Patients who present with persisting noncancer pain on a background of a past or current substance use disorder are a common management challenge. Often they are perceived as quintessential ‘heartsink patients’. However, by maintaining an empathic perspective clinicians can help to create a productive therapeutic relationship.
Over the past two decades, opioid prescribing for persisting noncancer pain has been increasing, both in Australia and internationally. This increase in prescribing may be justified by the evidence that oral opioids can be effective in controlling pain severity and improving function in the short term; however, the associated increase in risks of morbidity and mortality in some patients is also well documented. Long-term use of opioids for pain is associated with a wide range of harms, including addiction (characterised by physical and psychological dependence and aberrant behaviours related to opioids and pain), toxicity and overdose, drug–drug and drug–disease interactions, and problems of drug diversion and illicit use (e.g. the sale and purchase of opioid analgesics in black markets). Opioid misuse has become a major public health issue in Australia and in other countries – in the USA, for example, overdose deaths involving opioid analgesics now exceed deaths from heroin and cocaine combined.
Picture credit: Illustration composite: wheel with addictive substances, © Getty Images/Lisa Zador; human silhouettes, © Shutterstock/Majivecka.