Addressing Pain in People Who Have Struggled with Drug Use

Christine Collins, MD

Pain management can be challenging for healthcare providers in any context. Pain is a complex and critically important symptom that can affect outcomes and profoundly change a patient’s life.  

The improper issuance of prescription opioids in the late 1990s through the mid-2000s is widely recognized as a contributing factor to a particularly deadly wave of opioid addiction in the United States. As providers began to understand risks associated with prescription opioids, prescriptions for opioids plummeted, however many feel the pendulum may have swung too far in the other direction, resulting in the undertreatment of pain.  That said, when treating people who have a history of substance use disorders, additional considerations are necessary.

Fortunately, clinicians today have more tools and more knowledge than ever before to properly address a patient’s pain in a responsible way.  On February 20, Christine Collins, MD, and Joseph D’Orazio, MD, will present a lecture for the SNJMATCOE titled “Managing Pain in Patients with Substance Use Disorders.” Dr. Collins answered the questions below about the topic and what should be expected from the talk.  

Your upcoming lecture about managing pain in people with substance use disorders. Why this topic?  

I am passionate about improving pain care and patient outcomes. Pain itself is often minimized in medicine, and this can be even more pronounced in patients with a history of substance use. There are many effective, evidence-based tools available to manage pain safely, yet they are often underutilized. 

Providers considering this lecture should know that we will highlight available strategies and approaches that can be used to improve pain control, patient comfort, and overall satisfaction while providing safe, thoughtful care for patients with substance use disorders. 

Can you talk more about how pain can be minimized in patient care?  

Pain is often minimized in patient care not because it is unimportant or that clinicians do not care, but because of real clinical constraints. Clinicians face limited time, competing priorities, and often discomfort managing complex or chronic pain can compound these challenges. 

A common misconception that I would like to clear up is the idea that pain is simply a symptom and does not meaningfully affect health outcomes. Studies show that uncontrolled pain is associated with poor quality of life, increased disability, higher rates of depression and anxiety, and poorer overall clinical outcomes. Evidence also shows that when pain is addressed thoughtfully, patients experience better function, satisfaction, and quality of life.  

Addressing pain is as much a key component of improving patient outcomes as addressing other aspects of a patient’s medical care. 

Opioids are powerful and important drugs for managing many kinds of pain, but people with opioid use disorder have a complicated medical history with those medicines. How does a relevant use disorder change the way a provider can use opioids to manage pain?  

Opioids remain powerful and sometimes necessary tools for managing pain, but their use requires a more thoughtful and individualized approach in patients with substance use disorders, especially opioid use disorders. A thorough history is essential, along with open conversations about a patient’s goals and their preferences regarding opioid exposure. 

Another thing to consider is that patients with opioid use disorder may require higher or adjusted dosing strategies to achieve adequate pain control. This often requires close coordination with nursing, pharmacy, and the care team to develop a safe, effective plan. 

However, opioids are only one part of pain management. There are many effective multimodal options available to add to your toolbox, including non-opioid medications and targeted regional analgesia techniques. These will be discussed in the lecture. 

Can you talk more about the targeted regional analgesia techniques? What are the applications and limitations there?  

Targeted regional analgesia treats pain at its source by blocking specific nerves or pain points in the body. It’s useful for conditions such as postoperative pain, trauma, abdominal or chest wall pain, and certain chronic pain conditions.  

But it isn’t appropriate for every pain type, and the effects are time-limited, so it works best as part of a multimodal pain plan. These techniques also do require specialized training, usually with ultrasound guidance, so not every provider will perform them.  

Understanding the options and indications helps clinicians involve the right teams early and ultimately improve pain outcomes.

Do stimulant or sedative use disorders also change the way pain should be addressed? 

Yes, they definitely can. With stimulant use disorders, patients may be more anxious or agitated, which can make pain harder to assess and can actually amplify how pain is experienced. In those cases, addressing anxiety and creating a targeted plan is key. 

With sedative use disorders, the concern is tolerance and safety. These patients can be at higher risk for oversedation or withdrawal, so pain medications often need to be dosed more carefully and monitored closely, with input from the care team. 

In general, it is important to know a patient’s substance use history to create a more thoughtful and individualized pain management plan for each patient.