Practice ABC of Pain

Treating Pain in Patients with Drug-dependence Problems

BMJ 2013; 347 doi: (Published 09 December 2013) Cite this as: BMJ 2013;347:bmj.f3213
  1. Jane C Ballantyne
  1. Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA

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  • Pre-existing substance dependence does not preclude use of opioids for pain, but does complicate opioid use

  • Substance dependence virtually never arises de novo during the treatment of acute pain, or pain at the end of life

  • Substance dependence can interfered seriously with opioid treatment of chronic pain

  • Both existing substance dependence and assessed risk of substance dependence warrant careful and structured chronic opioid pain management

  • Structured chronic opioid pain management can include use of written consents or agreements, urine testing, regular visits and prescription pick-ups, and good communication between pharmacists and prescribers


Reasonably one can be concerned in patients with known drug dependence that their dependence will interfere with pain treatment, particularly treatment of pain with opioids. Concerns centre mainly on fears of addiction relapse when patients are given addictive drugs in the medical setting, but there may also be issues with drug interactions, with dosing for active users or with drug seeking for recreational use. Drug dependence does not preclude using addictive drugs during medical treatment of pain, but it does introduce several complications that must be considered when treating these patients. The acute pain, pain at the end of life and chronic pain situations are different, and are treated as separate entities in this chapter. The chapter focuses on dependence during chronic pain treatment, since this is where most of the complexities of concurrent pain and substance dependence arise.

Defining Addiction

Much effort has been placed towards developing uniform criteria and descriptors for addiction, so that it becomes a recognised …

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