Medication and the Substance Abuse Patient

On the issue of medication management, what would you recommend?

A patient with a history of substance abuse who has been sober for 3 years is referred to you. He reports a severe level of constant pain that is not being relieved by his methadone, and a reluctance on the part of his primary care provider to prescribe additional pain medication, especially opioids. The patient believes he is being discriminated against because of his substance abuse history.

Jayne Pawasuaskas, Pharm.D.:

It is important to remember that patients with substance abuse histories also feel pain. The presence of pain can negatively impact a patient like this in the same ways that it could affect a non-abuser (i.e. decreased healing response, decreased quality of life, depression, etc). Sometimes they will require higher doses (compared to non-abusers) of analgesic medications to achieve a therapeutic effect.

For patients who are receiving methadone as part of a maintenance program, who then develop a painful condition, there are a couple of options for managing the pain. The first step that should be taken is verification of the methadone maintenance dose with the patient’s maintenance program. Then, one option is to increase the methadone dose and split that total dose into 3 or 4 daily doses. (Typically methadone is used every 6 to 12 hours for pain.) Another option is to continue the once daily methadone and add a different opioid for pain relief. In this case, the maintenance program may have specific recommendations about which opioid(s) to use or avoid. This will be determined by the type of urine testing that a particular program uses to check if their patients are using illicit drugs while in the maintenance program. A third option would be to avoid use of opioids altogether for managing the pain, and opt for another class of medications. The appropriateness of this option would depend on the type and severity of the pain that the person is having.