Pain management in the opioid-dependent patient

Abstract

The opioid-dependent patient presents great challenges for pain management. These challenges are not limited to potential addictive behaviors. In contrast to the profound pain relieving effects of acute opioid intake, chronic opioid intake can promote a counterintuitive state of enhanced pain sensitivity. Multiple biologic mechanisms inducing opioid tolerance and hyperalgesia have recently been elucidated. The potential hyperalgesic state accompanying opioid dependence complicates pain management somewhat for acute pain and cancer pain, but it especially does so for chronic pain. Guidelines for treatment of opioid dependence in the pain patient are proposed. Treatment oriented toward the long term requires limit setting and psychologic support that go beyond simple medication management.

Pharmacological pain control for human immunodeficiency virus–infected adults with a history of drug dependence

“…These authors argue that the acknowledgement of pain may be a starting point to discuss its management, particularly among patients with a history of substance abuse whose pain may have not been acknowledged by others. Case reports and surveys have also suggested a format for history taking among patients with a history of substance abuse who also have a history of HIV or HIV-related risk factors (see Table 2; Koo, 2003;Prater et al, 2002;Streltzer, 2001). Although supported through clinical experience rather than empirical evidence, the approaches outlined are intended to place the patient at ease while gleaning important information about past drug use behaviors that the clinician may wish to take into account.…”

“…Inquire openly about a patient's past personal and family history of substance use Include use of alcohol and over-the-counter preparations Solicit every history to eliminate profiling any patient or missing patients who do not fit a bdrug-abusing profileQ Complaints of chronic pelvic and rectal pain that may disguise a patient's history of sexual assault (Streltzer, 2001) Suggested questions to put the patient at ease, based on Koo (2003):…”

Trust Violated: Analgesics for Addicts

“…Addressing the multiple dimensions of pain is a major part of holistic palliative care, but this realization has only slowly been adopted in oncology. These simple issues are far more common barriers than esoteric challenges such as potential hyperalgesic states accompanying opioid dependence [9], or pseudoaddiction, an iatrogenic syndrome resulting from poorly treated pain [10].…”

Tramadol addict: a rare but real challenge for the anaesthesiologist

“…It is neither an opioid derivative nor a non-steroidal anti-inflammatory(NSAID) medication. Tramadol is a racemic mixture of two enantiomers with a synergistic analgesic effect [2]. The (+) and (-) enantiomers weakly connect to mu opioid receptors [3].…”

“…Regional anaesthesia is always preferred if indicated [1,2]. If opioid-based anaesthetic management is planned, naltrexone should be discontinued at least 24-72 hours prior to surgery.…”