PAIN CONTROL CONSIDERATIONS FOR PEOPLE WHO USE OPIOIDS
Incidence of opioid use and opioid use disorder is increasing in the U.S. (CDC 2021). People who use opioids regularly may develop tolerance to opioid medications and / or may be on medication assisted therapy (MAT).
| Common Medication Assisted Therapy (MAT) for Opioid Use Disorder | ||
| Methadone | Full opioid agonist | People on methadone and buprenorphine should continue their medications as prescribed to prevent withdrawal and reduce the risk of return to use. |
| Buprenorphine +/- Naloxone (Suboxone, Subutex) | Partial opioid agonist +/- antagonist | |
| Naltrexone | Opioid antagonist | People on oral naltrexone should hold their medication for 72 hours if possible to allow opioids to work. An abortion should not be delayed to allow IM naltrexone to wear off. |
There is no difference in the goal of pain management for people with opioid tolerance (or opioid use disorder) compared to those who do not use opioids regularly. Here are general principles (Snyder, NAF 2018, SAMHSA 2021, ASAM 2020, Huxtable 2011):
- People who use opioids or are on MAT may need higher opioid doses to achieve adequate analgesia, particularly to overcome the opioid receptor blocking effects of buprenorphine and IM naltrexone.
- MAT for opioid use disorder will not contribute to the analgesia provided.
- Short acting, high affinity opioids like fentanyl or hydromorphone (Dilaudid) are effective and safe to use.
- Benzodiazepines may be more sedating for people on buprenorphine and methadone.
- Determine dosing by monitoring reported pain, alertness, and respiratory rate.
- Ensure reversal agent (naloxone) is available, and start with a low dose if needed to reduce withdrawal risks.
- Reassure that you will provide adequate pain control. Be aware that people with opioid use disorder, particularly people of color, may have experienced medical discrimination and inadequate pain control in the past.
- Don’t forget to additionally utilize other pain control methods such as NSAIDS, local anesthetic, breathing and visualization techniques, and a support person.
- Trauma informed care is for everyone. Rates of physical, emotional, and sexual trauma are higher in this population. Acknowledge that using opioids for pain management may be triggering for some people.
- The expected duration of pain from uterine aspiration is the same as with people not on MAT, and post-procedural pain management should not differ.
- MAT prescribers can often provide guidance for acute pain control, and can help provide close follow up after the patient received opioids. Communicate with the prescribing clinic or physician if possible, or offer a note documenting the opioids received under your care.
- For additional considerations, see the RHAP Contraceptive Pearl on “Special Considerations for People with Substance Use Disorder” (Attaie 2022).
PAIN MANAGEMENT OPTIONS FOR PEOPLE WITH OPIOID USE DISORDER
| Aspiration Abortion | Management Options | |
| Managing MAT prior to procedure | Buprenorphine: Continue home dose. Methadone: continue dose on day of procedure. Naltrexone (po): hold for 72 hours prior to procedure Naltrexone (IM): avoid procedural delay as opioids may be ineffective if <30days since last injection. |
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| Oral pain medication pre-procedure | Give NSAID (e.g., ibuprofen or ketorolac) if used. Any opioid may be given**. May give twice the standard dose. Opioids are less effective if the patient is on naltrexone. Lorazepam 1-2 mg (avoid if also using IV midazolam during procedure). Consider gabapentin 300 -600 mg (may cause sleepiness after procedure). |
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| Moderate Sedation | For patients on Methadone or Buprenorphine | For patients on Naltrexone (po < 72 hours, IM < 30 days) |
| Cervical block Fentanyl 200 mcg IV (higher initial doses are often needed). Midazolam 2 mg IV (may repeat 1-2 mg q 2-5 minutes). Can take 3-6 minutes before full effect. Consider ketamine 0.3-1.0 mg/kg (25- 50 mg, slow push IV. Consider dexmedetomidine 25 mcg slow push IV (repeat q5-10 min as needed). |
Cervical block Fentanyl ineffective at office-based doses. Midazolam 2 mg IV (may repeat 1-2 mg q 2-5 minutes). Can take 3-6 minutes before full effect. Consider ketamine 0.3-1.0 mg/kg (25- 50 mg, slow push IV. Consider dexmedetomidine 25 mcg slow push IV (repeat q5-10 min as needed). |
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| Deep sedation | Cervical block Propofol per facility protocol Careful escalation of fentanyl with monitoring. |
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| Post-procedure pain management for home use | Give NSAIDs (e.g., ibuprofen) Give acetaminophen (maximum daily dose < 4000 mg) Avoid opioids or mixed narcotic analgesics (e.g., Tylenol with codeine) |
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| Medication Abortion | ||
| Home pain management | Continue regular dose of medication-assisted treatment Give NSAIDs (e.g., ibuprofen) Give acetaminophen (maximum daily dose < 4000mg) Avoid opioids or mixed narcotic analgesics (e.g., Tylenol with codeine) |
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**While data show oral opioids may increase nausea without improving pain, there are situations in which they are used, and may require higher doses in opioid use disorder.