Treating acute pain in opioid-dependent patients

As healthcare providers see more patients with opioid abuse and dependence, they face a difficult challenge in identifying the best way to manage acute pain without contributing to the patient's opioid use disorder (OUD). A review with recommendations for treating acute pain patients with OUD is the subject of the September/October Journal of Trauma Nursing, the official publication of the Society of Trauma Nurses published by Wolters Kluwer. The review was announced in a press release earlier today.

Coleen Dever, MSN, AGCNS-BC, CEN, TRCN, a nurse at the Christiana Care Health System in Wilmington, Delaware, advocates a "holistic, multimodal" approach to acute pain treatment in patients who are dependent on opioids. She believes that education, for healthcare providers as well as patients, is a key step in providing effective pain control in patients who have OUD or risk factors for opioid dependence.

The United States is in the midst of an opioid epidemic, with unprecedented rates of overdose, abuse, and addiction to prescription opioid pain relievers and heroin. "Pain and addiction often occur together," Coleen Dever writes. However, the nature of the association remains unclear. Pain may lead to opioid use then addiction, or substance abuse may lead to pain syndromes. Adequate treatment of acute pain may play an essential role in preventing both chronic pain and opioid dependence.

Many patients with opioid dependence have chronic pain, which leads to changes in the physiological and emotional aspects of pain. Abnormal pain responses may develop both in patients with chronic pain (central sensitization) and opioid use (opioid-induced hyperalgesia).

Treating new acute pain in patients with OUD after traumatic injury poses special challenges. "Treatment for acute pain in the opioid-dependent patient is multifactorial, although there are no set guidelines to follow," says Dever in the review.

She outlines practical recommendations for acute pain management for patients with or at risk of OUD. Education can help nurses become more aware of attitudes and behaviors, including negative stereotypes about drug users--that may influence pain management and patients' experience of pain. Various screening tools have been developed to assess risk factors for developing OUD in individual patients, she says.

The treatment plan for acute pain management must account for the patient's medical and psychological history, physical status, emotional stage, previous pain experience, and injury-related factors. Psychological tools for pain management include caring and respectful behaviors by healthcare practitioner. Measures such as relaxation/imagery techniques and cognitive behavioral therapy can reduce the need for pain medications.

Treatment should consider the range of multimodal medication options. Alternatives include nonsteroidal anti-inflammatory drugs and certain types of antidepressant and anticonvulsant medications. Some patients with chronic pain may need to continue their long-acting pain medications while receiving additional medications to control acute pain.

"Whenever initiating opioid therapy, it is important to start at the lowest dose then titrate [adjust] appropriately, taking into consideration that pain is the experience of the patient and needs to be managed until effective pain control is obtained," says Dever. "This does not mean elimination of pain entirely, but allowing pain to be manageable."

Dever emphasizes the need to assess possible risk of OUD before the patient is sent home, with continued monitoring of pain relief and medication use afterward. "There is great need for future research regarding safe prescribing of opioids at time of discharge from the acute care setting," she says.