• Patients with opioid use disorder experience greater pain severity and sensitivity, and have less tolerance to pain.
• Greater than 50% of patients on opioid agonist therapy (OAT) experience chronic pain.
• They are less likely to divulge being on OAT due to fear of stigma in the context of acute pain episodes.
• Inadequate pain management has been linked to decrease retention to treatment and increase rates of self-treatment through ongoing illicit use.
• Tenants of adequate pain management for patient with opioid use disorder include (Warner et al):
  • Guiding the patient safely through the acute care episode.
  • Avoid iatrogenic harms, including immediate complications (e.g. respiratory depression) and long-term complications (e.g. relapse to opioid use in patients with OUD).
  • Treat acute pain in a manner which is both safe and effective.
  • Promote return to baseline function with discontinuation of additional opioids as rapidly as feasible.

Non-pharmacotherapy

• Create trauma-informed and safe care space.

Basal Analgesia

NSAIDs and Acetaminophen

• Frontline use of NSAIDs and acetaminophen can reduce opioid requirements by 25-30% and leads to superior analgesia.
• Consider if no contraindication:
  • Ibuprofen 400-600mg po and acetaminophen 1g po

Ketamine

• Can be used as adjunct to opioids or alone for pain management
• Reduces opioid related hyperalgesia
• Supported by ACEP: 1-0.3mg/kg bolus IV +/- infusion
• Keep to lower dose range to avoid dysphoria, which is not well tolerated in this patient population
• Consider:
  • Ketamine 10-20mg IV push dose

Clonidine

• Adjunct to reduce opioid requirements and pain scores
• Side effects include bradycardia, hypotension
• Consider:
  • Clonidine 0.1-0.2mg po

Opioids

• Need to address underlying withdrawal prior to successfully treating pain.
• Immediate release opioids are more practical in the ED – more easily titratable and more rapid onset. They can easily temporize even in cases of missed OAT.
  • Oral is preferred over parental administration given longer duration of action (3-4 hours vs 1-2 hours), but IV can be used in severe cases given more rapid onset (15 min vs 90 min)
  • Avoid morphine in renal failure
  • Consider following orders (oral liquid for faster onset and minimizes cheeking)
    • Morphine oral liquid 20-30 mg po q2h PRN for cravings, withdrawal or pain. Hold if drowsy/not easily rousable
      • Increase to 30-40mg as needed
    • Hydromorphone oral liquid 4-6mg po q2h PRN
      • Can consider lower range of 2-4mg given higher affinity

Opioid Agonist Therapy (OAT)

• Peak effect of OAT beyond typical length of stay in ED (e.g. SROM 6-8 hours, methadone 2-4 hours)
• Consider dosing in ED if:
  • Pharmacy is closed (prolonged stay in ED)
  • Admission
  • Missed doses that could lead dose reduction/discontinuation of prescription
• Know your hospital’s protocol for dosing OAT and notify patient’s usual pharmacy of dose administered

Special Scenarios

• Injectable OAT
  • Managed in specialty clinics
  • Administration of high IV opioids doses BID or TID (either diacetylmorphine or hydromorphone)
  • Low threshold to ask for advice from addiction specialist- requires high doses of IV hydromorphone for pain/withdrawal (5-20mg IV)
• Buprenorphine/naloxone (bup/nlx)
  • Response to IR opioids will depend on mu receptor binding – related to dose of bup and last dose administered
  • Need higher affinity opioids (fentanyl and hydromorphone) at higher doses

Discharge Planning

• Maintain similar pain approach as per guidelines: consider non-opioid analgesics as first line
• If opioid prescription is required: short prescription at lowest dose, daily dispense with OAT, avoid oxycodone and provide THN
• Ensure continuation of OAT

1. 24/7 Addiction Medicine Clinician Support Line

   
   

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22. BC Centre on Substance Use – Opioid Use Disorder Guideline