Abuse of illicit substances and prescription
opioids is a growing problem that presents challenges for
pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter
hospital stays and more same-
day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of
pain that can subsequently worsen tolerance and addiction, and the undertreatment of
pain that can lead to pseudoaddiction.
RECENT FINDINGS: Through recognition of maladaptive behaviors, use of screening programs, and
pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN
opioids are recommended for chronic
opioid users, and good communication with the patient's outpatient prescriber of
pain medications is essential. For surgical patients on chronic
opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate
NSAIDs, tricyclics, gabapentinoids,
anticonvulsants,
opioid tapering, and
regional anesthesia can help alleviate high
postoperative pain control requirements. In conjunction with such medication management, setting realistic expectations for
pain control with preoperative counseling may be highly beneficial. For
postoperative pain refractory to other strategies, the use of inpatient low-dose
ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated
pain service.