Managing Pain with Opioids in the Setting of Substance Use Disorder

Purpose of ReviewThis review discusses clinical considerations for the potential use of opioid therapy in pain management for individuals with substance use disorder (SUD). It includes a brief overview of epidemiology, as well as the management of acute and chronic pain in those with an opioid use disorder (OUD).Recent FindingsThe use of opioids is not recommended as a first line treatment for chronic pain, regardless of the risk for SUD. For those with co-occurring SUD and chronic pain, treatment with opioids should be limited to buprenorphine or methadone unless pain is managed in an acute care or a monitored setting. In individuals who have pain associated with active cancer or another serious illness, the need to treat the pain with opioids other than medications for opioid use disorder (MOUD) may be necessary to achieve pain control. Special considerations are required in terms of opioid management when treating acute pain in individuals with active OUD, such as the initiation of MOUD. For those receiving MOUD, it is crucial to continue their MOUD regimen and collaborate with their treatment provider when considering the prescription of additional opioids for acute pain.SummaryPain is best treated with a non-opioid, multimodal approach to care except in the setting of acute pain, serious and advanced chronic illness, or pain refractory to other treatments. If opioids are considered in individuals with a SUD, the potential benefits versus the risks of harm must be carefully considered.