Guest editorial
From the Editor-in-Chief
The management of acute pain in patients with substance use disorder continues to present complex challenges for healthcare practitioners. In this issue, we are republishing an article by Dr Lindy Roberts, originally published in Medicine Today in 2021, which offers practical, patient-centred guidance on this topic. Although some aspects of opioid prescribing have evolved since the article first appeared, the clinical principles remain highly relevant. To provide updated context, we invited Associate Professor Bridin Murnion to share her expert commentary, highlighting key developments and new resources that support best practice.
The management of acute pain in patients with substance abuse disorder (SUD) has always demanded a nuanced approach – balancing effective pain relief with strategies to reduce harm, prevent misuse and support long-term recovery. While the principles outlined by Dr Roberts in her 2021 article, titled ‘Acute pain in patients with substance use disorder’, remain relevant, the landscape has shifted in recent years. We have seen significant developments in opioid stewardship, improved transitions of care and greater access to real-time prescription monitoring – tools that are helping clinicians navigate this complex space. Against this backdrop, revisiting Dr Roberts’ work provides an opportunity to reflect on both enduring challenges and the evolving resources now available to support evidence-based care.
This article is not limited to considerations for patients with an existing SUD experiencing acute pain. Dr Roberts summarises the management of acute and chronic pain, and persistent opioid use in chronic pain. Importantly, she notes that acute pain is often an acute on chronic phenomenon. For instance, an acute low back pain or migraine episode could well be part of a chronic picture. To add to the complexity, there are mechanistic overlaps between the two conditions, with high rates of comorbidity. Preventing chronicity of opioid use subsequent to an episode of acute pain is emphasised, as is the importance of applying universal precautions and screening for SUD.
So, what has changed in this space? The need to appropriately safeguard the use of opioids in hospital and for discharge, and optimising transitions of care, is enshrined in the 2022 Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard from the Australian Commission on Safety and Quality in Health Care. The resources published by the Australia and New Zealand College of Anaesthetists, particularly the pain medicine discharge plans, offer clinicians practical tools for managing postdischarge pain, minimising the risk of long-term opioid use. The evidence for use of atypical opioids is gaining traction, although ongoing pharmaco-vigilance for harms is needed.
The availability of real-time prescription monitoring has become widespread and more available in the last four years. Each state and territory is at different stages of implementing their prescription monitoring schemes, with details on the current status of these schemes and guidance for their use available from the Department of Health website. Recent NHMRC-endorsed guidelines can assist practitioners in managing chronic opioid use.
In summary, the principles of management remain current, while the evidence base and resources needed to support best practice have developed. As healthcare systems continue to evolve, it is essential for clinicians to stay informed and incorporate the latest guidelines and resources in managing acute pain and substance use disorder. The emerging evidence base and resources offer support in navigating this challenging clinical space. PMT
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