This document aims to identify elements of good practice in the management of pain and in the prescription of opioid drugs. It provides non-specialists with appropriate information to assess the needs of and manage pain in patients who are or have previously been substance misusers. The document also gives guidance on models of collaborative working among relevant healthcare professionals involved in the care of patients with pain who are using, or are at risk of using, drugs inappropriately. It therefore aims to improve practice in managing this group of patients with complex needs. The document particularly addresses the dual challenges of safe use of opioids for long term pain control and the effective management of persisting pain symptoms in the addicted patient. The group recognizes that substance misusing patients will frequently present to hospital for surgery or following trauma. These individuals will need short term pain management in this acute setting and many hospitals have protocols to guide professionals in these circumstances. Key elements of good practice in acute pain management in this population are outlined in section 5.

A cohesive plan for the management of pain has the patient at its centre. Treatment of pain should not impose additional burdens for the patient. Mutual understanding of the type of problems which may develop, and an agreed plan of how such problems may be managed, improves the patient’s experience of treatment. Similarly, if concerns are discussed openly with patients misusing prescribed or illicit substances, it is possible to provide effective management of pain safely. Persistent pain is common and disabling. Treatment with opioid medication will be appropriate for a significant proportion of patients. Professionals caring for these patients need to be aware that these drugs may be used inappropriately and should be able to identify and manage problems if they arise. Patients with pain and a past or current history of substance misuse pose particular challenges when prescribing analgesics. Lack of understanding of relevant pharmacology and concern regarding potential for misuse of prescribed medication can result in pain being inadequately managed in substance misusers.

This document does not attempt to provide prescriptive guidelines for the management of particular presentations, but accepts that pain needs individualised management. The document considers the epidemiology of pain and of substance misuse, relevant neurobiology and pharmacology as well as definitions, legal requirements and therapeutic interventions to inform clinicians and improve practice. It is not within the scope of this document to discuss all substances of misuse. The focus is on commonly misused substances and those with specific relevance to the management of pain. The document examines the issues as they relate to both acute and chronic pain as well as special populations, as each requires different clinical management.