Managing Opioid-Seeking Patients

Assessment and Identification

The American College of Physicians recommends conducting a careful clinical assessment for objective evidence of pain, which decreases the chance of being manipulated by drug-seeking behavior and supports appropriate use of opioid analgesics when needed 2
The assessment should distinguish between different types of drug-seeking behaviors, including pseudoaddiction, therapeutic dependence, and pseudo-opioid resistance, to provide appropriate treatment 2
The Centers for Disease Control and Prevention recommends assessing for opioid use disorder using DSM-5 criteria or arranging for evaluation by a substance use disorder specialist 1

For patients with legitimate pain needs, the American College of Physicians recommends continuing the usual dose of opioid agonist therapy (OAT) if the patient is already receiving maintenance treatment, and verifying maintenance doses with the patient's methadone clinic or prescribing physician 3
The American College of Physicians also recommends reassuring patients that their addiction history will not prevent adequate pain management, and using conventional analgesics, including opioids when necessary, for acute pain in patients on OAT 4
For patients with opioid use disorder, the Centers for Disease Control and Prevention recommends offering or arranging evidence-based treatment, preferably medication-assisted treatment with buprenorphine or methadone maintenance therapy in combination with behavioral therapies 1

The American College of Physicians recognizes that patients dependent on opioids may be perceived as demanding when hospitalized with acute pain due to distrust of the medical community, concern about being stigmatized, and fears of undertreatment or discontinuation of OAT 2
The American College of Physicians recommends addressing patient anxiety by discussing the pain management plan in a nonjudgmental manner, and being aware that patients receiving OAT typically receive treatment doses that block most euphoric effects of additional opioids 4
The Centers for Disease Control and Prevention recommends that physicians prescribing opioids should identify treatment resources for opioid use disorder in their community and work to ensure sufficient treatment capacity 1

The American College of Physicians recommends avoiding allowing concerns about being manipulated to cloud clinical judgment about the patient's need for pain medications, and recognizing that undertreating acute pain may lead to decreased responsiveness to opioid analgesics 4
The American College of Physicians also recommends avoiding discontinuing OAT during acute pain episodes, as this can worsen pain due to increased sensitivity associated with opioid withdrawal, and not using mixed agonist-antagonist opioids in patients on OAT as they may precipitate withdrawal 3