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Management of acute pain in the patient chronically using opioids

Robert M Arnold, MD
Julie W Childers, MD
Section Editors
Janet Abrahm, MD
Andrew J Saxon, MD
Deputy Editor
Diane MF Savarese, MD


Prescription of chronic opioid therapy, defined as the daily use of opioids for at least 90 days, has increased substantially in developed countries since 1980 [1,2]. Opioids are a recommended treatment for cancer pain and have been increasingly used for the treatment of chronic nonmalignant pain. In the United States, one study estimated that approximately 3 percent of patients in the primary care setting were receiving chronic opioid therapy for pain [3].

Patients receiving chronic opioid therapy for pain often experience episodes of acute pain, either because of a new injury or surgical procedure. Acute pain may also develop in patients who are receiving chronic opioid maintenance therapy for addiction or who are chronically using inappropriately prescribed or illegally obtained opioids. (See "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis" and "Pharmacotherapy for opioid use disorder".)

The goals of treating acute pain in patients chronically using opioids are to prevent withdrawal, to provide adequate analgesia, and, for patients with a history of a substance use disorder, to avoid triggering a relapse or worsening of the addiction disorder. This topic will describe a stepwise approach to patients on chronic opioids who experience acute pain. An overview of the treatment of chronic noncancer pain, opioid treatment for patients with pain related to cancer (including management of breakthrough pain), as well as issues related to prescription drug abuse and addiction and opioid use disorders, are covered elsewhere.

(See "Overview of the treatment of chronic non-cancer pain".)

(See "Cancer pain management: General principles and risk management for patients receiving opioids".)

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Literature review current through: Nov 2017. | This topic last updated: May 17, 2017.
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  1. Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain 2004; 109:514.
  2. Olsen Y, Daumit GL, Ford DE. Opioid prescriptions by U.S. primary care physicians from 1992 to 2001. J Pain 2006; 7:225.
  3. Boudreau D, Von Korff M, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf 2009; 18:1166.
  4. Gardell LR, Wang R, Burgess SE, et al. Sustained morphine exposure induces a spinal dynorphin-dependent enhancement of excitatory transmitter release from primary afferent fibers. J Neurosci 2002; 22:6747.
  5. Vanderah TW, Gardell LR, Burgess SE, et al. Dynorphin promotes abnormal pain and spinal opioid antinociceptive tolerance. J Neurosci 2000; 20:7074.
  6. Mao J, Sung B, Ji RR, Lim G. Chronic morphine induces downregulation of spinal glutamate transporters: implications in morphine tolerance and abnormal pain sensitivity. J Neurosci 2002; 22:8312.
  7. Chu LF, Clark DJ, Angst MS. Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral morphine therapy: a preliminary prospective study. J Pain 2006; 7:43.
  8. Compton P, Charuvastra VC, Ling W. Pain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend 2001; 63:139.
  9. Doverty M, White JM, Somogyi AA, et al. Hyperalgesic responses in methadone maintenance patients. Pain 2001; 90:91.
  10. Demyttenaere K, Bruffaerts R, Lee S, et al. Mental disorders among persons with chronic back or neck pain: results from the World Mental Health Surveys. Pain 2007; 129:332.
  11. Lavin R, Park J. Depressive symptoms in community-dwelling older adults receiving opioid therapy for chronic pain. J Opioid Manag 2011; 7:309.
  12. Finestone HM, Stenn P, Davies F, et al. Chronic pain and health care utilization in women with a history of childhood sexual abuse. Child Abuse Negl 2000; 24:547.
  13. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1990; 113:828.
  14. Geisser ME, Roth RS, Bachman JE, Eckert TA. The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain. Pain 1996; 66:207.
  15. Beckham JC, Crawford AL, Feldman ME, et al. Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans. J Psychosom Res 1997; 43:379.
  16. Buckelew SP, Parker JC, Keefe FJ, et al. Self-efficacy and pain behavior among subjects with fibromyalgia. Pain 1994; 59:377.
  17. Frank RG, Beck NC, Parker JC, et al. Depression in rheumatoid arthritis. J Rheumatol 1988; 15:920.
  18. Summers MN, Haley WE, Reveille JD, Alarcón GS. Radiographic assessment and psychologic variables as predictors of pain and functional impairment in osteoarthritis of the knee or hip. Arthritis Rheum 1988; 31:204.
  19. Järvikoski A, Härkäpää K, Mellin G. Symptoms of psychological distress and treatment effects with low-back pain patients. Pain 1986; 25:345.
  20. Lin EH, Katon W, Von Korff M, et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA 2003; 290:2428.
  21. Ballantyne JC, Carr DB, Chalmers TC, et al. Postoperative patient-controlled analgesia: meta-analyses of initial randomized control trials. J Clin Anesth 1993; 5:182.
  22. Rahman NH, DeSilva T. A randomized controlled trial of patient-controlled analgesia compared with boluses of analgesia for the control of acute traumatic pain in the emergency department. J Emerg Med 2012; 43:951.
  23. Davis MP, Weissman DE, Arnold RM. Opioid dose titration for severe cancer pain: a systematic evidence-based review. J Palliat Med 2004; 7:462.
  24. Moryl N, Coyle N, Foley KM. Managing an acute pain crisis in a patient with advanced cancer: "this is as much of a crisis as a code". JAMA 2008; 299:1457.
  25. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Adult Cancer Pain, v.1.2012. ww.nccn.org (Accessed on November 05, 2012).
  26. Walsh D, Rivera NI, Davis MP, et al. Strategies for pain management: cleveland clinic foundation guidelines for opioid dosing for cancer pain. Support Cancer Ther 2004; 1:157.
  27. Mercadante S, Portenoy RK. Opioid poorly-responsive cancer pain. Part 3. Clinical strategies to improve opioid responsiveness. J Pain Symptom Manage 2001; 21:338.
  28. Mercadante S, Portenoy RK. Opioid poorly-responsive cancer pain. Part 2: basic mechanisms that could shift dose response for analgesia. J Pain Symptom Manage 2001; 21:255.
  29. Fine PG, Portenoy RK, Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation. Establishing "best practices" for opioid rotation: conclusions of an expert panel. J Pain Symptom Manage 2009; 38:418.
  30. Bruera E, Roca E, Cedaro L, et al. Action of oral methylprednisolone in terminal cancer patients: a prospective randomized double-blind study. Cancer Treat Rep 1985; 69:751.
  31. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 2009; 338:a3115.
  32. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med 2012; 172:1444.
  33. Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth 2008; 101:151.
  34. Mitchinson AR, Kim HM, Rosenberg JM, et al. Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial. Arch Surg 2007; 142:1158.
  35. Bradt J, Dileo C, Grocke D, Magill L. Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database Syst Rev 2011; :CD006911.
  36. Bruera E, Schoeller T, Wenk R, et al. A prospective multicenter assessment of the Edmonton staging system for cancer pain. J Pain Symptom Manage 1995; 10:348.
  37. Rowley D, McLean S, O'Gorman A, et al. Review of cancer pain management in patients receiving maintenance methadone therapy. Am J Hosp Palliat Care 2011; 28:183.
  38. Hines S, Theodorou S, Williamson A, et al. Management of acute pain in methadone maintenance therapy in-patients. Drug Alcohol Rev 2008; 27:519.
  39. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med 2006; 144:127.
  40. Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK64164/
  41. Mitra S, Sinatra RS. Perioperative management of acute pain in the opioid-dependent patient. Anesthesiology 2004; 101:212.
  42. Compton P, Kehoe P, Sinha K, et al. Gabapentin improves cold-pressor pain responses in methadone-maintained patients. Drug Alcohol Depend 2010; 109:213.
  43. Heit HA, Gourlay DL. Buprenorphine: new tricks with an old molecule for pain management. Clin J Pain 2008; 24:93.
  44. Orman JS, Keating GM. Buprenorphine/naloxone: a review of its use in the treatment of opioid dependence. Drugs 2009; 69:577.
  45. Anderson TA, Quaye ANA, Ward EN, et al. To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology 2017; 126:1180.
  46. Macintyre PE, Russell RA, Usher KA, et al. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care 2013; 41:222.
  47. Kornfeld H, Manfredi L. Effectiveness of full agonist opioids in patients stabilized on buprenorphine undergoing major surgery: a case series. Am J Ther 2010; 17:523.
  48. Roberts DM, Meyer-Witting M. High-dose buprenorphine: perioperative precautions and management strategies. Anaesth Intensive Care 2005; 33:17.
  49. Johnson RE, Fudala PJ, Payne R. Buprenorphine: considerations for pain management. J Pain Symptom Manage 2005; 29:297.
  50. Robers LJ. Managing acute pain in patients with an opioid abuse or dependence disorder. Aust Presc 2008; 31:133.
  51. Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from: http://www.samhsa.gov/data/. (Accessed on December 15, 2016).
  52. Krashin D, Murinova N, Ballantyne J. Management of pain with comorbid substance abuse. Curr Psychiatry Rep 2012; 14:462.
  53. Scimeca MM, Savage SR, Portenoy R, Lowinson J. Treatment of pain in methadone-maintained patients. Mt Sinai J Med 2000; 67:412.
  54. Center for Substance Abuse Treatment. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Substance Abuse and Mental Health Services Administration (US), Rockville, MD 2012. Report No: (SMA) 12-4671.
  55. Passik SD, Theobald DE. Managing addiction in advanced cancer patients: why bother? J Pain Symptom Manage 2000; 19:229.
  56. Coben JH, Davis SM, Furbee PM, et al. Hospitalizations for poisoning by prescription opioids, sedatives, and tranquilizers. Am J Prev Med 2010; 38:517.
  57. Modesto-Lowe V, Brooks D, Petry N. Methadone deaths: risk factors in pain and addicted populations. J Gen Intern Med 2010; 25:305.
  58. Centers for Disease Control and Prevention (CDC). Vital signs: risk for overdose from methadone used for pain relief - United States, 1999-2010. MMWR Morb Mortal Wkly Rep 2012; 61:493.
  59. Jamison RN, Ross EL, Michna E, et al. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain 2010; 150:390.