Patients with substance use disorder presenting with acute pain may be challenging to assess and manage. Key steps are excluding serious pathology and instituting management that promotes comfort, reduces distress and minimises harm. As in other patients with acute pain, nonpharmacological and nonopioid treatments are first-line options. Opioids have only a limited role for more serious pathologies and in accordance with published guidelines and regulatory frameworks.
- Treating doctors should consider the possibility of substance use disorder (SUD) in all patients presenting with pain (‘universal precautions’).
- Strategies promoting a positive therapeutic relationship are crucial for successful assessment and treatment of all patients with SUD.
- Potentially serious pathology should be sought in patients presenting with SUD and acute pain, while considering that some drugs are associated with specific painful conditions and other effects that influence acute pain presentations.
- For all patients, nonpharmacological and nonopioid treatments should be maximised and opioids used sparingly, with use of atypical opioids preferred.
- Patients taking opioid agonist therapy for SUD should be assessed and managed similarly to other patients with SUD.
- The relationship between SUD and chronic pain is bidirectional; self-management approaches help patients with SUD and chronic pain deal with their chronic symptoms as well as cope with acute pain flare-ups.
- A patient’s level of risk, according to the presence of active drug use, mental illness and other comorbidities should guide referral to a primary care specialist or drug and alcohol facility.