Aims

1. Effective pain management
2. Avoidance of withdrawal symptoms
3. Maintenance of usual dose of medication assisted treatment (MAT) where the patient is discharged on the same regime where possible.

Key points

• Patients established on MAT should continue their usual prescription with an aim to treat pain separately.
• The treatment of acute pain eases suffering but also avoids the negative physiological effects of severe pain (see the list below).
• Patients with problematic drug use commonly present with painful conditions and can be challenging to manage.
• Patients often expect their pain will be poorly managed and are frequently anxious about the possibility of drug withdrawal symptoms.
• Clinicians can be uncertain about prescribing opioids and other analgesia for these patients.
• Patients often report higher pain scores than average and experience acute pain for longer than usual. Rather than aim for a specific number on pain assessment scores or NEWS2 charts, aim to control pain to a level that allows functional goals such as deep breathing, coughing, mobilising or self care.
• Complete pain relief is not a realistic goal. Discussing pain management with the patient helps to manage expectations, improve compliance and can enhance success.
• As ever for patients with pain, empathy and reassurance are key and a multimodal plan for pain management should be implemented.
• Simple analgesia – paracetamatol and Ibuprofen should be employed where possible.
• Avoid new prescriptions of anti-neuropathic agents such as gabapentinoids or Tricyclic Antidepressants without prior discussion with the Inpatient Pain Team or Drug Liaison Service.
• Use the oral route where possible although be aware that this may not be available depending on the patient’s condition / expected surgery.
• Treat the causes of pain as appropriate. Consider non-pharmacological measures in addition to medication. Examples include immobilisation or physiotherapy, hot and cold packs or TENS machines.
• Methadone or Buprenorphine alone are often inadequate for acute pain management in this patient group. Very occasionally, improved analgesia can be achieved by splitting the total daily dose into two or three divided doses – only if discussed with the Inpatient Pain Team and / or Drug Liaison Service.
• For patients with a history of substance use disorder who are now opioid free, it is important to discuss their thoughts about being given opioids for pain management. Opioid-free pain management can be challenging but is possible.
• If ever in doubt, seek specialist help. The Inpatient Pain Management Team are available during office hours. Out of hours, contact the anaesthetist on call. Available via Switchboard.

Potential effects of severe acute pain

• Increased stress response
• • Hypertension
  • Tachycardia
  • Increased oxygen consumption
• Impaired deep breathing / cough
• • Increased risk of chest infection
• Reduced mobility
• • Poor compliance with physiotherapy
  • Increased risk of DVT
• Suppressed immune function / impaired wound healing
• Poor sleep
• Nausea / reduced appetite
• Drug seeking behaviour (under treated pain)
• Risk of relapse