The broad guidelines for pain management apply to all patients, including those with a substance abuse history.³ A comprehensive assessment of the pain can clarify the strategies that are most appropriate to consider. If the patient has a disorder for which opioid therapy is widely considered the mainstay approach, such as advanced cancer or HIV/AIDS, healthcare providers should follow established guidelines for pharmacologic management.^8,9 The role of long-term opioid therapy for persistent noncancer pain remains controversial, but is considered by pain specialists in selected cases. If the pain is moderate to severe, there are limited other therapies conventionally used to manage it (or other therapies are limited by availability, the medical condition of the patient, cost or other factors), the pharmacologic risks of the therapy are not excessive, and a careful history suggests that the patient’s substance use disorder would not preclude responsible medication use in the present (e.g., those in well established recovery), then opioid therapy may be considered for a trial.

If opioids or other potentially abusable drugs are prescribed for a patient with pain and a history of a substance use disorder, or a patient at high risk of substance abuse, monitoring must be carefully structured, the route of administration should be the least invasive one, and the need for pain relief and other outcomes must be re-evaluated on an ongoing basis. Aberrant drug-related behaviors should be specifically evaluated through history and other means (urine drug screening, pharmacy contact, key family informants)(see Table: Aberrant Drug-Related Behaviors That May Occur During Long-Term Opioid Therapy). A variety of other strategies should be considered (see Table: Principles and Strategies for Opioid Use in the Patient with Substance Abuse Problems). Nonopioid co-analgesics and nonpharmacologic therapies (e.g., physical therapy; psychological approaches, such as relaxation training; interventional strategies, such as injection; or nerve blocks) should be considered in every case.