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Pain and substance misuse: improving patient care


Up-to-date knowledge about effective and appropriate use of opioids is essential for acute pain management, palliative care, obstetric analgesia and pain relief for current or previous substance misusers

Roger Knaggs
PhD MRPharmS

Specialist Pharmacist Anaesthesia and Pain Management
Nottingham University Hospitals NHS Trust
Queen’s Medical Centre Campus

Both persistent pain and substance misuse are relatively common in the general population. Persistent pain affects around one in seven people in the UK, with up to a quarter of people reporting pain on any one day.[1] Similar prevalences have been reported throughout Europe.[2]

The prevalence of drug misuse is much harder to assess. In 2000, the British Crime Survey reported that about one third of people aged 15–54 years have taken illegal drugs at some point in their lives, 11% reporting use within the past year and 6% describing themselves as regular users. Substance misuse predisposes individuals to many other health and social problems. The management of pain for these individuals can be complex and problematic.

The British Pain Society (see Resource) has recently produced a document titled Pain and substance misuse: improving the patient experience[3] that provides a useful resource for promoting effective pain management for these patients and the safe use of opioids in persistent pain. A patient information leaflet, approved by the Plain English Campaign, is also available.

Pain and substance misuse reviews the epidemiology and neurobiology of pain and addiction, gives practical definitions of the often confused terms “tolerance”, “withdrawal”, “dependence” and “addiction”, and reviews the pharmacology of specific drugs and addiction treatments. The legal framework relating to controlled drugs in the UK is outlined, although this is a rapidly changing area following the implementation of recommendations from the Shipman Inquiry.

The rest of the document is dedicated to clinical issues. Particular emphasis is placed on appropriate use of opioids in the management of persistent pain. Potential problems, including the often overlooked phenomena of opioid induced hyperalgesia and headache associated with simple analgesics are discussed. Practical solutions to common clinical scenarios are described. Finally, the principles of acute pain management, palliative care, obstetric analgesia and pain relief for current or previous substance misusers in the prison setting are discussed.

Opioids are effective analgesics in a range of painful conditions, not just cancer pain, when used as part of a comprehensive rehabilitation plan that includes other medical, psychological and social interventions.[4]

Anticipated treatment benefits, defining what will be used to determine treatment success and an acceptable balance between reduction in pain intensity and side-effects, should be negotiated with the patient at the outset. Improvements in physical, psychological and social functioning are secondary outcomes to achieving adequate analgesia. Increased opioid availability may in turn increase the risk of addiction to prescribed opioids and opportunities for diversion.[5]

Healthcare professionals, including pharmacists, should be aware of behaviours that can suggest addiction and diversion and be able to intervene where appropriate.

It is important that patients do not receive contradictory information from different healthcare professionals, hence it is the responsibility of the specialist and nonspecialist alike to ensure up-to-date knowledge of this topic.

A suitably educated pharmacist can greatly contribute to effective medicines management for patients with pain.

Pain and substance misuse provides a succinct overview of a complex and complicated area of clinical practice. Although not heavily referenced, the document provides a useful starting point for any pharmacist who wants to get up to speed with current thinking in this field. â–

1. NOP World. Summary report prepared for Galliard Health on pain. London: GfK NOP/BPS.
2. Eur J Pain 2006;10:287-333.
3. British Pain Society. Pain and substance misuse: improving the patient experience. London: BPS; 2007. Available online at:
4. New Engl J Med 2003;349:1943-53.
5. Eur J Pain 2007;11:490-518.

British Pain Society

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