Perspectives17 January 2006
    Author, Article, and Disclosure Information

    Abstract

    More patients with opioid addiction are receiving opioid agonist therapy (OAT) with methadone and buprenorphine. As a result, physicians will more frequently encounter patients receiving OAT who develop acutely painful conditions, requiring effective treatment strategies. Undertreatment of acute pain is suboptimal medical treatment, and patients receiving long-term OAT are at particular risk. This paper acknowledges the complex interplay among addictive disease, OAT, and acute pain management and describes 4 common misconceptions resulting in suboptimal treatment of acute pain. Clinical recommendations for providing analgesia for patients with acute pain who are receiving OAT are presented. Although challenging, acute pain in patients receiving this type of therapy can effectively be managed.

    References

    • 1. Institute of MedicineFederal Regulation of Methadone Treatment. Washington, DC: National Academy of Medicine; 1995:21-6. Google Scholar
    • 2. Ball JCRoss AThe Effectiveness of Methadone Maintenance Treatment. New York: Springer-Verlag; 1991. Google Scholar
    • 3. Metzger DSWoody GEMcLellan ATO'Brien CPDruley PNavaline Het alHuman immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immune Defic Syndr1993;6:1049-56. [PMID: 8340896] MedlineGoogle Scholar
    • 4. Effective medical treatment of opiate addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA1998;280:1936-43. [PMID: 9851480] CrossrefMedlineGoogle Scholar
    • 5. O'Connor PGFiellin DAPharmacologic treatment of heroin-dependent patients. Ann Intern Med2000;133:40-54. [PMID: 10877739] LinkGoogle Scholar
    • 6. Cooper JRIncluding narcotic addiction treatment in an office-based practice. JAMA1995;273:1619-20. [PMID: 7745777] CrossrefMedlineGoogle Scholar
    • 7. Fiellin DAO'Connor PGNew federal initiatives to enhance the medical treatment of opioid dependence. Ann Intern Med2002;137:688-92. [PMID: 12379070] LinkGoogle Scholar
    • 8. Krantz MJMehler PSTreating opioid dependence. Growing implications for primary care. Arch Intern Med2004;164:277-88. [PMID: 14769623] CrossrefMedlineGoogle Scholar
    • 9. Clark HWOffice-based practice and opioid-use disorders. N Engl J Med2003;349:928-30. [PMID: 12954740] CrossrefMedlineGoogle Scholar
    • 10. Fiellin DAO'Connor PGClinical practice. Office-based treatment of opioid-dependent patients. N Engl J Med2002;347:817-23. [PMID: 12226153] CrossrefMedlineGoogle Scholar
    • 11. Merrill JOPolicy progress for physician treatment of opiate addiction. J Gen Intern Med2002;17:361-8. [PMID: 12047733] CrossrefMedlineGoogle Scholar
    • 12. Quality improvement guidelines for the treatment of acute pain and cancer pain. American Pain Society Quality of Care Committee. JAMA1995;274:1874-80. [PMID: 7500539] CrossrefMedlineGoogle Scholar
    • 13. Federation of State Medical Boards of the United States, IncModel Guidelines for the Use of Controlled Substances for the Treatment of Pain. Euless, TX: Federation of State Medical Boards of the United States; 2003. Google Scholar
    • 14. Gordon DBDahl JLMiaskowski CMcCarberg BTodd KHPaice JAet alAmerican Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med2005;165:1574-80. [PMID: 16043674] CrossrefMedlineGoogle Scholar
    • 15. The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain1997;13:6-8. [PMID: 9084947] MedlineGoogle Scholar
    • 16. Joint Commission on Accreditation of Healthcare OrganizationsComprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1999. Google Scholar
    • 17. Joint Commission on Accreditation of Healthcare OrganizationsJoint Commission Focuses on Pain Management. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1999. Google Scholar
    • 18. Marks RMSachar EJUndertreatment of medical inpatients with narcotic analgesics. Ann Intern Med1973;78:173-81. [PMID: 4683747] LinkGoogle Scholar
    • 19. Rupp TDelaney KAInadequate analgesia in emergency medicine. Ann Emerg Med2004;43:494-503. [PMID: 15039693] CrossrefMedlineGoogle Scholar
    • 20. Cleeland CSGonin RHatfield AKEdmonson JHBlum RHStewart JAet alPain and its treatment in outpatients with metastatic cancer. N Engl J Med1994;330:592-6. [PMID: 7508092] CrossrefMedlineGoogle Scholar
    • 21. Breitbart WRosenfeld BDPassik SDMcDonald MVThaler HPortenoy RKThe undertreatment of pain in ambulatory AIDS patients. Pain1996;65:243-9. [PMID: 8826513] CrossrefMedlineGoogle Scholar
    • 22. Hill CSWhen will adequate pain treatment be the norm? [Editorial]. JAMA1995;274:1881-2. [PMID: 7500540] CrossrefMedlineGoogle Scholar
    • 23. Melzack RThe tragedy of needless pain. Sci Am1990;262:27-33. [PMID: 2296714] CrossrefMedlineGoogle Scholar
    • 24. Carr DBGoudas LCAcute pain. Lancet1999;353:2051-8. [PMID: 10376632] CrossrefMedlineGoogle Scholar
    • 25. Savage SROpioid use in the management of chronic pain. Med Clin North Am1999;83:761-86. [PMID: 10386124] CrossrefMedlineGoogle Scholar
    • 26. Lander JFallacies and phobias about addiction and pain. Br J Addict1990;85:803-9. [PMID: 1974156] CrossrefMedlineGoogle Scholar
    • 27. Morgan JPAmerican opiophobia: customary underutilization of opioid analgesics. Adv Alcohol Subst Abuse1985;5:163-73. [PMID: 2870626] CrossrefMedlineGoogle Scholar
    • 28. Scimeca MMSavage SRPortenoy RLowinson JTreatment of pain in methadone-maintained patients. Mt Sinai J Med2000;67:412-22. [PMID: 11064492] MedlineGoogle Scholar
    • 29. Hoffman MProvatas ALyver AKanner RPain management in the opioid-addicted patient with cancer. Cancer1991;68:1121-2. [PMID: 1913484] CrossrefMedlineGoogle Scholar
    • 30. Portenoy RKDole VJoseph HLowinson JRice CSegal Set alPain management and chemical dependency. Evolving perspectives. JAMA1997;278:592-3. [PMID: 9268282] CrossrefMedlineGoogle Scholar
    • 31. Savage SRAddiction in the treatment of pain: significance, recognition, and management. J Pain Symptom Manage1993;8:265-78. [PMID: 7525743] CrossrefMedlineGoogle Scholar
    • 32. Schnoll SHWeaver MFAddiction and pain. Am J Addict2003;12 Suppl 2 S27-35. [PMID: 12857661] CrossrefMedlineGoogle Scholar
    • 33. Martin JEInglis JPain tolerance and narcotic addiction. Br J Soc Clin Psychol1965;4:224-9. [PMID: 5872680] CrossrefMedlineGoogle Scholar
    • 34. Compton PGebhart GThe neurophysiology and pain and addiction.. In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, eds. Principles of Addiction Medicine. 3rd ed. Annapolis, MD: American Society of Addiction Medicine; 2003:1385-404. Google Scholar
    • 35. Gardner ELBrain reward mechanism.. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance Abuse: A Comprehensive Textbook. 3rd ed. Baltimore: Williams and Wilkins; 1997:51-84. Google Scholar
    • 36. Zacny JPMcKay MAToledano AYMarks SYoung CJKlock PAet alThe effects of a cold-water immersion stressor on the reinforcing and subjective effects of fentanyl in healthy volunteers. Drug Alcohol Depend1996;42:133-42. [PMID: 8889412] CrossrefMedlineGoogle Scholar
    • 37. Savage SRSchofferman JPharmacological therapies of pain in drug and alcohol addictions.. In: Miller N, Gold M, eds. Pharmacological Therapies for Drug and Alcohol Addictions. New York: Dekker; 1995:373-409. Google Scholar
    • 38. Compton MACold-pressor pain tolerance in opiate and cocaine abusers: correlates of drug type and use status. J Pain Symptom Manage1994;9:462-73. [PMID: 7822886] CrossrefMedlineGoogle Scholar
    • 39. Compton PPain tolerance in opioid addicts on and off naltrexone pharmacotherapy: a pilot study. J Pain Symptom Manage1998;16:21-8. [PMID: 9707654] CrossrefMedlineGoogle Scholar
    • 40. Prater CDZylstra RGMiller KESuccessful pain management for the recovering addicted patient. Prim Care Companion J Clin Psychiatry2002;4:125-131. [PMID: 15014719] CrossrefMedlineGoogle Scholar
    • 41. American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders. 4th ed. Text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000. Google Scholar
    • 42. Savage SRJoranson DECovington ECSchnoll SHHeit HAGilson AMDefinitions related to the medical use of opioids: evolution towards universal agreement. J Pain Symptom Manage2003;26:655-67. [PMID: 12850648] CrossrefMedlineGoogle Scholar
    • 43. Eriator INarcotic analgesics for chronic pain management. Current Review of Pain1998;2:193-200. CrossrefGoogle Scholar
    • 44. Vukmir RBDrug seeking behavior. Am J Drug Alcohol Abuse2004;30:551-75. [PMID: 15540493] CrossrefMedlineGoogle Scholar
    • 45. White JMPleasure into pain: the consequences of long-term opioid use. Addict Behav2004;29:1311-24. [PMID: 15345267] CrossrefMedlineGoogle Scholar
    • 46. Buprenorphine: an alternative to methadone. Med Lett Drugs Ther2003;45:13-5. [PMID: 12592214] MedlineGoogle Scholar
    • 47. Johnson REFudala PJPayne RBuprenorphine: considerations for pain management. J Pain Symptom Manage2005;29:297-326. [PMID: 15781180] CrossrefMedlineGoogle Scholar
    • 48. Fishman SMWilsey BMahajan GMolina PMethadone reincarnated: novel clinical applications with related concerns. Pain Med2002;3:339-48. [PMID: 15099239] CrossrefMedlineGoogle Scholar
    • 49. Walsh SLEissenberg TThe clinical pharmacology of buprenorphine: extrapolating from the laboratory to the clinic. Drug Alcohol Depend2003;70:S13-27. [PMID: 12738347] CrossrefMedlineGoogle Scholar
    • 50. Gutstein HBAkil HOpioid analgesics.. In: Hardman JG, Goodman Gilman A, Limbird LE, eds. The Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw-Hill; 2001:569-620. Google Scholar
    • 51. Inturrisi CEClinical pharmacology of opioids for pain. Clin J Pain2002;18:S3-13. [PMID: 12479250] CrossrefMedlineGoogle Scholar
    • 52. McNicol EHorowicz-Mehler NFisk RABennett KGialeli-Goudas MChew PWet alManagement of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. J Pain2003;4:231-56. [PMID: 14622694] CrossrefMedlineGoogle Scholar
    • 53. Houtsmuller EJWalsh SLSchuh KJJohnson REStitzer MLBigelow GEDose-response analysis of opioid cross-tolerance and withdrawal suppression during LAAM maintenance. J Pharmacol Exp Ther1998;285:387-96. [PMID: 9580575] MedlineGoogle Scholar
    • 54. Collett BJOpioid tolerance: the clinical perspective. Br J Anaesth1998;81:58-68. [PMID: 9771273] CrossrefMedlineGoogle Scholar
    • 55. Doverty MSomogyi AAWhite JMBochner FBeare CHMenelaou Aet alMethadone maintenance patients are cross-tolerant to the antinociceptive effects of morphine. Pain2001;93:155-63. [PMID: 11427327] CrossrefMedlineGoogle Scholar
    • 56. Laulin JPCélèrier ELarcher ALeMoal MSimonnet GOpiate tolerance to daily heroin administration: an apparent phenomenon associated with enhanced pain sensitivity. Neuroscience1999;89:631-6. [PMID: 10199599] CrossrefMedlineGoogle Scholar
    • 57. Mao JOpioid-induced abnormal pain sensitivity: implications in clinical opioid therapy. Pain2002;100:213-7. [PMID: 12467992] CrossrefMedlineGoogle Scholar
    • 58. Streltzer JPain management in the opioid-dependent patient. Curr Psychiatry Rep2001;3:489-96. [PMID: 11707163] CrossrefMedlineGoogle Scholar
    • 59. Compton PCharuvastra VCKintaudi KLing WPain responses in methadone-maintained opioid abusers. J Pain Symptom Manage2000;20:237-45. [PMID: 11027904] CrossrefMedlineGoogle Scholar
    • 60. Ho ADole VPPain perception in drug-free and in methadone-maintained human ex-addicts. Proc Soc Exp Biol Med1979;162:392-5. [PMID: 515020] CrossrefMedlineGoogle Scholar
    • 61. Doverty MWhite JMSomogyi AABochner FAli RLing WHyperalgesic responses in methadone maintenance patients. Pain2001;90:91-6. [PMID: 11166974] CrossrefMedlineGoogle Scholar
    • 62. Schall UKatta TPries EKlöppel AGastpar MPain perception of intravenous heroin users on maintenance therapy with levomethadone. Pharmacopsychiatry1996;29:176-9. [PMID: 8895942] CrossrefMedlineGoogle Scholar
    • 63. Compton PCharuvastra VCLing WPain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend2001;63:139-46. [PMID: 11376918] CrossrefMedlineGoogle Scholar
    • 64. Devillers JPBoisserie FLaulin JPLarcher ASimonnet GSimultaneous activation of spinal antiopioid system (neuropeptide FF) and pain facilitatory circuitry by stimulation of opioid receptors in rats. Brain Res1995;700:173-81. [PMID: 8624708] CrossrefMedlineGoogle Scholar
    • 65. Dunbar SAPulai IJRepetitive opioid abstinence causes progressive hyperalgesia sensitive to N-methyl-D-aspartate receptor blockade in the rat. J Pharmacol Exp Ther1998;284:678-86. [PMID: 9454814] MedlineGoogle Scholar
    • 66. Grilly DMGowans GCAcute morphine dependence: effects observed in shock and light discrimination tasks. Psychopharmacology (Berl)1986;88:500-4. [PMID: 3085139] CrossrefMedlineGoogle Scholar
    • 67. Devulder JBohyn PCastille FDeLaat MRolly GA case of uncommon withdrawal symptoms after a short period of spinal morphine administration. Pain1996;64:589-91. [PMID: 8783325] CrossrefMedlineGoogle Scholar
    • 68. Devulder JHyperalgesia induced by high-dose intrathecal sufentanil in neuropathic pain. J Neurosurg Anesthesiol1997;9:146-8. [PMID: 9100184] CrossrefMedlineGoogle Scholar
    • 69. Laulin JPLarcher ACélèrier ELeMoal MSimonnet GLong-lasting increased pain sensitivity in rat following exposure to heroin for the first time. Eur J Neurosci1998;10:782-5. [PMID: 9749743] CrossrefMedlineGoogle Scholar
    • 70. Laulin JPMaurette PCorcuff JBRivat CChauvin MSimonnet GThe role of ketamine in preventing fentanyl-induced hyperalgesia and subsequent acute morphine tolerance. Anesth Analg2002;94:1263-9. [PMID: 11973202] CrossrefMedlineGoogle Scholar
    • 71. Célèrier ELaulin JPCorcuff JBLeMoal MSimonnet GProgressive enhancement of delayed hyperalgesia induced by repeated heroin administration: a sensitization process. J Neurosci2001;21:4074-80. [PMID: 11356895] CrossrefMedlineGoogle Scholar
    • 72. Célèrier ELaulin JLarcher ALeMoal MSimonnet GEvidence for opiate-activated NMDA processes masking opiate analgesia in rats. Brain Res1999;847:18-25. [PMID: 10564731] CrossrefMedlineGoogle Scholar
    • 73. Célèrier ERivat CJun YLaulin JPLarcher AReynier Pet alLong-lasting hyperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology2000;92:465-72. [PMID: 10691234] CrossrefMedlineGoogle Scholar
    • 74. Kantor TGCantor RTom EA study of hospitalized surgical patients on methadone maintenance. Drug Alcohol Depend1980;6:163-73. [PMID: 6107237] CrossrefMedlineGoogle Scholar
    • 75. Manfredi PLGonzales GRCheville ALKornick CPayne RMethadone analgesia in cancer pain patients on chronic methadone maintenance therapy. J Pain Symptom Manage2001;21:169-74. [PMID: 11226767] CrossrefMedlineGoogle Scholar
    • 76. Karasz AZallman LBerg KGourevitch MSelwyn PArnsten JHet alThe experience of chronic severe pain in patients undergoing methadone maintenance treatment. J Pain Symptom Manage2004;28:517-25. [PMID: 15504628] CrossrefMedlineGoogle Scholar
    • 77. Jasinski DRTolerance and dependence to opiates. Acta Anaesthesiol Scand1997;41:184-6. [PMID: 9061104] CrossrefMedlineGoogle Scholar
    • 78. Bruera EMacmillan KHanson JMacDonald RNThe cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain1989;39:13-6. [PMID: 2812850] CrossrefMedlineGoogle Scholar
    • 79. Walsh TBaxter RBowerman KLeber BHigh-dose morphine and respiratory function in chronic cancer pain [Abstract]. Pain1981;S1:39. CrossrefGoogle Scholar
    • 80. Hanks GWTwycross RGLloyd JWUnexpected complication of successful nerve block. Morphine induced respiratory depression precipitated by removal of severe pain. Anaesthesia1981;36:37-9. [PMID: 6894066] CrossrefMedlineGoogle Scholar
    • 81. Dole VPNyswander MEKreek MJNarcotic blockade. Arch Intern Med1966;118:304-9. [PMID: 4162686] CrossrefMedlineGoogle Scholar
    • 82. Jones BEPrada JADrug-seeking behavior during methadone maintenance. Psychopharmacologia1975;41:7-10. [PMID: 47638] CrossrefMedlineGoogle Scholar
    • 83. Merrill JORhodes LADeyo RAMarlatt GABradley KAMutual mistrust in the medical care of drug users: the keys to the “narc” cabinet. J Gen Intern Med2002;17:327-33. [PMID: 12047728] MedlineGoogle Scholar
    • 84. Weissman DEHaddox JDOpioid pseudoaddiction—an iatrogenic syndrome. Pain1989;36:363-6. [PMID: 2710565] CrossrefMedlineGoogle Scholar
    • 85. Portenoy RKFoley KMChronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain1986;25:171-86. [PMID: 2873550] CrossrefMedlineGoogle Scholar
    • 86. Evers GCPseudo-opioid-resistant pain. Support Care Cancer1997;5:457-60. [PMID: 9406359] CrossrefMedlineGoogle Scholar
    • 87. Mao JPrice DDMayer DJMechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions. Pain1995;62:259-74. [PMID: 8657426] CrossrefMedlineGoogle Scholar
    • 88. Kehlet HDahl JBThe value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg1993;77:1048-56. [PMID: 8105724] MedlineGoogle Scholar
    • 89. Botney MFields HLAmitriptyline potentiates morphine analgesia by a direct action on the central nervous system. Ann Neurol1983;13:160-4. [PMID: 6219612] CrossrefMedlineGoogle Scholar
    • 90. Mitra SSinatra RSPerioperative management of acute pain in the opioid-dependent patient. Anesthesiology2004;101:212-27. [PMID: 15220793] CrossrefMedlineGoogle Scholar
    • 91. O'Brien CPDrug addiction and drug abuse.. In: Hardman JG, Goodman Gilman A, Limbird LE, eds. The Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw-Hill; 2001:621-42. Google Scholar
    • 92. Tilson HARech RHStolman SHyperalgesia during withdrawal as a means of measuring the degree of dependence in morphine dependent rats. Psychopharmacologia1973;28:287-300. [PMID: 4734848] CrossrefMedlineGoogle Scholar
    • 93. Paige DProble LWatrous GKaalaas-Sittig JCompton PPCA use in cocaine using patients: a pilot study. American Journal of Pain Management1994;4:101-5. Google Scholar
    • 94. Boyle RKIntra- and postoperative anaesthetic management of an opioid addict undergoing caesarean section. Anaesth Intensive Care1991;19:276-9. [PMID: 2069256] CrossrefMedlineGoogle Scholar
    • 95. Pasternak GWMultiple opiate receptors: déjà vu all over again. Neuropharmacology2004;47 Suppl 1 312-23. [PMID: 15464147] CrossrefMedlineGoogle Scholar
    • 96. O'Connor PGSamet JHStein MDManagement of hospitalized intravenous drug users: role of the internist. Am J Med1994;96:551-8. [PMID: 8017454] CrossrefMedlineGoogle Scholar
    • 97. Fultz JMSenay ECGuidelines for the management of hospitalized narcotics addicts. Ann Intern Med1975;82:815-8. [PMID: 1138596] LinkGoogle Scholar
    • 98. Center for Substance Abuse Treatment. Clinical Guideline for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS publication no. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. Google Scholar
    • 99. Edge WGCooper GMMorgan MAnalgesic effects of sublingual buprenorphine. Anaesthesia1979;34:463-7. [PMID: 474948] CrossrefMedlineGoogle Scholar
    • 100. Moa GZetterström HSublingual buprenorphine as postoperative analgesic: a double-blind comparison with pethidine. Acta Anaesthesiol Scand1990;34:68-71. [PMID: 2309545] CrossrefMedlineGoogle Scholar
    • 101. McCance-Katz EFOffice-based buprenorphine treatment for opioid-dependent patients. Harv Rev Psychiatry2004;12:321-38. [PMID: 15764468] CrossrefMedlineGoogle Scholar
    • 102. Johnson REStrain ECAmass LBuprenorphine: how to use it right. Drug Alcohol Depend2003;70:S59-77. [PMID: 12738351] CrossrefMedlineGoogle Scholar
    • 103. Center for Substance Abuse Treatment. State Methadone Treatment Guidelines. Treatment Improvement Protocol (TIP) Series 1. DHHS publication no. (SMA) 93-1991. Rockville, MD: Substance Abuse and Mental Health Services Administration; 1993. Google Scholar