Page 477 Acute Pain Management

Pain management in patients with an addiction disorder often presents significant challenges
because of their fears of being stigmatised, concerns about inadequate pain relief, past
experiences, expectations, and responses to interventions (Roberts, 2008). Inappropriate
behaviours can be prevented to a significant extent by the development of a respectful,
honest and open approach to communication and, as with all other patients, an explanation of
treatment plans and the fact that complete relief of pain may not be a realistic goal, as well as
involvement of the patient in the choice of plan (within appropriate boundaries)
(Roberts, 2008).
In all cases, close liaison with other treating clinicians and drug and alcohol services is
required. This is especially important if additional opioids are thought to be needed for pain
relief for a limited period after discharge, or if any alteration has been made, after
consultation with the relevant services, to methadone or buprenorphine doses while in
hospital. In many countries regulatory requirements will dictate that only one physician has
the authority to prescribe for these patients. However, restricted use of additional opioids
after discharge may be possible in some circumstances. For example, it could be arranged for
the patient to also pick up a limited and progressively decreasing number of tablets each day
or every other day, along with their usual methadone or buprenorphine (Peng et al, 2005).

11.8.1 Management of acute pain in pregnant patients with an
addiction disorder

The majority of women with an addiction disorder are of child bearing age; 0.76% of all births
at one institution were to women using opioids and 0.42% to those using amphetamines
(Ludlow et al, 2007) The management of acute pain in pregnant patients with an addiction
disorder must take into account treatment of the mother as well as possible effects on the
child, both before and after birth. Identification of these patients during pregnancy allows
time to plan for appropriate management — but this is not always possible. Poor antenatal
care is more common in these patients as are other factors related to their use of drugs such
as respiratory infections, endocarditis, untreated cellulitis and abscesses, HIV/AIDS and
hepatitis (Ludlow et al, 2007). For a detailed review of the anaesthetic issues in these patients
see Ludlow et al (Ludlow et al, 2007).
It has been suggested that pregnant patients taking methadone as part of a drug‐dependence
treatment program should receive whatever dose is needed to prevent heroin use, and that
the dose may need to be increased in the third trimester because the physiological changes
associated with pregnancy can alter the pharmacokinetics of the drug (Ludlow et al, 2007).
Additional opioid will be required for any postoperative pain, as with any opioid‐tolerant
patient, and the infant will require high‐level neonatal care because of the risk of withdrawal
(Ludlow et al, 2007; Jones et al, 2008). Opioid requirements during labour may not be significantly
increased although methadone‐maintained patients in this study did have higher pain scores CHAPTER 11
(Meyer et al, 2007). Those taking buprenorphine will also have higher opioid requirements after
surgery, and the newborn is still at risk (albeit maybe a lower risk) of withdrawal (Ludlow et al,
2007); again, opioid requirements during labour may not be increased (Jones et al, 2008). Both
methadone and buprenorphine should be continued without interruption or, if the patient
cannot take oral medications, then an alternative route (or opioid) should be used (Jones et al,
2008). Opioid requirements and the risk of withdrawal — for the patient and the infant — will
also be higher in patients still taking heroin prior to delivery (Ludlow et al, 2007). For further
information on maternal and neonatal outcomes see Section 11.1.3.
Opioid requirements in those addicted to substances other than opioids should be similar to
other patients.

Acute pain management: scientific evidence 429