When is it appropriate to use opioids in the palliative care setting for a patient with a history of a substance use disorder (SUD)?  This Fast Fact addresses strategies for initiating opioids for patients with a history of SUD; Fast Fact #312 will address best practices for monitoring opioids for these patients. 

Definitions:

SUD: a maladaptive pattern of substance use leading to clinically significant impairment or distress.

Aberrant drug behaviors: medication-related behaviors that depart from strict adherence to the prescribed therapeutic plan of care.

Addiction: overwhelming involvement with the acquisition and use of a drug, characterized by: loss of control, compulsive drug use, and use despite harm (see Fast Facts #68, 69).

Diversion: the illegal transfer of a pharmaceutical controlled substance from the person it was prescribed to another person for use. Patients with SUDs are at higher risk for diversion of opioids. 

Risks of Opioid Therapy in Patients with a history of SUD:

• Inability to achieve effective analgesia due to opioid tolerance.
• Adverse opioid effects when higher doses are used including unintentional overdose, aberrant drug behaviors, diversion, delirium, and even death.

Patient Selection:  The goal is to ensure that opioid prescribing is safe, effective, and does not contribute to worsening of an SUD.  Opioids for acute severe pain (such as hospitalization for a broken bone) can be used in a closely monitored setting. Patient selection for moderate-to-severe chronic pain is more complex and involves the interplay of:

• Prognosis of the serious illness
• Status of the SUD: in recovery vs. active substance abuse
• Pain severity/risk of adverse opioid effects.

Except those with a limited prognosis (e.g. < 2 months) or with an acute pain problem (e.g. bone fracture), we do not recommend starting opioidsfor patients who are actively using drugs to maintain a SUD (heroin, cocaine, methamphetamine, alcohol, prescription drugs).  Marijuana use should be evaluated on a case-by-case basis. Patients with a more distant history of SUD, those who are established in a substance abuse treatment program, and those with aberrant drug behaviors without evidence of a SUD should be evaluated carefully in terms of risk. Long-term opioids for selected non-life-threatening conditions are potentially harmful (e.g. chronic headaches, fibromyalgia, chronic lower back pain, osteoarthritis) (4). The risks likely outweigh the benefits. 

Initial Pain Assessment: The initial assessment is similar to patients without previously identified SUDs in that a comprehensive identification of the type of pain and its etiology is pivotal. Clinicians should:

• Perform a careful history of past, present, and quantity of tobacco, alcohol, recreational drug use, and prescription drug misuse. Use a validated screening tool to stratify risk of opioid misuse (FF #244).
• Differentiate active substance use, at-risk behaviors, recovery, and enrollment in a treatment program.
• Evaluate for potentially treatable psychiatric disorders such as depression and anxiety, which are common both in chronic pain and those with SUDs.
• Assess for current use of sedatives (like muscle relaxants and benzodiazepines).

Initial Opioid Management   

• Describe treatment expectations. Opioids will not completely eradicate pain and their effect on both pain and function may only be short term (4).
• Counsel the patient on the associated risks of opioid therapy for patients with chronic pain and a history of SUD including addiction, overdose, delirium, and death (10).
• Though access can be limited, ideally patients with an active SUD and chronic pain should be referred to an addiction medicine specialist (4). Multi-disciplinary teams engaging social workers, and mental health professionals can enhance treatment adherence and social support (5). See Fast Fact #127.
• Use an opioid agreement at initiation of therapy to delineate safe practices and when opioids would be discontinued.  Specify the consequences related to the presence of illicit drugs on a urine drug screen (UDS), requests for early refills, or attempts to obtain controlled substances from other clinicians. 
• For patients on maintenance therapy for opioid addiction such as buprenorphine or methadone, discuss the care plan with the addiction treatment program.  If opioids are agreed to be appropriate, be prepared that higher doses may be needed to achieve therapeutic expectations (6,7).
• Published data and expert opinion on the use of long acting opioids in SUDs offer conflicting advice (4,5,8). One study has shown a higher rate of unintentional overdose with long-acting opioids, most pronounced in the first 2 weeks after initiation (9). This may suggest clinicians have a difficult time identifying patients who misuse long-acting opioids. 
• A 1-2 week course of short-acting opioids with a follow up date less than 2 weeks may be the safest initial regimen. If available, offer a rescue naloxone prescription and opioid overdose education. 
• Combination opioid agonist/antagonist therapy (e.g. oxycodone/naloxone, buprenorphine/naloxone) under the guidance of a pain specialist has shown promise in the treatment of patients with SUD.

References:

1.    Tsang A, Von Korff MV, Lee S, et al. Chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. Pain. 2008; 9(10): 883-891.
2.    Morasco BJ, Gritzner S, Lewis L, et al. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011; 152(3):488-97.
3.    Merikangas KR, McClair VL. Epidemiology of substance use disorders. Human Genetics. 2012. 131:779-789.
4.    Franklin, GM. Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology. 2014;83:1277-1283.
5.    Passik SD, Kirsh KL. Opioid therapy in patients with a history of substance abuse. CNS Drugs. 2004; 18(1):13-25.
6.    Compton P, Charuvastra VC, Ling W. Pain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend.2001;63:139-146.
7.    Doverty M, White JM, Somogyi AA, et al.Hyperalgesic responses in methadone maintenance patients. Pain.2001; 90:91-96.
8.    Chang Y and Compton P.  Management of chronic pain with chronic opioid therapy in patients with substance use disorders. Addiction Science & Clinical Practice. 2013. 8:21. http://www.ascpjournal.org/content/8/1/21.
9.    Miller M, Barber CW, Letherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Internal Medicine. 2015; 75(4): 608-615.
10. Bohnert ASB, Valenstein M, Bair MJ, et al.  Association between opioid prescribing patterns and opioid overdose-related deaths.  JAMA 2011; 305(13):1315-1321.
11. Chou R, Turner JA, Devine EB, et aal.  The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health’s Pathways to Prevention Workshop. Annals of Internal Medicine 2015; 162(4):276-286.

Author’s Affiliations: University of Pittsburgh Medical Center

Version History: Originally edited by Sean Marks MD and electronically published in February 2016; updated in April 2019.

Conflicts of Interests: none reported