Simplifying Pain Management with Opioid Use Disorder (OUD) 

In honor of American Pharmacists Month this October, we want to highlight the essential role healthcare professionals play in managing opioid use disorder (OUD). OUD presents significant challenges, especially when treating patients with concurrent pain. This complexity arises from the delicate balance between providing effective pain relief and avoiding relapse or harm. Explore how healthcare providers can simplify this process, ensuring patients with OUD receive optimized, individualized care. 

Understanding OUD: A Chronic Medical Condition 

Opioid use disorder is defined as a chronic medical condition characterized by compulsive opioid use despite harmful consequences. The American Society of Addiction Medicine (ASAM) describes addiction as a complex disease involving brain circuits, genetics, environment, and life experiences. To diagnose OUD, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines 11 criteria, categorizing severity as mild (2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms). 

The 11 Criteria for OUD Diagnosis: 

1. Using opioids in larger amounts than intended. 

2. Persistent desire to reduce opioid use but unsuccessful. 

3. Excessive time spent obtaining or using opioids or recovering from their effects. 

4. Craving opioids. 

5. Continued use despite failure to fulfill responsibilities. 

6. Social or interpersonal issues caused by opioid use. 

7. Reduced participation in activities due to opioid use. 

8. Using opioids in hazardous situations. 

9. Continued use despite physical or psychological problems caused by opioids. 

10. Tolerance development. 

11. Withdrawal symptoms in the absence of opioids. 

Addressing OUD with patients can be a difficult but necessary conversation. Pro Tip: Use DSM criteria as a conversation starter! 

Pain and OUD: A Challenging Conundrum 

Patients with OUD often face unique barriers to pain management due to: 

• Tolerance 

• Opioid-induced hyperalgesia (OIH) 

• Alterations in nociception 

• Co-occurring psychiatric conditions 

• Co-occurring medical conditions 

• Co-occurring psychosocial problems 

• Stigma—both perceived and actual 

• Provider bias, education, and experience 

• Potential secondary gain 

These factors can hinder effective care and must be addressed for effective treatment. 

Medications to Treat Opioid Use Disorder (MOUD) Options 

Patients with OUD can benefit from medications to treat opioid use disorder (MOUD), which include: 

1. Methadone: Enrolled through an Opioid Treatment Program (OTP), it is an oral solution and a full opioid agonist prescribed daily. 

2. Buprenorphine: A partial opioid agonist and antagonist with lower overdose risks; available as a sublingual film/tablet or long-acting injection. 

3. Naltrexone: Available in intramuscular or oral forms, it is an opioid antagonist used for alcohol and opioid use disorders. 

It’s important to continue patients' MOUD during hospitalization or surgery unless clinically contraindicated. 

Managing Pain in Patients on MOUD 

Opioid use disorder does not exempt patients from experiencing pain, and effective management is vital. When treating pain for patients on MOUD, providers must carefully consider the type of surgery, anticipated pain, opioid tolerance, and the feasibility of regional blocks. Multi-modal analgesic regimens, including non-opioid adjuncts, are recommended for pain management. 

In cases involving buprenorphine use, research suggests continuing the medication alongside other opioids for optimal pain control. Adjusting the buprenorphine dose to more frequent, smaller amounts can provide effective analgesia without increasing the risk of relapse. 

Harm Reduction and Stigma Reduction Techniques 

Harm reduction plays a critical role in managing OUD. It involves minimizing opioid exposure, avoiding interruptions in MOUD, and providing trauma-informed care. Reducing stigma—both societal/public and internal beliefs—is essential for effective treatment. Simple changes in language can make a significant difference. For example, use “person with substance use disorder” instead of “addict” and “testing negative for substance use” rather than “clean.” 

Words to Avoid vs. Words to Use 

Healthcare professionals are encouraged to collaborate with patients and other providers to support recovery, reduce harm, and destigmatize OUD treatment. This holistic, supportive approach ensures patients receive the best care possible without feeling judged or marginalized. 

Best Practices in OUD Management 

• Normalize OUD treatment. 

• Support patients with continuous follow-up, like other chronic conditions. 

• Collaborate with patients and providers to personalize care. 

• Educate patients on the risks of interrupting MOUD and encourage adherence to prescribed treatment. 

• Reduce stigma and harm! 

• Use the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder – 2020 Focused Update. 

Final Thoughts 

Managing pain in patients with OUD requires a balance of effective pain relief and uninterrupted OUD treatment. With the right strategies—including MOUD continuation, multi-modal pain management, and stigma reduction—healthcare providers can deliver compassionate and effective care. 

For additional resources on opioid use disorder and effective pain management, visit the American Society of Addiction Medicine (ASAM) or explore the following support services: 

• Substance Abuse and Mental Health Services Administration (SAMHSA): Provides several physician resources targeted at the treatment of OUD, including: 

  • Practitioner Guidelines 

  • Practioner Trainings 

  • Providers Clinical Support System for Medications for Opioid Use Disorders (PCSS-MOUD) 

• Centers for Disease Control and Prevention (CDC): Offers OUD prescriber resources and web-based interactive training and webinars, including: 

  • Prescribing Guidelines 

  • Prescribing Guidelines Resources 

  • Prescriber Training for Providers 

  • Prescription Drug Monitoring Program (PDMP) Overview 

For those unable to attend PAINWeek 2024, on-demand access to the live content will be available from November 2024 to November 2025. Pre-order Digital All Access 2024 to unlock over 65 credit hours of expert-led sessions, including special topics on pharmacotherapy and opioid use disorder.