1

Best Practice in Treating Pain in Patients with OUD Without Contributing to the Opioid

Epidemic

Nicole Cage, Reagan Todd, Gina Vennetti

Centofanti School of Nursing, Youngstown State University

NURS 3749: Nursing Research

Ms. Randi Heasley

June 19, 2022

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Best Practice in Treating Pain in Patients with OUD Without Contributing to the

Opioid Epidemic

Introduction

The opioid epidemic has impacted our society tremendously and is now seen in

most healthcare settings. We are only beginning to understand the complexities

surrounding this epidemic, and one main issue with it is the treatment of pain. Pain and

opioids often go hand in hand. Before knowledge was obtained that such an epidemic

was occurring, opioid analgesics such as OxyContin were being prescribed for all types

of pain, and it was being promoted as safe. We now know our previous prescribing

practices were not safe and played a significant role in the current opioid epidemic

including addiction to prescription opioids, and non-prescription opioids such as heroin.

The relationship between pain and opioids is complex and an ever-changing body of

knowledge and research. “There are two theories as to how this relationship of pain and

addiction develops: pain leads to opioid use and then addiction OR substance abuse leads

to a pain syndrome (Wachholtz et all, as cited in Treating acute pain cite).” To treat pain

in patients with Opioid Use Disorder (OUD), we need to understand how to appropriately

and accurately assess and screening for risk/presence of OUD, the dynamic relationship

between pain and opioids, and how to treat patients with OUD who are suffering from

pain using pharmacological measures. In seeking information in these areas, our purpose

is to find out what the current best practice is for treating pain in patients with OUD

without contributing to the opioid epidemic.

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Search Strategy
We used EBSCO and PubMed search engines to find resources and literature regarding
our research question. We used the terms OUD, Opioid Use Disorder, and pain. We also
included the term nursing in later searches. From there, we further refined the search and choose
only peer reviewed journal articles written in the English language. We limited the literature
from 2017 to 2022. The databases used in this search were Cumulative Index to Nursing and
Allied Health Literature (CINAHL), MedLine, and PubMed. Our initial search yielded 288
articles. Many of the abstracts reviewed from this search were not sufficient to our question. We
created a new search and included pain management with OUD, and treatment. We have 167
options from this search criteria. We yielded three sources from this search. We wanted to
further refine the search and included pain management OR pain treatment and "OUD", and
nursing. This resulted in 70 search results, and we were able to narrow down three more articles

to use in this literature review. We attempted to narrow down three to four themes of the six
articles selected, however we struggled to find a third theme amongst the six chosen articles. We
threw out two of the six articles and using the most recent search strategy, successfully gathered
two more articles that aid in our research question.

Assess and Screen

To provide proper and effective pain management to individuals with OUD, we first need

to understand how to assess and identify the presence of OUD. Specifically, we need to identify
some of the barriers to doing so. Nurses are at the forefront of healthcare and are often the first
point of contact for patients. This gives nurses a tremendous opportunity to screen, assess, and
gather information to determine if someone is suffering from or is at risk for OUD. “It is
important to identify risk factors for developing OUD so that we may appropriately screen and
possibly prevent or intervene with this disorder” (Webster et al., 2016, as cited in Dever, 2017,
para. 12). There are several screening and assessment tools that can be used to identify at-risk
and current opioid use.
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“The Screener and Opioid Assessment for Patients with Pain-Revised includes 24 items
each rated from 0 (never) to 4 (often). The higher the score, the more at risk for
developing an addiction. The Opioid Risk Tool is a self-administered questionnaire for
those 16–45 years of age, which assesses both familial history and personal history of
abuse (Webster et al., 2016, as cited in Dever, 2017). The Brief Risk Interview is used at
the beginning of opioid use and is completed by the practitioner by interviewing the
patient. The Current Opioid Misuse Measure is a monitoring tool for those who are
already being treated with long-term opioids (Dela Cruz & Trivedi, 2015, as cited in
Dever 2017). This is a self-rated measurement of 17 items about their behavior in the past
30 days. Screening tools are often combined with urine drug monitoring to detect illicit
drugs and the presence of prescribed drugs (Dela Cruz & Trivedi, 2015; Webster et al.,
2016, as cited in Dever, 2017)” (Dever, 2017, para. 12).

These assessment and screening tools are not full proof, and more evidence is needed to discern
how helpful each tool is at improving patient outcomes and mitigating the opioid epidemic. It is
reported that due to the severity of the opioid crisis, the CDC still recommends using such tools
to assess risk (Dever, 2017).
There is more information relating to the emergency department (ED) setting and how to
screen and assess for opioid risk, use, and misuse. Despite being specific to the ED setting,
where the need to be accurate, reliable, and easy to administer (Duber et al., 2018) is essential,

we can hypothesize how the following tools can play a role in other healthcare settings outside of
the ED. The Opioid Risk Tool (self-report tool), The Current Opioid Misuse Measure, and the
Addiction Behavior Checklist are two screening tools that have been successfully validated in
the ED setting (Duber et al., 2018). There is also a Revised Screener and Opioid Assessment for
Patients with Pain tool that is used for individuals seeking treatment for pain. This is used prior
to the patient receiving opioid therapy (Duber et al., 2018). “The World Health Organization
designed and validated the Alcohol, Smoking, and Substance Involvement Screening Test to
detect substance use problems among primary care patients” (Duber et al, 2018, p. 3).
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The consensus: more information and studies are needed to evaluate how effective each

screening/assessment tool is at identifying and preventing opioid misuse in patients without

withholding necessary pain treatment. Being able to identify risk and harm will help healthcare

practitioners to discern proper and effective pain treatment for a specific patient based on such

screening and assessment tools.

Relationship Between Pain and Opioids

Opioid use in the United States has become a crisis. Many individuals now use opioid

drugs as part of pain management plans, yet an immense amount of individuals misuse

prescription or illegal opioids. With consistent opioid use, individuals develop a tolerance and a

physical dependence. Both are predictable, physiologic responses to repeated opioid exposures

(Pergolizzi, et al., 2020). However, a numerous amount of these individuals will develop Opioid

Use Disorder (OUD). As discovered by Pergolizzi, et al. (2020, page 2), “Among patients

prescribed opioids for chronic pain relief, often for long periods, an estimated 2-6% will develop

some sort of substance use disorder.” The use of prescription opioids has decreased in recent

years whereas simultaneous misuse of prescription opioids has increased.

Now, in clinical practice, OUD must be distinguished from physical dependence. OUD

reflects the alteration in the neurocircuitry of the brain’s reward system. The result is craving,

uncontrollable drug-seeking behavior, loss of control over intake, and negative emotional state

and withdrawal symptoms when access is restricted. These occurrences reflect adaptive

mechanisms in opioid receptors and the associated intracellular signaling of the cascades

(Pergolizzi, et al., 2020). While this is happening, healthcare providers are receiving inadequate

training and lack information regarding OUD, therefore, individuals with OUD are receiving
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ineffective available treatment. Patient fear is a major barrier to voluntary opioid discontinuation.

Craving for pain relief, euphoria, and or stress reduction may drive early opioid use, yet with

prolonged use, the avoidance of opioid withdrawal symptoms (OWS) and a desire to “feel

normal” often become the most powerful drivers of drug-seeking behaviors (Pergolizzi, et al.,

2020).

Pergolizzi’s study uncovered that in an absence of OUD, opioid withdrawal is normally

managed by gradual tapering of opioids to a lower dose or to discontinuation, which can

minimize the effects of withdrawal and enable adaptation to reduced estranged opioids. Patients

with OUD have been treated with pharmaceutical management of the opioid withdrawal process

rather than abrupt cessation to reduce the risk of cravings, continued use, or relapse. In addition

to this,

“Opioid-based medications and adjunctive drugs can be used to address

symptoms that “may arise during medical withdrawal when transitioning patients

to antagonists for relapse prevention, or when opioid agonists are not available or

preferred for use during the detoxification phase” (Pergolizzi, et al., 2020).

Non-opioid medications include those that target autonomic withdrawal symptoms related to

noradrenergic hyperactivity, this includes elevated blood pressure, irritability, chills, and

sweating (Pergolizzi, et al., 2020).

Following Pergolizzi’s findings, Amy Wachholtz and her team discovered that pain is a

critical factor in relapse to opioids. Waccholtz (2022, page 2) stated, “Individuals with comorbid

pain and opioid addiction are 3-5 times more likely to relapse to opioids than those with opioid

addiction but no pain.” Sole reliance on medication management to treat this co-morbidity is

controversial. In some measures, this is due to the higher likelihood of Comorbid Opioid Use
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Disorder and Pain (COAP) patients relapsing on opioids. Additionally, it is influenced by the

relationship between elevated pain sensitivity and cravings. The addition of other treatment tools

such as cognitive-behavioral therapy (CBT) and self-regulation (SR) techniques may be critical

treatment components to help COAP patients enter and maintain recovery (Waccholtz, 2022).

One recent study found support for cognitive-behavioral therapy’s viability and prefatory

efficacy in promoting abstinence among COAP patients but did not find significant differences

between conditions on pain outcomes. Participants engaged in a psycho-physiological

assessment using a cold-pressor pain task and physiological measures were taken. This included

the participant’s heart rate, peripheral temperature, galvanic skin response, and frontalis

electromyography. Data was also gathered on time to first pain (pain sensitivity), time to

disengage from the pain task (pain tolerance), ratings of the pain experienced (pain-rating), and

level of opioid craving (Waccholtz, 2022).

Pharmacological Treatments for Pain in Patients with OUD

When an individual is suffering from both pain and opioid use disorder (OUD), whether

it be someone with a history of OUD or someone who is actively addicted, many challenges and

complications arise when it comes to finding the best way to treat them. The main goal when

treating patients with OUD and pain is to prevent opioid withdrawal and to provide adequate

pain control while avoiding excessive opioid use without disrupting the current treatment of

OUD (Smith et al., 2022). Healthcare providers can do this by determining and administering the

right pharmacological treatments for these patients that will relieve suffering and help them

achieve and maintain a better quality of life.

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To determine the best treatment for pain and addiction, it is important to first understand

the medications for opioid use disorder (MOUD) themselves. Methadone is the most used

medication to treat OUD and has been shown to be effective in pain trials on its own and in

conjunction with other medications. Methadone is a full opioid agonist that acts on the opioid

receptors in the central and peripheral nervous systems that block the sensation of pain from

signaling to the brain, which is what leads this drug to provide analgesia. However, as stated by

Smith et al. (2022), “When used alone, these medications may not be adequate for providing

analgesia in the presence of acute pain,” indicating that additional medications in combination

with MOUD may be needed sometimes to manage pain appropriately.

An article by De Aquino et al. (2020) cites a study that investigated pain with the

administration of nonopioid medications and methadone. However, the only non-opioid

medication that was truly effective in the study was gabapentin. Gabapentin is an anticonvulsant

and nerve pain medication; its primary use is to treat nerve pain. While no addiction-related

outcomes were reported, the study “reported a significant improvement in pain threshold and

tolerance within 5 weeks of gabapentin therapy (2,4000 mg/day) at both peak and trough

methadone levels” (De Aquino et al., 2020, para. 20). Gabapentin is the only medication cited

throughout the article that was effective in treating pain in combination with MOUD, specifically

methadone.

Multiple medications have been used in clinical trials to test the effectiveness of pain

management in OUD without the concurrent administration of MOUD. Ketamine is one

medication that was tested alone and showed positive effects. At present, Ketamine is primarily

used as a surgical anesthetic; it is a controlled substance and while it is not considered an opioid,

it does have similar effects to opioids. It is also being increasingly prescribed for the
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management of chronic pain. De Aquino et al. (2020) identify three studies that tested ketamine

in patients with comorbid opioid dependence and chronic pain. They administered the ketamine

by means of intravenous (IV) infusions with a dosage range of 0.25-10 mg/kg. Results showed

that ketamine improved pain responses and reduced the analgesic opioid requirement. “Further, a

follow-up study showed that ketamine may also enhance long-term functional outcomes, such as

remaining employed after 1 year” (De Aquino et al., 2020, para. 21). Another clinical trial cited

by De Aquino et al. (2020) performed a randomized, placebo-controlled trial that tested a

combination of midazolam, which is a sedative, and haloperidol, which is an antipsychotic. The

two medications were administered intramuscularly (IM) and given at a dosage of 2.5mg for

each medication. The conclusion was that these medications produced, “Alleviation of acute pain

and reduction of the analgesic opioid requirement among persons with OUD in the emergency

room setting” (De Aquino et al., 2020, para. 21).

Alpha-2 receptor agonists, specifically dexmedetomidine and clonidine, are known for

their sedative and antihypertensive properties, but they also provide analgesia centrally and

peripherally by reducing noradrenergic neuron activity (Smith et al., 2022). Trials have

demonstrated adequate pain control and opioid-sparing effects with dexmedetomidine. Both

clonidine and dexmedetomidine were found to “play a role in reducing withdrawal symptoms

and augmenting analgesia in opioid-tolerant patients” (Smith et al., 2022, para. 29). Studies also

showed that clonidine and dexmedetomidine may reduce opioid-induced hyperalgesia, which is

characterized by increased pain sensitivity and extreme response to pain.

While each patient will have an individualized treatment plan for managing their pain

with OUD, there are many different options to do this safely and effectively without contributing

to the opioid epidemic. Whether the patient is taking medications for opioid use disorder
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(MOUD), such as methadone, or not, we can treat them with additional medications to improve

their pain. It is always important to treat pain, especially in OUD patients to improve health and

well-being and to prevent relapse caused by uncontrolled pain.

Conclusion

To reiterate, the Opioid Epidemic is an ongoing crisis we are facing. To succeed in safe

healthcare practices and managing the pain in patients with Opioid Use Disorder, we need to

discover the best treatment and how to assess for signs of an addiction. Discovered from our

studies, we learned that when screening patients, the higher the score the more at risk a patient is

to develop an addiction. Furthermore, we learned that patients with OUD have been treated with

pharmaceutical management of the opioid withdrawal process rather than abrupt cessation to

reduce the risk of cravings, continued use, or relapse. The most common pharmaceutical measure

we can give our patients is gabapentin, resulting to be the most effective non-opioid. Other non-

opioid medications have proven to be effective, but overall, treating patients with OUD with

pharmaceutical practices is the safest and best pain management treatment.

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References

De Aquino, J. P., Flores, J. M., Avila‐Quintero, V. J., Compton, P., & Sofuoglu, M. (2020).

Pharmacological treatment of pain among persons with opioid addiction: A systematic

review and meta‐analysis with implications for drug development. Addiction Biology,

26(4), 1–17. Retrieved May 24, 2022, from https://doi.org/10.1111/adb.12964

Dever, C. (2017, October). Treating acute pain in the opiate-dependent patient. Journal of

trauma nursing : the official journal of the Society of Trauma Nurses. Retrieved May 24,

2022, from https://pubmed.ncbi.nlm.nih.gov/28885516/

Duber, H., Macias-Konstantopos, I., Ryan, S., Stavros, M., & Whiteside, L. (2018, October).

Identification, management, and transition of care for patients with opioid use disorder in

the emergency department. Annals of emergency medicine. Retrieved May 24, 2022, from

https://pubmed.ncbi.nlm.nih.gov/29880438/

Pergolizzi, J., Raffa, R., & Rosenblatt, M. (2020, January 5). Opioid withdrawal symptoms, a

consequence of chronic opioid use and opioid use disorder: Current understanding and

approaches to management. EBSCO Information Services, Inc. | www.ebsco.com.

Retrieved May 24, 2022, from

https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=7&sid=7bd4755d-0c93-

43c8-ad3f-416ddae0a522%40redis
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Smith, K., Wang, M., Abdukalikov, R., McAullife, A., Whitesell, D., Richard, J., Sauer, W., &

Quaye, A. (2022). Pain management considerations in patients with opioid use disorder

requiring critical care. The Journal of Clinical Pharmacology, 62(4), 449–462. Retrieved

May 24, 2022, from https://doi.org/10.1002/jcph.1999

Waccholtz, A., Robinson, D., Epstein, E. (2022). Developing a novel treatment for patients with

chronic pain and Opioid User Disorder. EBSCO Information Services, Inc. |

www.ebsco.com. Retrieved May 24, 2022, from

https://web.p.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=6&sid=e7b72d27-90d8-

4dee-817b-ae9b571d628f%40redis
 Citation: De Aquino, J. P., Flores, J. M., Avila‐Quintero, V. J., Compton, P., & Sofuoglu, M. (2020). Pharmacological treatment of pain among persons with 13
opioid addiction: A systematic review and meta‐analysis with implications for drug development. Addiction Biology, 26(4), 1–17. Retrieved May 24,
2022. https://doi.org/10.1111/adb.12964

Problem Purpose Research Sample Framework Design Instruments Results Implications

Question
The opioid To What are the 12 studies were No framework Literature Keywords: These current Even though
epidemic has systematically most effective reviewed for this stated. Review adverse effects, studies provide much has been
taken over review the pharmacological literature review analgesia, pain preliminary accomplished in
public health in available studies treatments for sensitivity, support for the the disciplines of
America. While investigating pain in OUD pharmacotherapy analgesic pain and OUD in
the first-line pharmacological treatmnt? development effects of recent decades,
treatments for treatments for gabapentin, there is still an
opioid use pain among GABA urgent need to
disorder (OUD) persons with agonists, and develop safe and
include opioid OUD by NMDA effective
agonists, such as summarizing antagonists in treatments in
methadone and shared clinical persons with order to enhance
buprenorphine, features, OUD. the lives of
there are neurobiological patients
limitations to mechanisms of This review struggling with
these OUD and pain, identifies early both pain and
medications. discussing the warning signs OUD.
Other than human studies. for medications
patients’ lack of with these By
long-term. modes of implementing
engagement in action, the
treatment, an indicating that pharmacological
increase in pain more research treatments cited
sensitivity (aka is needed. In in this article,
opioid-induced future trials, it these patients’
hyperalgesia) is also emphasizes OUD and pain
a major the need for can be
limitation. methodological appropriately
improvements managed without
as well as larger causing further
safety and complications or
therapy goals. interfering with
current
treatment.
 Citation: Dever, C. (2017, October). Treating acute pain in the opiate-dependent patient. Journal of trauma nursing : the official journal of the Society of 14
Trauma Nurses. Retrieved May 24, 2022, from https://pubmed.ncbi.nlm.nih.gov/28885516/

Problem Purpose Research Sample Framework Design Instruments Results Implications

question
Opioid drugs, The purpose of It goes on to 30 studies Pain Literature Key Words: Screening tools: The role of nurses
including this literature suggest that reviewed Management Review Acute pain and in assessing pain
prescription as well review is to we need to for this chronic pain, Opioid, • Prescription Drug and how important
as heroin, have provide fully literature Opioid use disorder, of a role nurses
Monitoring
come to the national
spotlight due to the
resources to treat understand the review Pain Program play in identifying
unprecedented rate pain, given a complexity of • Risk assessment of and treating a
of overdose and tolerant opioid- this problem Published journals OUD person with OUD.
addiction. The dependent to used to review current • Patient history Furthermore, the
Centers for Disease patient. Health appropriately information • Referral for important role
Control and care practitioners deal with the substance abuse screening and
Prevention (CDC) are faced with implications providing risk
treatment
has termed this the challenge of for assessment of
problem as an Education:
treating acute practitioners, • Practitioners and OUD within the
“epidemic” that has
reached record
pain without especially nurses healthcare setting
numbers of deaths contributing to when • Patients and is important to our
in 2014. the opioid epi- prescribing families question of best
Approximately half demic. In opioid pain practice approach.
• System: Policies
of these deaths are addition, many relievers for and protocols We first need to
the result from patients who are acute and identify who is at
prescribed opioids.
Psychological tools:
hospitalized, chronic pain risk or suffers
Also on the rise are • Practitioner and
especially (Volkow, from OUD in
the numbers of staff: Respect,
trauma patients, 2014). Health order to
individuals who are caring behaviors,
diagnosed with
experience pain care adequately treat
acknowledge
chronic pain and and potentially practitioners the patient’s pain.
biases
are treated with have a prior are now
opioid or questioning • Patient beliefs
opioids, methadone
substance use how to about pain
and buprenorphine.
Individuals history, placing prescribe • Relaxation/imagery
currently taking them at opioids safely techniques
opioids for chronic increased risk and screen for • Cognitive
pain confound the behavioral therapy
for opioid use possible abuse
treatment of acute
pain after traumatic
disorder (OUD) and/or
addiction. Medication:
injury. Goals of Multimodal treatment:
treatment include
effective pain relief, • Continue home
prevention of opioid maintenance
withdrawal, and therapy of long-
 Citation: Dever, C. (2017, October). Treating acute pain in the opiate-dependent patient. Journal of trauma nursing : the official journal of the Society of 15
Trauma Nurses. Retrieved May 24, 2022, from https://pubmed.ncbi.nlm.nih.gov/28885516/

managing the acting pain

associated regimen if present.
behavioral and • Acetaminophen,
psychological
COX-2 inhibitors,
factors with drug
addiction and tricyclic
dependence. The antidepressants,
CDC has put forth serotonin and
guidelines on how norepinephrine
to treat chronic pain reuptake inhibitors,
but has yet to anticonvulsants
provide given around the
recommendations clock
on how to treat
acute pain in this
• Opioid—use
unique population. immediate release.
Start low and then
titrate up till
effective relief.
• Schedule opioids
around the clock
initially for
moderate to severe
pain or consider
patient controlled
analgesia with
hydromorphone or
morphine.
 Citation: Duber, H., Macias-Konstantopos, I., Ryan, S., Stavros, M., & Whiteside, L. (2018, October). Identification, management, and transition of care for 16
patients with opioid use disorder in the emergency department. Annals of emergency medicine. Retrieved May 24, 2022, from
https://pubmed.ncbi.nlm.nih.gov/29880438/

Problem Purpose Research Sample Framework Design Instruments Results Implications

question
Because of a In this clinical This article 68 Studies Pain Literature Published journals “…much work remains This article highlights
soaring number review article, examines the were Management review: used to review to be done to create, the importance of
of opioid-related we examine current body reviewed current information validate, disseminate, screening, identifying,
deaths during the current of evidence and implement effective and treating persons
“This article
past decade, strategies for underpinning evidence-based with opioid use
examines the
opioid use identifying the strategies to accomplish disorder.
current body these challenging tasks
disorder has patients with identification of
become a opioid use of patients at within the unique care This study relates to our
evidence…” environment of the ED.
prominent issue disorder, the risk for opioid research question
Future research will
in both the treatment of use disorder, regarding current best
need to focus on more
scientific patients with ED-based practice evidence and
than opioid prescribing
literature and lay acute opioid symptomatic and alternative pain supports the idea that
press. Although withdrawal treatment of management strategies assessing and
most of the focus syndrome, acute opioid in the ED. Specifically, identifying persons at
within the approaches to withdrawal, more work is required to risk or currently
emergency medication- medication- identify which patients suffering from opioid
medicine assisted assisted to screen, what tools to use disorder is an
community has therapy, and treatment of use, and what essential first step in a
been on opioid the transition opioid use technology can be healthcare setting. This
prescribing— of patients disorder on leveraged (eg, portable article
specifically, on with opioid discharge electronic devices,
reducing the use disorder from the ED, waiting room kiosks) to
incidence of from the and transition adequately assess opioid
opioid emergency to outpatient use disorder risk while
prescribing and department to services. minimizing the effect on
examining outpatient ED patient turnaround
alternative pain services. times and ED provider
workload.” Consider
treatment—
targeted screening of
interest is individuals at risk (eg,
heightening in history of opioid misuse,
identifying and positive drug screen
managing result) for opioid use
patients with disorder. We do not
opioid use recommend universal
disorder in an screening.
effective and
 Citation: Duber, H., Macias-Konstantopos, I., Ryan, S., Stavros, M., & Whiteside, L. (2018, October). Identification, management, and transition of care for 17
patients with opioid use disorder in the emergency department. Annals of emergency medicine. Retrieved May 24, 2022, from
https://pubmed.ncbi.nlm.nih.gov/29880438/

evidence-based All current opioid use

manner. disorder screening tools
have some weakness. Of
the tools currently
available, we recommend
using the SOAPP-R or
National Institute on Drug
Abuse-modified Alcohol,
Smoking and Substance
Involvement Screening
Test given before testing
and feasibility in the ED
setting.

ED providers should use

the prescription drug
monitoring program when
prescribing opioids and
consider it as an adjunct
tool when screening for
opioid use disorder.
Citation: Pergolizzi, J., Raffa, R., & Rosenblatt, M. (2020, January 5). Opioid withdrawal symptoms, a consequence of chronic opioid use and opioid use 18
disorder: Current understanding and approaches to management. EBSCO Information Services, Inc.

Problem Purpose Research Sample Framework Design Instruments Results Implications

question
Opioid use in the A substantial What is the 14 searches were Pain Literature The research Tolerance/ The opioid crisis has
United States has number of best conducted using management Review articles physical produced many
reached individuals practice in terms such as regarding OUD dependence and challenges for
unprecedented— who misuse treating “opioid and its the behavioral physicians, one being
some would say opioids will pain in withdrawal management characteristics the need to determine
crisis levels. develop opioid patients symptoms” and have been associated with which patients would
Although many use disorder with OUD “neurophysiolog reviewed OUD reflex benefit most from
individuals use (OUD), a without y opioid thoroughly complex maintenance therapy
opioid drugs as complex, contributin withdrawal,” based on neurobiological and which may be
part of legitimate primary, g to the unfiltered by PubMed adaptations in candidates for opioid
pain management chronic, Opioid date. literature several major discontinuation. In
plans, a neurobiologica Epidemic? search using systems of the addition to
significant l disease 116 articles were keywords brain, including summarizing the
number misuse rooted in pulled for related to the locus ceruleus current understanding
prescription or genetic, evaluation. opioid and mesolimbic of OUD, a new
illicit opioids. environmental, dependence, its systems. Physical algorithm for
and pathophysiolog dependence is determining the need
psychosocial y, and current responsible for for continued opioid
factors. treatment the distressing use as well as
strategies. withdrawal examples of
symptoms situations where
individuals management of
experience upon opioid withdrawal
abrupt cessation symptoms is
or rapid dose indicated.
reduction of
exogenous
opioids.
Citation: Smith, K., Wang, M., Abdukalikov, R., McAullife, A., Whitesell, D., Richard, J., Sauer, W., & Quaye, A. (2022). 19
Pain management considerations in patients with opioid use disorder requiring critical care. The Journal of Clinical Pharmacology, 62(4), 449–462.
Retrieved May 24, 2022. https://doi.org/10.1002/jcph.1999
Problem Purpose Research Sample Framework Design Instruments Results Implications
Question
Overdose To provide How can 26 studies No framework Literature Keywords: This article’s To avoid
deaths linked guidance and healthcare were stated Review acute pain findings support opioid
to opioid therapeutic providers reviewed for management, the use of withdrawal and
abuse soared recommendations manage pain in this buprenorphine, acetaminophen, promote
critically ill literature
to over for the patients with methadone, clonidine, retention in
69,000 in management of review naltrexone, dexmedetomidine, treatment
OUD while
2017, the acute pain in taking special opioid use gabapentin, programs after
deadliest year opioid-tolerant consideration disorder, opioid ketamine, and discharge,
on record and patients on for those on withdrawal pregabalin in patients'
a 28 percent medications for MOUD? treatment critically ill outpatient
increase over opioid use patients with MOUD
the previous disorder OUD and pain. regimens,
year. (MOUD) and Treatment of pain specifically
Providers those actively should include buprenorphine
caring for misusing opioids nonopioid and
patients with admitted to ICU analgesics and methadone,
opioid use settings, as well nonpharmacologic should be
disorder as suggestions strategies to confirmed and
(OUD) must for inpatient provide followed
balance OUD treatment. multimodal during ICU
between analgesia and admission.
preventing reduce
opioid requirements for The
withdrawal short-acting management of
and opioids. acute pain in
providing critically ill
adequate pain patients with
control while OUD is a
avoiding significant
excessive problem for
opioid use critical care
and ensuring professionals,
that OUD and the
treatment is strategies
not disrupted. outlined here
Citation: Smith, K., Wang, M., Abdukalikov, R., McAullife, A., Whitesell, D., Richard, J., Sauer, W., & Quaye, A. (2022). 20
Pain management considerations in patients with opioid use disorder requiring critical care. The Journal of Clinical Pharmacology, 62(4), 449–462.
Retrieved May 24, 2022. https://doi.org/10.1002/jcph.1999
deserve
additional
investigation
and should be a
focus of future
research.
 Citation: Waccholtz, A., Robinson, D., Epstein, E. (2022). Developing a novel treatment for patients with 21
chronic pain and Opioid User Disorder. EBSCO Information Services, Inc.

Problem Purpose Research Sample Framework Design Instruments Results Implications

question
Since 2012, efforts have To further What is N=14 Pain Experimental Cognitive-behavioral STOP had high Preliminary results of
been made to raise develop the best Individuals Management Design therapy (CBT) attendance rates STOP are promising with
awareness and create empirically practice in on (80%; and active high patient engagement
safer opioid prescription based, treating medication Self-regulation (SR) patient and adherence and
guidelines, however, the community- pain in for OUD with techniques engagement). significant reductions in
ramifications of opioid treatment patients co-occurring Urine toxicology drug use and pain.
overprescribing and the friendly, with OUD chronic pain. Pain scales showed no illicit
rise in opioid abuse are psychotherapy without drug use after
still prevalent. interventions contributi STOP program (Self- week 8. Data
to improve ng to the regulation Therapy for analysis from pre-
treatments for Opioid Opioid addiction and intervention and a
patients with Epidemic? Pain) 3-month follow-up
comorbid showed significant
chronic pain functional
and Opioid improvement and
Use Disorder. decreased pain
severity levels.
Participants also
reported benefits
from in-session
visual aids,
applicable pain
psychology
information, take-
home worksheets,
tools for relaxation
practice, learning
how to apply the
therapy tools.