Challenges in Acute Pain Management

A common question is how do you manage acute pain in folks with chronic pain and opioid tolerance. It’s similar to the general principles, and using plan of care, multimodal analgesia, having in a professional team, understanding what the goals are realistically in terms of recovery, not just focusing on a single thing like opioids. All patients deserve pain treatment and whether they have the disease of addiction or substance use disorder or not, they may need opioids in their lifetime. Exposing people to opioids does not cause this complicated disease, this vile psychosocial disease of addiction. Certainly, when people have that disease present, we have to be very vigilant and careful and have clear guidance about tapering opioids and looking at their risks around that. But there’s no evidence that using opioids to treat acute pain is going to cause relapse and probably, if anything, if we undertreat patients with opioids, it’s going to cause more problems--people will probably go out and look for illicit sources. Should we refrain from using opioids, try to detoxify patients with substance use disorder in the hospital while they’re there? There is really little evidence that has anything to do with their sobriety. In fact, it just puts them at risk for overdose and death when they leave the hospital. I think we have to use pharmacologic principles. We have to think about safety but we can safely use opioids in all patients including patients with substance use disorder. It takes multidisciplinary plans of care. It takes a multimodal approach using other strategies in addition to opioids. It’s really surprising when you ask people about their addiction history, often how open and honest they’ll be. You have to establish trust and rapport with someone. They’ve often been through poor medical encounters where they’ve felt a lot of judgment or have been treated inconsistently. Sometimes it’s pretty obvious what brought them to the hospital. Do universal precautions, such as urine drug testing, to uncover kind of what substances are present when people are in the hospital and appear intoxicated. And I think you have to thank them for that open honesty and say it’s important for us to know so that we can give you a better and safer care.