How should I approach the management of acute pain in patients with a history of substance misuse?

When managing acute pain in patients with a history of substance misuse, careful assessment and cautious prescribing are essential. Evaluate the patient's pain severity, history of substance misuse, and current medications to avoid exacerbating dependence or misuse risks. Avoid initiating opioids or other dependence-forming medicines unless absolutely necessary, and if opioids are required, use the lowest effective dose for the shortest duration, with close monitoring and specialist advice where needed.

Consider non-opioid analgesics and non-pharmacological treatments first, and involve the patient in shared decision-making about the benefits and risks of treatment options. Regularly review and monitor for signs of misuse, dependence, or withdrawal symptoms, and coordinate care with addiction specialists or pain services as appropriate.

For patients already on opioids or other dependence-forming medicines, review the ongoing need and consider tapering or stopping these medicines safely if risks outweigh benefits, with support for withdrawal management.

In summary, the approach should prioritise minimising harm from dependence-forming medicines, using specialist advice, and involving the patient in decisions about their pain management plan.