PAIN MANAGEMENT CONSIDERATIONS FOR PEOPLE WHO USE OPIOIDS

Incidence of opioid use (OU) and opioid use disorder (OUD) is increasing in the U.S. (CDC 2022). People regularly using opioids usually develop tolerance to opioid medications and/or may be on medication assisted therapy (MAT).

There is no difference in pain management goals for people with opioid tolerance (or OUD) compared to those who do not use opioids regularly. Here are general principles (ASAM 2020, Huxtable 2011, NAF 2018, SAMHSA 2021):

• People using opioids or MAT may need higher opioid doses to achieve adequate analgesia, particularly to overcome opioid receptor blocking effects of buprenorphine and IM naltrexone.
• MAT for opioid use disorder will not contribute to analgesia; additional treatment will be needed.
• Short acting, high affinity opioids like fentanyl or hydromorphone (Dilaudid) are effective and safe to use.
• 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 OUD.
• Benzodiazepines may be more sedating for people on buprenorphine or methadone.
• Determine dosing by monitoring reported pain, alertness, and respiratory rate.
• Ensure reversal agent (naloxone) is available and titrate with small doses to reduce withdrawal risks.
• Ketamine is a useful option in people with significant opioid tolerance.
• Reassure that the goal is to provide adequate pain management. Be aware that people with OUD, particularly people of color, may have experienced medical discrimination and inadequate pain control in the past.
• Utilize various pain management methods such as NSAIDS, local anesthetic, breathing and visualization techniques, and a support person.
• Trauma responsive care is for everyone. Rates of physical, emotional, and sexual trauma are higher in this population.
• 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 management, and follow-up after an individual receives opioids. Communicate with the MAT clinician if possible, or offer a note documenting the controlled substancesopioids received.

For additional considerations, see “Special Considerations for People with Substance Use Disorder” (Attaie 2022).

^{1 Alternative or supplemental options for pain management include dexmedetomidine IV, gabapentin (Gray 2019), and nitrous oxide (Singh 2017), although data are limited on pain improvement with use.}