Using opioid therapy for pain in clinically challenging situations: questions for clinicians

Abstract

Healthcare professionals and organizations increasingly face the conundrum of treating patients with active substance use disorder, a history of personal or familial substance use disorder, or those at elevated risk for substance abuse. such patients need compassionate care when facing painful conditions; in fact, denying them pain control makes it likely that they will seek out ways to self-medicate with illicit drugs. Yet it remains unclear how to safely and effectively treat patients in these challenging situations. the authors have formulated ten questions to address in order to provide adequate analgesia for such patients. these questions demand a highly individualized approach to analgesia. these ten questions involve understanding the painful condition (presumed trajectory, duration, type of pain), using validated metrics such as risk assessment tools, guidelines, protocols, and safeguards within the system, selection of the optimal analgesic product(s) or combination therapy, and never starting opioid therapy without clear treatment objectives and a definitive exit plan. it is tempting but inaccurate to label these individuals as "inappropriate patients," rather they are high-risk individuals in very challenging clinical situations. the challenge is that both options-being in pain or being treated with opioids to control pain-expose the patient to a risk of rekindling an addiction. the question is how do we, as clinicians, adequately respond to these very perplexing clinical challenges?

What to Do and What Not to Do in the Management of Opioid-Induced Constipation: A Choosing Wisely Report

“…Yet, a number of factors can contribute to postoperative constipation, such as changes in diet related to hospitalization and preexisting conditions. Some literature suggests that preoperative long-term opioid use is a risk factor for long-term use after surgery and new-onset constipation [ 24 , 25 ]; for this reason, physician education about OIC as part of perioperative pain management should cover strategies for challenging situations such as individuals with opioid dependence or tolerance [ 26 , 27 ]. The expert panel also noted a need to distinguish OIC from general post-surgical constipation to avoid unnecessary discontinuation of effective pain therapy and improve patient outcomes.…”

A year in review in Minerva Anestesiologica 2022: anesthesia, analgesia, and perioperative medicine

“…Pergolizzi et al proposed a series of questions/answers that can help the pain specialist in the decision-making process even in patients with an active opioid use disorder. 147 Further useful strategies for reducing the risk of abuse may be the use of appropriate screening tools and the activation of a government monitoring program of opioid prescriptions. 148 A significant percentage of women report chronic pain six months after delivery, more frequently after cesarean section, but also after vaginal delivery.…”

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