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The management of acute and chronic pain in patients with substance use disorders is a complex neurobiological phenomenon and presents the clinician with a number of challenges. A comprehensive assessment of both pain and substance misuse (including alcohol) is essential when managing pain in patients with current or past substance use disorders. Non-pharmacological interventions should also be considered in the development of a pain management plan.
Although caution is necessary, patients who are dependent on opioids or have a history of drug dependence may be treated with opioid analgesics when there is a clinical need. Treatment with opioid analgesics in this patient group should normally be carried out with the advice of specialists.
Liaise with substance misuse/pain specialists as appropriate – ideally prior to prescribing opioids, or non-opioids which may be liable to misuse or diversion e.g. gabapentin and pregabalin. It is recommended opioids in this context are prescribed within a specific framework: single medical prescriber and contract; regular monitoring of use (e.g. warning on practice computer system and to Out of Hours service if necessary) and emphasis on the use of controlled release opioid formulations only if necessary.
Remember: Substance misuse services are available to advise and/or assess patients with complex presentations in addition to local pain clinics. Clinicians may either phone for advice or refer patients to the specialist service using the appropriate route:
Plymouth Specialist Addiction Service
Plymouth Chronic Pain Management Team (chronic pain for over three months)
Torbay Primary Care Substance Misuse Service (TPCSMS)
Devon Partnership Trust – Drug and Alcohol Service
Torbay Chronic Pain Management Team (chronic pain for over three months)