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Inpatient Pain Management in Patient with Opioid Use Disorder

  • Ojas Mainkar
  • Miranda Greiner
  • Jonathan Avery
  • Neel MehtaEmail author
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  • 33 Downloads

Abstract

The opioid epidemic has ushered in a high-risk patient population that all pain physicians will encounter in the inpatient setting. With the increased emphasis on pain as the “fifth vital sign” and a wider array of new opioids, the 1990s marks the beginning of a dramatic rise in opioid prescriptions. Opioid analgesics are the most commonly prescribed medication in the United States. Additionally, ten million people in the United States use opioid prescriptions for nonmedical reasons (Raub and Vettese, J Hosp Med 12:375–379, 2017). Chronic opioid users exhibit signs of tolerance to opioids while also having increased perception of pain. Acute pain management in these patients is best managed by a multimodal approach using medications such as ketamine, lidocaine infusions, dexmedetomidine and regional anesthetic techniques.

More than two million of the opioid users meet criteria for opioid use disorder (OUD) (Ward et al., Anesth Analg 127:539–547, 2018). OUD is characterized by pronounced craving and preoccupation for opioids, inability to refrain from using, and escalation of use despite negative consequences. Although there are currently three FDA-approved medications to treat OUD (methadone, buprenorphine, and extended-release injectable naltrexone) only about 20% with OUD are on one of these medications (Ward et al., Anesth Analg 127:539–547, 2018). Pain physicians must be well-versed in how to manage these medications in the setting of acute pain and use clinical judgment to distinguish subjective pain from drug-seeking presentations. All OUD patients benefit from early psychiatric intervention to best address patient needs. For the roughly 80% of OUD patients not on medication for opioid use disorder (MOUD), this includes the opportunity to start one of the three medications while in the inpatient setting. Discharge planning for these patients is critical and relapse risk is best mitigated by providing adequate analgesia and connecting with outpatient substance use treatment. All patients discharged on daily opioid dosing greater than 90-mg morphine equivalents, those on longer-acting opioids (methadone or oxycodone), and those with a history of OUD or substance misuse should be discharged with intranasal naloxone kits.

Keywords

Opioid epidemic Opioid use disorder Medication for opioid use disorder Opioid agonist treatment Methadone Buprenorphine Naltrexone Multimodal analgesia Ketamine Lidocaine infusion 

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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Ojas Mainkar
    • 1
  • Miranda Greiner
    • 1
  • Jonathan Avery
    • 1
  • Neel Mehta
    • 1
    Email author
  1. 1.Weill Cornell Medical Center/NewYork-PresbyterianNew YorkUSA

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