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 (1) 

SUD: a maladaptive pattern of substance use leading to clinically significant impairment or distress. 
Unsafe medication (opioid) use behaviors: medication-related behaviors that depart from strict adherence to the prescribed therapeutic plan of care.  Previously referred to aberrant drug behaviors.  
Addiction: a more outdated term than SUD to describe an overwhelming involvement with the acquisition/ use of a drug, characterized by loss of control, compulsive use, and use despite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 chronic pain and a history of SUD:  

• Inability to achieve effective analgesia due to opioid tolerance (2). 
• Higher risk of adverse opioid effects when higher doses for extended periods of time are used including unintentional overdose, aberrant drug behaviors, diversion, delirium, and even death (2-5). 

Patient selection:  The goal is to ensure that opioid prescribing is safe, effective, and does not contribute to worsening of a SUD.  Opioids for acute severe pain (such as hospitalization for a broken bone) can be used in a closely monitored setting (6). 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 misuse 
• Pain severity, trajectory of tissue injury, and the 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 opioids for patients who are actively using drugs to maintain a SUD (heroin, cocaine, methamphetamine, alcohol, prescription drugs).  Marijuana use is becoming increasingly accepted and commonplace, hence termination of opioid prescription based solely on its presence in a urine drug screen is not usually warranted.  Patients with a more distant history of SUD, those who are established in a substance abuse treatment program, and those with unsafe opioid use behaviors without evidence of a SUD should be evaluated carefully in terms of risk. Long-term opioids for chronic, non-life-threatening conditions are potentially harmful (e.g., chronic headaches, fibromyalgia, chronic lower back pain, osteoarthritis) (2-7) and 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. Consider 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 SUDs (8). 
• Assess for current use of sedatives (like muscle relaxants and benzodiazepines (3,4,9). 

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 (7).  
• Provide counseling on the associated risks for patients with chronic pain and a history of SUD. 
• Though access can be limited, ideally patients with an active SUD and chronic pain are referred to an addiction medicine specialist (7). Multi-disciplinary teams engaging social workers, and mental health professionals can enhance treatment adherence and social support (8,9). 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 (9).   
• 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 (10,11).  
• Published data and expert opinion on the use of long-acting opioids in SUDs offer conflicting advice (7,9,11). One study has shown a higher rate of unintentional overdose with long-acting opioids, most pronounced in the first 2 weeks after initiation (12).  
• A 1- to 2-week course of short-acting opioids (or some circumstances, less than a week) with a follow-up date less than 2 weeks may be the safest initial regimen.  
• Offer a rescue naloxone prescription and opioid overdose education.   
• Combination opioid agonist/antagonist therapy (e.g., oxycodone/naloxone, buprenorphine/naloxone) has shown promise in the treatment of patients with SUD (11,13).  

References: 

1. Merikangas KR, McClair VL. Epidemiology of substance use disorders. Human Genetics. 2012. 131:779-789. 
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. 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.  
4. Bohnert ASB, Valenstein M, Bair MJ, et al.  Association between opioid prescribing patterns and opioid overdose-related deaths.  JAMA 2011; 305(13):1315-1321. 
5. 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. 
6. Veazie S, Mackey K, Peterson K, Bourne D. Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review. J Gen Intern Med. 2020 Dec;35(Suppl 3):945-953. 
7. Franklin, GM. Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology. 2014;83:1277-1283. 
8. 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. 
9. Passik SD, Kirsh KL. Opioid therapy in patients with a history of substance abuse. CNS Drugs. 2004; 18(1):13-25. 
10. Doverty M, White JM, Somogyi AA, et al. Hyperalgesic responses in methadone maintenance patients. Pain. 2001; 90:91-96. 
11. 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. 
12. 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. 
13. Adams, K.K., Machnicz, M. & Sobieraj, D.M. Initiating buprenorphine to treat opioid use disorder without prerequisite withdrawal: a systematic review. Addict Sci Clin Pract 2021; 16 (36). 

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 and in January 2024 by James Deming MD. 
Conflicts of Interests: None reported.