PEER REVIEWED FEATURE 3 CPD POINTS

Acute pain in
patients with
substance use
disorder
Steps for successful
assessment and
management
LINDY J. ROBERTS AM, MB BS(Hons), BMedSci(Hons), FANZCA, FFPMANZCA, FAICD, MMed, CertClinEd

Patients with substance use disorder presenting with acute pain

may be challenging to assess and manage. Key steps are excluding
serious pathology and instituting management that promotes comfort,
reduces distress and minimises harm. As in other patients with
acute pain, nonpharmacological and nonopioid treatments are
first-line options. Opioids have only a limited role for more serious
pathologies and in accordance with published guidelines and
regulatory frameworks.

I
n 2019, one in 25 Australians aged and nonprescribed use.2 Although overall
14 years and older reported taking use of alcohol and tobacco is declining,
drugs available to buy from pharmacies particularly in higher socioeconomic drugs has increased, raising risks of SUD
for nonmedical reasons in the previous areas, alcohol remains the most common and other harms. Those using prescription
year.1 Within this group, the use of pre- substance associated with substance use opioids frequently report they are unable
scription analgesics (including opioids) disorder (SUD).1 Illicit drug use is stable to stop their use, even if they would like
fell compared with 2016, largely due to in lower socioeconomic areas but is to do so.
codeine rescheduling in 2018. Regulation increasing in wealthier areas.1 More than There is significant concordance
of alprazolam also reduced its availability one in ten Australians report recent use between SUD and chronic pain, with over-
of cannabis, with one-third of these using lapping mechanisms in both conditions.3
cannabis at least weekly.1 Past-year use of Many individuals with SUD report long-
MedicineToday 2021; 22(9): 18-28 cocaine (2.5%) and ecstasy (3.0%) is term pain, and one fifth of those with
increasing, while use of methampheta- chronic pain meet SUD diagnostic crite-
Dr Roberts is a Specialist Pain Medicine Physician mine and other amphetamines, predom- ria.4,5 The range of patients seen in primary
at the Acute Pain Service, Sir Charles Gairdner inantly crystal meth or ‘ice’, is decreasing.1 care includes those on opioid agonist
Hospital, Perth, WA. The proportion of users taking multiple ­therapy (OAT) and those in SUD recovery.

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 KEY POINTS
• Treating doctors should consider the possibility
of substance use disorder (SUD) in all patients
presenting with pain (‘universal precautions’).
• Strategies promoting a positive therapeutic
relationship are crucial for successful
assessment and treatment of all patients with
SUD.
• Potentially serious pathology should be sought
in patients presenting with SUD and acute
pain, while considering that some drugs are
associated with specific painful conditions and
other effects that influence acute pain
presentations.
• For all patients, nonpharmacological and
nonopioid treatments should be maximised
and opioids used sparingly, with use of
atypical opioids preferred.
• Patients taking opioid agonist therapy for SUD
should be assessed and managed similarly to
other patients with SUD.
• The relationship between SUD and chronic
pain is bidirectional; self-management
approaches help patients with SUD and
chronic pain deal with their chronic symptoms
as well as cope with acute pain flare-ups.
• A patient’s level of risk, according to the
presence of active drug use, mental illness
and other comorbidities should guide referral
to a primary care specialist or drug and
alcohol facility.

such as needle tracks, intoxication and

withdrawal may also be present. In some
Australian states, real-time prescription
monitoring supports screening and
decision-making (e.g. SafeScript in
­
This article addresses acute pain in the factors for SUD include family or personal ­Victoria, which includes a clinical advisory
presence of SUD: screening for SUD, history of SUD, history of childhood ­sexual service).8
detecting serious pathology, and manage- abuse, concurrent psychiatric illness and The Prescription Shopping ­Program
ment, including for those with acute flare- younger age.3 and MyHealth Record are other potential
ups of chronic pain conditions or treated Screening questionnaires (e.g. CAGE sources of information about individuals,
MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY

with OAT. [cut down, annoyed, guilty, eye-opener] although each has limitations.9 An over-
Substance Abuse Screening Tool; AUDIT riding consideration is that SUD may
Assessment of patients with [Alcohol Use ­Disorders Identification occur in any patient, in any context.10
© DEAN DROBOT/SHUTTERSTOCK

SUD and acute pain Test]; ASSIST [Alcohol, Smoking and

Consider the possibility of SUD in all ­Substance Involvement Screening Test]) Ensure your approach reduces
patients presenting with acute pain may be used, although all tools rely on stigma and promotes clear
Treating doctors should consider the self-reporting and there are complex expectations
­possibility of SUD in all patients presenting ­reasons why this may not occur.6,7 Australians with SUD, especially injecting
with pain (‘universal precautions’).6 Risk Clear signs of drug and alcohol misuse drug users, report negative experiences in

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 Acute pain in patients with substance use disorder continued

reward circuits in the brain so that

TABLE 1. KEY TERMS RELATED TO SUBSTANCE USE DISORDER
drug use is intensely reinforcing,
Term Definition/description both physically and psychologically
• applying terms appropriately,
Chemical coping Using drugs to cope with emotional distress (primarily avoiding stigmatising terms (like
described in people with chronic pain) 3
‘addiction’) and using person-first
Misuse or Using prescribed medication other than as prescribed language (e.g. ‘a patient with SUD’)17
nonadherence3,18 (estimated to occur in one in four patients with chronic (Table 1)
pain) 3 • following practice policies on opioid
Opioid-induced Heightened pain sensitivity due to chronic opioid use. prescribing and adherence to
hyperalgesia (OIH) Pain relief improves if the dose is reduced or the opioid is relevant professional guidelines
stopped (although OIH can last for months after (see below)10
cessation) 3
• careful individualised risk
Physical dependence Sudden discontinuation of a drug causes withdrawal assessment.
symptoms3

Recovery Variable definitions, ‘can refer to a process of change

Look for symptoms and signs of
through which people improve their health and wellness, potentially serious pathology
live self-directed lives, and strive to reach their full A foundation of successful pain manage-
potential’18 ment is commencing disease-specific
Substance use and Variable definitions and terms, including ‘abuse’, ‘harmful treatment, when relevant. The implications
complications use’, ‘dependence’, ‘intoxication’, ‘withdrawal’.18,19 The of SUD in terms of diagnosis in acute pain
central DSM 5 term ‘substance use disorder’ is used in presentations include:
this article • Some drugs are associated with
Features may include cravings, impaired control over use,
specific painful conditions and other
an increasingly central role of the substance in the
person’s life and continued use despite harm 3,14,19 effects that influence acute pain
presentations, for example anxiety
Tolerance Predictable, declining effect of some drugs over time, and sleep disruption (Table 2).
(pharmacological) requiring increased dose to maintain the same effect3
• Injecting drug use increases the risk
Tolerance (psychological) More complex phenomenon with declining central effects of infections such as epidural abscess
(e.g. euphoria) over time, due to learning and and discitis, limb ischaemia from
environmental cues, requiring an increased dose to inadvertent arterial injection and
maintain the same effect 20
nonfatal drug overdose resulting in
Abbreviations: DSM 5 = Diagnostic and Statistical Manual of Mental Disorders, 5th edition. pressure injuries and venous
thrombosis.27
both hospitals and primary care. This suffer comorbid mental illness. 13,14
A • Long-term opioid use leads to
includes being ‘looked down on’, ‘treated ­further complicating factor is that pain-­ poorer surgical outcomes, such as
like less than nothing’ and subjected to relief seeking may look like drug seeking, deep vein thrombosis and infection,
derogatory remarks.11,12 Many have found with resolution of behaviours once pain so maintain a high index of suspicion
it difficult to access pain relief even when is adequately addressed (so-called for complications in a patient with
they present with clearly painful condi- pseudoaddiction).15 opioid use disorder (OUD) who
tions.11 These recollections lower their Some strategies to consider within the has undergone recent surgery
expectations that they will receive the care therapeutic relationship are: (Table 2).28
that others take for granted, and may • being open and nonjudgemental,
­hinder them seeking treatment.12 The with reassurance about the treatment Management of patients with
consequences are patient suspicion, dis- approach SUD and acute pain
trust, late presentations and increasing • empathy with therapeutic boundaries, For all patients, maximise
drug use to cope.12 Of course, there are including setting realistic nonpharmacological and nonopioid
some with SUD who are drug-seeking expectations and clear limits16 treatments
and who are sometimes perpetrators of • using a disease model of SUD, noting The first-line treatment options for acute
violence in general practices and hospitals, that it is due to pathological pain in the presence of SUD, as for other
particularly when intoxicated or if they processes such as disruption of patients, are nonpharmacological and

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 Acute pain in patients with substance use disorder continued

TABLE 2. POTENTIAL IMPACTS OF SPECIFIC DRUGS ASSOCIATED WITH SUBSTANCE USE DISORDER ON PATIENTS PRESENTING
WITH ACUTE PAIN*†

Drug Chronic use and intoxication Withdrawal

Alcohol Increased trauma risk, pancreatitis, increased cancer risk, liver Seizure-related injury
dysfunction
Used for chronic pain and insomnia

Amphetamines and Anxiety, insomnia, psychosis, violence Depression, anxiety, paranoia

metamphetamine

Benzodiazepines Used for insomnia in chronic pain Headaches, anxiety, seizure-related injury

Cannabinoids Used for chronic pain (despite limited evidence), associated with Headache, abdominal pain (in high-dose
increased opioid misuse, impaired co-ordination and judgement with users)
injury risk

Cocaine Lowered pain thresholds, myocardial ischaemia, subarachnoid Depressed mood, insomnia, restlessness
haemorrhage

Ketamine Hallucinations, confusion, depression, cholangiopathy, ulcerative Anxiety, emotional lability, headaches
cystitis,21 headaches (controversial)

Nicotine Mild analgesic effect; risk factor for cancers and coronary artery disease Increased pain

Opioids Hyperalgesia, increased infection risk due to immunosuppression Increased pain, anxiety, restlessness,
(e.g. community-acquired pneumonia, post-joint arthroplasty hyperalgesia
infection); 22,23 risk of adrenal suppression with (rarely) Addisonian
crisis if acutely unwell24

* Lists are not comprehensive but are examples of physical and psychological factors that cause or influence acute pain presentations.
† Unless specifically referenced, the information in this table is from The Alcohol and Drug Foundation website and Beaulieu.25,26

nonopioid. The precise approach will be that pregabalin in particular is a The consultation also may present an
determined by circumstances, but options drug of misuse as well as the risk of opportunity to divert the patient towards
that can be considered include: overdose with tricyclic harm minimisation and drug and alcohol
• following best practice professional antidepressants30 treatment services, and for management
guidelines on acute pain, e.g. for • use of disease-modifying agents in of comorbid psychiatric disorders, as
management of nonspecific low back the presence of relevant diagnoses, relevant.32
pain in primary care (Box 1)29 e.g. for antimigraine treatment or
• education and reassurance about the prophylaxis Use opioids sparingly and consider
role of investigations, the reason for • nonpharmacological treatments – atypical opioids which are effective
not prescribing opioids (as relevant) the NPS MedicineWise website has with lower risk
and the role of nonopioids excellent supporting information on Opioid-related harms in Australia include
• addressing psychological these31 three deaths and 150 hospital admissions
contributors such as anxiety14 • lifestyle-based management, as for per day.33 NPS MedicineWise promotes
• use of simple analgesics, especially other chronic conditions16 five reasons not to prescribe opioids:34
anti-inflammatories, with • providing symptomatic treatment for • adverse events
paracetamol only indicated in withdrawal symptoms, e.g clonidine • limited evidence for efficacy
selected conditions14 (off-label use) provides symptomatic • opioid-induced hyperalgesia (Table 1)
• use of adjuvant agents for treatment for opioid withdrawal, • misuse risk
neuropathic pain, e.g. duloxetine mild analgesic effect and anxiolysis. • comorbidities and drug interactions.
(off-label use), amitriptyline (off-label However, side effects, particularly Recent TGA and PBS changes empha-
use), gabapentin, pregabalin, hypotension, can limit its use. OAT sise the role that prescribing for acute
carbamazepine (first-line for is often the best opioid withdrawal pain can have in persistent long-term
trigeminal neuralgia), recognising treatment. use, requiring smaller pack sizes and

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 Acute pain in patients with substance use disorder continued

definitive and effective treatment for

1. MANAGEMENT OF NONSPECIFIC 2. RACGP GUIDANCE ON MINIMISING
their SUD (e.g. OAT) and for harm min- INAPPROPRIATE OPIOID
LOW BACK PAIN29
imisation strategies such as take-home PRESCRIBING40
naloxone.14,39
• Triage based on risk (of serious
pathology or progression to
The Royal Australian College of Do not routinely prescribe opioids for
chronic pain) ­General Practitioners (RACGP) provides specified conditions, for example:*
• Workup only when concerned about guidance on how to avoid ‘unnecessary • uncomplicated musculoskeletal pain
serious issues (avoid unnecessary opioid prescribing’ in acute conditions or headaches
imaging) and recommends that general practices • renal colic
• First line: simple measures, adopt the approaches in Box 2.40 Acute • nontraumatic dental pain
reassurance, education, activation, treatment with opioids may lead to longer • primary dysmenorrhoea
review within a fortnight • irritable bowel syndrome
term problematic use, particularly in those
• Second line: nonpharmacological • acute exacerbations of chronic
with pre-existing SUD.14
(physical and psychological) nonmalignant pain
• Third line: drugs at lowest dose for • pain as a leading manifestation of a
Patients taking opioid agonist psychiatric disorder
shortest time
therapy for SUD
• Complex presentations: If prescribing opioids for acute pain:
multidisciplinary referral, cognitive
In 2020, just over 53,000 Australians
• prescribe the lowest effective dose of
behavioural therapy, exercise received OAT with methadone, buprenor-
immediate release opioid for the
program with movement education phine, buprenorphine-naloxone and shortest duration (usually three days,
• Avoid treatments known not to work buprenorphine long acting injection rarely longer than a week)
e.g. bed rest, paracetamol, invasive (LAI).41 This is governed by state and For patients with chronic pain who
therapies ­territory-based legislation that often present with acute pain, issues to be
restricts dose, alterations and the prescrip- familiar with include:
promoting best-practice prescribing.35 tion of other opioids, except by the reg- • how to manage acute exacerbations
For example, recent more restrictive TGA istered prescriber.10 These patients should of chronic pain
indications for the high-potency opioid be assessed and managed in a similar • opioid withdrawal presenting as pain
fentanyl ­recognise the risks of significant way to other patients with SUD. OAT is • possible new acute diagnosis
misuse, diversion and overdose.35 Atypical associated with both opioid-­induced Abbreviation: RACGP = Royal Australian College of
General Practitioners.
opioids (tramadol and tapentadol) have hyperalgesia (influencing pain experience) * For full list see RACGP 2017.40
multimodal action and are effective for and pharmacological tolerance (influenc-
neuropathic pain and in opioid tolerance ing opioid dosing should this be required,
(no tolerance to the nonopioid compo- noting that relevant legislation must be disorder report suffering with chronic
nent).36 When compared with conven- considered). Communication between pain, often reporting that pain maintains
tional ­opioids, they have reduced risk of the practitioner treating the acute pain their SUD.42 Anyone taking opioids on
misuse, diversion, doctor-shopping and and the OAT prescriber is vital for opti- a regular basis has a high likelihood of
overdose deaths.3,37,38 However, drug inter- mal care. pharmacological tolerance and experi-
actions and side effects, particularly with encing withdrawal symptoms that may
tramadol, should be considered. The relationship between SUD, include pain (Table 2).
If prescribing opioids, it is recom- chronic pain and acute pain There is limited evidence that opioids
mended to do so at the smallest dose for In 2018, 3.24 million Australians reported are effective for chronic pain. Long-term
the shortest duration possible. The suffering from chronic pain. Of these, opioid treatment leads not only to
patient who is opioid-tolerant (due to one in 500 sees a specialist pain service increased pain (probably from opioid-­
heroin or prescription opioid use) may each year.16 The remaining 499 in every induced hyperalgesia), but also other
require higher opioid doses due to phar- 500 are managed in primary care, repre- adverse events,43 with four out of five
macological ­tolerance (Table 1). There is senting 20 to 40 per cent of all adult con- patients who take opioids for at least three
also some cross-tolerance between can- sultations.14 The relationship between months experiencing related harms.33
nabis and o ­ pioids, but not between most chronic pain and SUD is bidirectional. Ceasing opioids often improves their pain
other drugs and opioids, so usual doses Patients with chronic pain may display experience, so opioid tapering should be
are appropriate in most other cases. Addi- problematic medication use such as considered, even when SUD is not sus-
tionally, each presentation presents an chemical coping and misuse (Table 1). Six pected.44 The NPS MedicineWise website
opportunity to assist the patient to access in ten people with prescription opioid use includes useful decision-support tools

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 Acute pain in patients with substance use disorder continued

TABLE 3. USEFUL RESOURCES FOR DOCTORS AND PATIENTS ON PAIN PRACTICE POINTS ON ASSESSING
MANAGEMENT AND SUBSTANCE USE DISORDER AND MANAGING ACUTE PAIN IN
PATIENTS WITH SUBSTANCE USE
Resource Details DISORDER (SUD)

ANZCA and Faculty of Pain Medicine3 Evidence-based information on

• Consider the possibility of SUD in all
Schug S, et al. Acute pain management: assessment and management;
patients presenting with acute pain.
scientific evidence (5th ed), Sections 9.7 free PDF
(opioid tolerance) and 9.8 (substance use • Approach the patient with SUD or
disorders) suspected SUD empathically, in a
[Link] way that does not stigmatise their
apsme5 disease and provides clear limits on
behaviours and prescribing.
Chronic Pain Australia Consumer information and resources • When assessing the patient, consider
[Link] the painful conditions associated
with specific drugs used in SUD, and
Faculty of Pain Medicine, ANZCA Twelve online modules on contemporary
the increased risks associated with
Better Pain Management Program nonmalignant chronic pain management
injecting drug use and with chronic
[Link] at a modest charge
opioid use.
training/cme-courses-and-resources/ Free ‘better pain prescribing’ module
better-pain-management-course • Develop a management approach
that uses nonpharmacological and
NPS MedicineWise33 Resources include opioid tapering nonopioid treatments.
[Link] algorithm, patient information sheets, • Opioids are not indicated routinely for
opioids-chronic-pain videos on difficult conversations and acute pain, except when there is a
skills such as motivational interviewing, clear acute diagnosis known to cause
podcasts and CPD activities severe pain. When opioids are
Pain Australia Consumer information about pain prescribed, attendant risks should
[Link] including a pain services directory be considered and the lowest dose
Health professional information about of an immediate release preparation
training and events for the shortest reasonable duration
used. Atypical opioids (tramadol
RACGP Comprehensive information on pain and tapentadol) may have a better
Prescribing drugs of dependence in general assessment and management, risk-benefit profile when compared
practice including for acute conditions; free with other opioids.
[Link] PDF downloads • Patients receiving opioid agonist
resources/clinical-guidelines/key-racgp- therapies with methadone or
guidelines/view-all-racgp-guidelines/drugs- buprenorphine should be assessed
of-dependence and managed using similar principles
to other patients with SUD,
The Alcohol and Drug Foundation25 Consumer fact sheets on individual
recognising underlying legislative
[Link] drugs with links to support services
requirements and the likelihood of
for help
heightened pain sensitivity and opioid
Abbreviations: ANZCA = Australian and New Zealand College of Anaesthetists; RACGP = Royal Australian College tolerance.
of General Practitioners. • Provided that serious pathology has
been excluded, flare-ups of chronic
and videos to assist both opioid tapering for many the management of future flare- noncancer pain are best managed
with nonopioids, optimally along with
and patient-driven goal setting and alter- ups is probably best addressed when
self-management strategies within a
native chronic pain management plans.33 symptoms are relatively stable. Optimally, chronic disease management
Self-management approaches, com- management is undertaken by the approach.
monly used for other chronic conditions, patient’s usual GP.14 • Consider the need for advice about
help patients deal with their chronic If a patient with chronic pain has devel- patients assessed as at high risk.
symptoms as well as cope with pain flare- oped problematic drug use that meets
ups and even reduce their frequency.16 In the criteria for SUD, definitive and harm When to seek advice
some patients, an acute pain flare-up reduction treatments are indicated.16 The RACGP recommends risk stratifying
represents an opportunity (or ‘teachable These include staged supply, supervised patients according to the presence of
moment’) to steer them toward more dosing, engagement with the dispensing active drug use, mental illness and other
effective long-term approaches. However, pharmacist and OAT. comorbidities, and considering referral

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 Acute pain in patients with substance use disorder continued

to a GP with advanced addiction medi- approach recommended in this article.

cine training or drug and alcohol facilities Although most presentations are not COMPETING INTERESTS: Dr Roberts has received
in the following cases:45 for serious pathology, careful assessment financial support for work- and committee-related
travel and activities from the Australian and
• comorbid serious psychiatric illness should exclude sinister and treatable New Zealand College of Anaesthestists, the
• use of combinations of drugs – ­conditions. Management can then focus Australian Medical Council and the Australian
opioids and illicit drugs, opioids and on a multimodal approach, avoiding Government (as a member of the MBS Pain
Management Clinical Committee).
benzodiazepines potential harm, and using first-line non-
• discharge from another general pharmacological and nonopioid treat-
ONLINE CPD JOURNAL PROGRAM
practice for ‘problematic behaviour’ ments tailored to the individual’s situation.
• recently in a correctional facility ­Opioids are required for severely painful True or false? 'Substance use
• high-risk behaviours. conditions when referral for acute emer- disorder should be considered in all
patients presenting with pain.'
This is a significant challenge in rural gency care is planned. Otherwise, if they
and remote areas.45 All Australian states and are prescribed this should be at the lowest
territories have drug and alcohol ­clinical dose and for the shortest reasonable

MODELL USED FOR ILLUSTRATIVE PURPOSE S ONLY

advisory services;10 and many organisations ­duration, considering regulatory require-
produce informative resources both for ments. These acute presentations may
doctors and patients (Table 3). present opportunities to improve chronic

© VLADTEODOR/[Link]
disease management, for example initi-
Conclusion ation of definitive treatment of SUD with
Patients with SUD who present with acute OAT.  MT
Review your knowledge of this topic
pain are challenging to assess and manage. and earn CPD points by taking part
Central to this is a nonjudgemental References in MedicineToday’s Online CPD Journal
approach that engages the person in care. A list of references is included in the online version of Program. Log in to
[Link]/cpd
A list of Practice Points summarises the this article ([Link]).

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 MedicineToday 2021; 22(9): 18-28

Acute pain in patients

with substance use
disorder
Steps for successful
assessment and management
LINDY J. ROBERTS AM, MB BS(Hons), BMedSci(Hons), FANZCA, FFPMANZCA, FAICD, MMed, CertClinEd

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