaflex)isacentrallyacting,alpha2-adrenergicagonist,reducingspasticitybyincreasingpresynaptic
inhibitionofmotorneuronexcitation.Tizanidineisverysedatinganda useful adjunct inpatientswith
sleep disturbances as a result of musculoskeletal pain. Benzodiazepines, such as diazepam, may be
effective for acute pain associated with muscle spasms. The predominance of adverse reactions,
especiallysedationandriskofabuse,limitbenzodiazepineuseforthisindication.
AntispasticAgents
Limitedevidenceexistsforusingantispastic agentstotreatmusculoskeletalconditions.Baclofenis the
mostutilized agentin this class.Baclofen isindicated for managing signs and symptoms of spasticity
resultingfrommultiplesclerosisandspinalcordinjuries.Someanecdotalevidenceexistsfortheuseof
baclofeninpersistentneuropathicstatesandisusedofflabelforhiccups.Availableformulationsinclude
anoraltabletandaninjectableformulationforintrathecaladministration.Commonsideeffectsoftheoral
form include drowsiness, hypotension, weakness, nausea/vomiting, and headache. Intrathecal
administration results in hypotension, somnolence, dizziness, constipation, and headache. Respiratory
depressionanddifficultywithconcentrationorcoordinationarealsoseenwithintrathecaladministration.
Duetothepossibleprecipitationofwithdrawalsymptomswithabruptdiscontinuation,taperingbaclofen
is recommended when discontinuing thedrug,especiallywiththeintrathecal formulationor prolonged
oral use. Seizures and delirium may occur and can progress to rhabdomyolysis, disseminated
intravascularcoagulation,andhepatic/renalfailurewithabruptdiscontinuation.
Cannabis
Cannabisisbeingusedmoreoftenasamethodforpaincontrol,butitsuseiscontroversial.Cannabismay
provideanalgesiathroughanti-nociceptiveandanti-hyperalgesicpropertiesandmaybesynergisticwith
exogenousandendogenousopioids.Preclinical evidencehasshownthatcannabis maybe beneficialin
thetreatment ofchronic cancer andneuropathic pain,withminimal efficacywhenused for acutepain.
Cannabis isconsidered Schedule 1 at thefederallevel;however, moreandmore statesareapproving
cannabisformedical use.Evidence is lacking,however;morequalitystudies needto be conducted to
determine theplace ofcannabis inpaincontrol. However,researchoncannabis isdifficultduetothe
variabilityofstrainsandterpineprofilesinindividualstrains.PleaseseeChapter11,“CannabisandPain
Management,”formoreinformation.
CONCLUSION
Painisdifficulttomanageandoftenneedsamultidisciplinaryapproachtotherapy.Treatmentneedstobe
individualizedfor each patient, especially when a chronic pain condition exists.A properassessment
mustbe performed in order to differentiate the type and chronicity of pain. Once the type of pain is
determined,patient-specificfactorsshouldbeevaluatedinordertochoosetheappropriateanalgesicfor
pain treatment. A combination of therapies is often needed to provide a pain management goal of an
acceptable level of pain and improvement in function. By utilizing the information provided in this
chapter,thenursingpractitionerwillobtaintheknowledgeandthetoolstoeffectivelyassess,treat,and
monitor pain. The subsequent development of the individualized treatment plan will then provide
improvementinthequalityoflifeofthepatientsufferinginpain.
CASESTUDY1
J.T.isa65-year-oldmaleadmittedtothehospitalwithahistoryofchroniccancerpainusingmorphine
sustained-release(SR)60mgorallyevery8hour.Onadmission,morphine2mgIVevery4hourwas
ordered. Thepatientreportsthathispainwentfroma9toan8onlyafterthemorphinedoseandis
asking for more pain medication. The staff begin to question the motivation of the patient and if
addictionispresent.Theresidentdecidestostartpatientcontrolledanalgesia(PCA).(APCAdevice
isadeliverysystemthatallowsthepatienttoself-administeranalgesicmedicationataspecificdose
andtimeinterval).Inafewhours,thepatientiscomfortable,restinginbed.
1.J.T.’sbehaviorisbestdescribedas
a.Tolerance
b.Addiction
c.Pseudo-addiction
d.Dependence
Answer:c.
2. During his hospital stay, J.T. went into acute renal failure. He is increasingly lethargic and is
experiencing confusion and some hallucinations. The physician believes that the morphine
metabolitesmayberesponsibleandwouldliketoconverttoanalternativeregimen.Whatwouldbe
yourrecommendation?
a.DecreasemorphineSRdoseto60mgorallyevery8hour.
b.Switchtohydromorphone8mgorallyevery4hourasneeded.
c.Addhaloperidol1mgorallyevery6hour.
d.Switchtoafentanylpatch75mcgevery3days.
Answer:d.
3.Tolerancewillnotdeveloptowhichadverseopioideffect?
a.Respiratorydepression
b.Sedation
c.Constipation
d.Nausea
Answer:c.
CASESTUDY2
1.L.Z.isa75-year-oldfemalecurrentlyonMSContin60mgthriceadayforchroniclowbackpain.
L.Z.’sinsurancewillnotallowanyfurtherincreasestotheMSContindose,andL.Z.isconsidering
stoppingthe morphine. The patient describes the pain as being present in the lower back,with
radiation down her legs. What would be an appropriate addition to the treatment plan for pain
control?
a.Fentanylpatch
b.Ibuprofen
c.Duloxetine
d.Amitriptylene
Answer:c.
1.Oneyearlater,L.Z.stilliscomplainingofseverepaindespiteadditionofadjunctiveagents.Which
ofthefollowingmayofferbenefitovermorphineforherbackpain?
a.Oxycodone
b.Meperidine
c.Methadone
d.Hydrocodone
Answer:c.
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10
PainManagementinOpioidUseDisorder(OUD)
Patients
RachelTrichtingerandMariaC.Foy
LearningObjectives
1.Screenandassesspaininpatientswithopioidusedisorder(OUD).
2. Develop treatment plans to both alleviate pain and prevent relapse when on medication-assisted
treatment.
3.MonitorthesafetyandefficacyofpharmacotherapyforpaininOUD.
INTRODUCTION
In2017,theU.S.DepartmentofHealthandHumanServicesdeclaredtheopioidcrisisa“publichealth
emergency”(U.S.Departmentof Healthand HumanServices, 2019). Approximately 2 million people
were diagnosed with an opioid use disorder (OUD) in 2018 (U.S.Department of Health and Human
Services, 2019). The course of this disorder is both chronic and relapsing. Currently only 20% of
diagnosedpatientsarereceivingsubstanceabusetreatment,leavingalargeportionofpatientsuntreated.
Addressing the crisis involves not only supporting the treatment of OUD but also confronting the
underlyingissuesthatmayhaveprecipitatedtheaddictioninthefirstplace,withoneoftheseissuesbeing
undertreatedpain.Reliefofpainisthemostfrequentreasonthatopioidsareabused.Historically,opioids
have beeneffectiveinmanagingacutepain;however,there isless evidencesupportingthe useofthis
classofmedicationinlong-termtreatmentofchronicnoncancerpain.Conversely,thereisevidencethat
long-termopioid useleads to anincreased riskof OUDandother adverseoutcomes.Inpatientswith
currentor remittedOUDwhoareexperiencingpain,theappropriatemanagementofthepainwill help
preventinappropriateuseofopioidsoftenobtainedfromnonmedicalsources.
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