Management of acute pain in the patient chronically using opioids
- Robert M Arnold, MD
Robert M Arnold, MD
- Editor-in-Chief — Palliative Care
- Section Editor — General Principles of Palliative Care
- Chief, Section of Palliative Care and Medical Ethics
- University of Pittsburgh School of Medicine
- Julie W Childers, MD
Julie W Childers, MD
- Assistant Professor of Medicine
- University of Pittsburgh
- Section Editors
- Janet Abrahm, MD
Janet Abrahm, MD
- Section Editor — Pain: Assessment and Management
- Professor of Medicine
- Harvard Medical School
- Andrew J Saxon, MD
Andrew J Saxon, MD
- Section Editor — Substance Use Disorders
- Professor and Director, Addiction Psychiatry Residency Program, Department of Psychiatry & Behavioral Sciences
- University of Washington
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 .
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.
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- Differential diagnosis
- TREATMENT IN PATIENTS RECEIVING CHRONIC OPIOID THERAPY FOR PAIN
- Potentially treatable cause
- Empiric treatment
- - Prescribing opioid analgesics for patients on chronic opioid therapy
- - Choice of opioid route and regimen
- Intermittent opioids
- Patient-controlled analgesia (PCA)
- Risks of rapid opioid titration
- When should bolus dosing be added to basal dosing
- Opioid rotation
- Opioid-sparing strategies
- SPECIAL SITUATIONS
- Patients receiving opioid maintenance therapy for addiction
- - Methadone maintenance therapy
- - Buprenorphine
- - Naltrexone
- Acute pain in patients who are actively addicted to opioids
- SUMMARY AND RECOMMENDATIONS