Chronic pain management in patients with substance use disorders

PURPOSE: To review the evidence and provide a practical guide for the management of chronic pain among patients with substance use disorders. EPIDEMIOLOGY: Chronic pain affects between 24% and 67% of patients with substance use disorders, and is frequently undertreated. REVIEW SUMMARY: The approach to the patient with chronic pain and a prior or active substance use disorder begins with a thorough assessment of the severity and history of past treatments of both conditions, and the presence of psychiatric disorders. Patients benefit the most from combinations of pharmacologic agents, ranging from nonsteroidal anti-inflammatory drugs to antidepressants, neuroleptics, and opioids if needed. Nonpharmacologic interventions play an adjunctive role. When using opioid analgesics, initiating a treatment agreement provides a framework within which opioids can be prescribed in a safe and effective manner. Aberrant drug-taking behavior should be assessed fully as it may signify prescription medication abuse, poorly treated pain, or worsening mental health. TYPE OF AVAILABLE EVIDENCE: Consensus statements and guidelines from specialty organizations, including the American Pain Society, the American Society of Addiction Medicine, and the American Academy of Pain Medicine; unstructured reviews; cross-sectional surveys; prospective cohort studies; randomized trials; meta-analyses. GRADE OF AVAILABLE EVIDENCE: Poor to fair. CONCLUSION: Although more extensive, high-quality evidence is needed to help guide chronic pain management in patients with past or current substance use, physicians can still deliver effective, appropriate care to this group if they adopt a systematic, well thought out approach that takes into consideration our current understanding of the complex interplay between pain and addiction.