Prescribing Controlled Substances to Patients with a History of Addiction

Introduction to Guideline

The American College of Physicians and other medical societies recommend that prescribing controlled substances to patients with a history of addiction is not inherently negligent when done within a structured risk-benefit framework with appropriate monitoring and safeguards 1
A thorough risk assessment and documentation of the decision-making process are emphasized by the Clinical Infectious Diseases journal 1

The American Academy of Addiction Medicine suggests applying careful evaluation and risk stratification using validated screening tools to identify risk factors, such as prior overdose history, active substance use disorder, concurrent use of benzodiazepines with opioids, unstable psychiatric conditions, and lack of social support systems 1, 2
High-risk indicators should be considered, including younger age, family history of substance use disorders, childhood trauma, personal/family psychiatric history, and history of motor vehicle collisions 1

The American College of Physicians states that a patient's history of addiction is not an absolute contraindication to receiving controlled substances, and benefits of controlled substance therapy should be weighed against risks, with a strength of evidence level of moderate 1
Non-opioid analgesics, such as NSAIDs and acetaminophen, are recommended as first-line treatment for pain management in patients with substance use disorder, with a strength of evidence level of high 1
Buprenorphine is considered a preferred opioid option for pain management in patients with substance use disorder, with a strength of evidence level of moderate 1

The Centers for Disease Control and Prevention (CDC) recommends implementing regular Urine Drug Testing (UDT) and checking Prescription Drug Monitoring Program (PDMP) data before prescribing and periodically during therapy 3
The American Academy of Addiction Medicine suggests scheduling more frequent follow-up visits and considering naloxone prescription for patients receiving opioids 2, 3
Ongoing communication with addiction treatment providers is recommended, with signed release for information exchange if patient is in an opioid treatment program 4

The American Academy of Family Physicians recommends avoiding benzodiazepines in patients with opioid use disorder when possible and implementing slow taper for dependence 5
Chronic pain can enhance reinforcing effects of opioids, and patients with undertreated pain may exhibit drug-seeking behaviors 2
Patients with addiction history often have legitimate pain needs, and tolerance to respiratory depression occurs rapidly and reliably 4

Withholding pain treatment based solely on addiction history may constitute inadequate care, and access to pain management is considered a fundamental human right 1
Proper storage of controlled substances, education of patients and families about overdose risk, and naloxone prescription and education for patients at higher risk are recommended 3
Validated screening tools, such as the single-question drug screen, should be used to assess current risk of opioid misuse in patients with a history of substance use disorder, with 100% sensitivity and 73.5% specificity 1
Comprehensive screening tools like ASSIST, AUDIT, DAST, or CAGE-AID can identify risk factors for opioid misuse 1

Buprenorphine dosing for opioid use disorder typically starts at 4-8 mg sublingually on day 1, increased to 16 mg by day 2, and maintained at 16 mg daily, while for pain management, divided doses of 4-16 mg daily are recommended 1
The recommended range for pain management is 4-16 mg daily in divided doses, with a mean effective dose of 8 mg daily showing substantial pain relief in a significant proportion of patients 1
Non-opioid analgesics, such as NSAIDs or acetaminophen, may be added for multimodal pain management in patients with acute pain who are on buprenorphine maintenance therapy 4
For severe pain, short-acting opioid analgesics can be titrated alongside buprenorphine maintenance therapy, with monitoring of the patient's response to the dose 4

A first-line approach for pain management is increasing buprenorphine dose in divided doses, as recommended by the American College of Physicians 1
A second-line approach considers switching from sublingual to transdermal formulation, which provides comparable pain relief with fewer adverse events compared to other opioids 1
A third-line approach involves adding high-potency opioids if the maximum buprenorphine dose is reached, with options including fentanyl, hydromorphone, or morphine 1, 6
Monitoring for concerning behaviors, such as pseudo-addiction and true addiction behaviors, and differentiating between them to provide effective pain management, with a strength of evidence level of moderate 1
Monitoring for signs of opioid-induced hyperalgesia, which may paradoxically increase pain sensitivity, with a strength of evidence level of high 1

The Joint Commission recommends discussing pain management plans openly and non-judgmentally as a safety issue, and obtaining signed release for information exchange between providers if patient is in an opioid treatment program, with a strength of evidence level of high 1
The American Medical Association suggests documenting risk assessment, treatment plan, and monitoring strategy to ensure coordinated care and minimize risks of opioid misuse, with a strength of evidence level of moderate 1
Patients should be educated about overdose risk, and naloxone prescription and education should be provided for patients at higher risk 3
Monitor for sedation when combining buprenorphine with other CNS depressants, and be aware of common side effects at higher doses, including headache, constipation, and nausea 1, 6