Question#: 648

Question:

Opioid pain control for recovering addicts.

What is the RPPEO stance on this? It could be severely detrimental to introduce opioids to someone currently in recovery of opioid addiction. It is not contraindicated. I often don’t bring up the possibility of opioid pain relief when presented with a recovering addict in pain. Should we be offering it anyway? What if they are on methadone currently? What is the standard here? Of course, it is detrimental to not treat pain but sending someone back into the depths of addiction while in recovery is possibly a death sentence. I have discussed this with tons of medic’s colleges teachers no one remembers ever having clear direction from anyone.

Of course you should never assume that someone is not in real pain and it is very important to treat pain. Having said that there are circumstances we run into when it is very strongly apparent a person is seeking opioids. If they state they have pain what is the direction on this?

Answer:

Where opioid use disorder (OUD) is suspected, nonpharmacological (heat/cold packs, immobilisation, dressings, repositioning, reassurance) and non-opioid pharmacological therapies (NSAIDs and acetaminophen) should be maximised before addition of opioids. 

For short transport times or where the pain is manageable we suggest not administering opioid analgesics. 

For long transport times with severe, unmanageable pain, consider the information below and consider consulting with a BHP.

Patients who are in remission/recovery from OUD without methadone or other other opioid agonists

• They may return to uncontrolled OUD if opioids are administered.
• If the decision is made to administer opioids, treat as opioid naïve with low doses. 

Patients with OUD controlled with methadone or other other opioid agonists

• The ideal is to consult with an addictions specialist and have ED continue with the current opioid, as with any any patient on long-term opioids.
• If the decision is made to administer morphine or fentanyl, usually higher doses are required

Patients with untreated OUD

• Pain should be treated to achieve effective analgesia - the setting of acute pain is not the time to start detoxification.
• If the decision is made to administer opioids, usually higher doses are required,

If you do elect to administer opioids to a patient with OUD, ensure that the patient has provided explicit informed consent. This means that you should inform the patient, and make sure they understand, that

1. The medication you are offering for pain relief is an opioid;
2. This has the potential to impact their recovery;
3. The alternative pain management available; and
4. This is their decision (you may allow the patient a few minutes to consider the information)

Then obtain clear, unambiguous consent from the patient, making sure that you document the informed consent process that you followed.

Patient Care Standards: N/A

References

Carr, D. 2022. Management of acute pain in adults with opioid use disorder. UpToDate https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder
Shah P, et al. Informed Consent. 2022. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430827/