Opiates and Ketamine for patients with OUD

You bring up a good point in your question, specifically surrounding giving narcotics to someone that is actively trying to stop using them recreationally. You are correct in attempting to avoid the use of opiates for patients in this situation. However, pain is pain, and there are situations that would still warrant the use of an opiate for pain management for these patients. Specifically for these patients, a good conversation surrounding the benefits and the risks of both treatment and non-treatment is paramount and ensuring consent for treatment is maintained during the treatment process.

The main goals of acute pain management are to relieve suffering, facilitate function, enhance recovery, and satisfy patients. The optimal strategy for acute pain control consists of multimodal therapy to increase efficacy, reduce side effects of therapy, and minimize the need for opioids.

Both nonpharmacologic and nonopioid pharmacologic therapy should be maximized before adding further opioid therapy. Nonopioid strategies are often sufficient for treating mild acute pain and can decrease reliance upon opioids. If nonopioid strategies are not adequate, they should be continued while opioids are initiated, to reduce opioid requirement.

The general approach to acute pain management in patients treated with methadone is similar to the approach used for patients treated with stable doses of other opioids on a chronic basis: continue the baseline opioid and dose and apply multimodal nonopioid analgesic strategies, supplemented with incremental opioid if necessary during the interval of acute pain. It is of critical importance to continue methadone throughout all phases of care.

Something to consider, due to increased tolerance, patients on methadone maintenance treatment (MMT) typically require higher doses of additional opioid than opioid naïve patients. It is common for severe acute pain to be inadequately controlled in the hospital and postoperative settings among patients on MMT because supplemental doses of opioids are too low or the doses are not titrated rapidly enough.

Additional short-term opioids for acute pain should not be withheld for fear of worsening the opiate use disorder (OUD). It is imperative to re-evaluate patients frequently in the initial period after adding opioids or changing doses to assess pain and sedation levels, then readjust the treatment plan as needed.

It should also be noted that not treating someone’s pain can have other deleterious effects including physical, mental, social, and financial implications. Adequate pain management is particularly important in patients with opioid use disorder (OUD) because undertreated pain has been shown to drive poor health outcomes for these patients, including premature discharges, in-hospital drug use, experiences of stigma, and mistrust of the healthcare system. We cannot control how often a patient will call 911 for treatment by paramedics; all we can do is assess the patient and provide patient-centered care to the best of our abilities. Another option, if available in your area, would be to consider offering other resource options to this patient such as outpatient clinics and rehabilitation centers.

Now speaking specifically to Ketamine for this situation, yes, it could have been used as an analgesic option. While we are not recommending it as first line for all patients requiring analgesia, those with intolerances or who prefer not to take opiates are considered good candidates for Ketamine. Since it’s so new and the dosing regimen is considerably different than for sedation, a quick review:

A patient weighing 70kg would receive:

• IV- 17.5mg or 0.35ml (of 500mg/10ml concentration)
• IN- 70mg or 1.4ml (of 500mg/10ml concentration)