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• complications related to drug abuse including organ impairment and infectious diseases;
and
• the presence of tolerance, physical dependence and the risk of withdrawal.
Evidence for the most appropriate management of acute pain in patients with an addiction
disorder is limited and advice is based primarily on case series, case reports, expert opinion
and personal experience.
Effective analgesia may be difficult, may be required for longer periods than in other patients
(Rapp et al, 1995) and often requires significant deviations from ‘standard’ treatment protocols
(Macintyre & Schug, 2007). In addition, ethical dilemmas can arise as a result of the need to
balance concerns of undermedication against anxieties about safety and possible abuse or
diversion of the drugs (Basu et al, 2007).
Identification of patients in whom there may be a risk of drug abuse is difficult. The ability of
clinicians to predict which patients may misuse or abuse opioids is known to be poor (Jung &
Reidenberg, 2007) and patient self‐reports of drug use may not correlate with evidence from
drug screens (Turk et al, 2008). Passik and Kirsh (Passik & Kirsh, 2008) recently reviewed a number
of the screening tools that can be used to assess the risk of opioid abuse in patients given
opioids for the management of chronic pain.
The first step in managing patients with an addiction disorder is identifying the problem,
although obtaining an accurate history can sometimes be difficult. Polysubstance abuse is
common and many of these patients will use drugs from different groups, the most common
of which include CNS depressant drugs such as alcohol, opioids and benzodiazepines, or CNS‐
stimulant drugs including cocaine, amphetamines (amfetamines) and amphetamine‐like drugs,
cannabis and other hallucinogens. The group from which the drugs come determines their
withdrawal characteristics (if any) and their interaction with acute pain therapy (Mitra &
Sinatra, 2004; Peng et al, 2005). Patients should be asked about the route of administration used,
as some may be injecting drugs intended for oral use. Confirmation of opioid doses should be
sought where possible (Alford et al, 2006).
A number of centres worldwide monitor the use of illicit drugs on a regular basis, including
prescription opioids. These include:
• in Australia, the National Drug and Alcohol Research Centre (NDARC) (see the section on
Australian Drug Trends Series for Illicit Drug Reporting System [NDARC, 2009]);
• in New Zealand, the Centre for Social and Health Outcomes Research and Evaluation
(SHORE) (see the section on the Illicit Drug Monitoring System [SHORE, 2009]);
CHAPTER 11 • the surveillance systems set up by the National Health Service in the United Kingdom (see
the section on Statistics of Drug Misuse [NHS, 2008]); and
in the United States, the Substance Abuse and Mental Health Services of the US
•
Department of Health and Human Services (SAMHSA, 2007), or other schemes specifically
tracking prescription opioid abuse, such as Researched Abuse, Diversion and Addiction‐
Related Surveillance (RADARS) (Cicero et al, 2007).
Management of pain in patients with an addiction disorder should focus on:
• effective analgesia;
• use of strategies that may attenuate tolerance, and prevention of withdrawal (as outlined
in Section 11.7);
• symptomatic treatment of affective disorders and behavioural disturbances; and
• the use of secure drug administration procedures.
428 Acute Pain Management: Scientific Evidence
