Health care professionals can combat stigma by examining their own attitudes and beliefs and by consciously and consistently using neutral, “person-first,” and non-stigmatizing language such as “being in recovery” instead of “being clean” or “person with opioid use disorder” rather than “addict,” “user,” or “drug abuser.” 175 Pregnancy and OUD Pregnant women with untreated OUD have up to six times more maternal complications than women without OUD, including low birth weight and fetal distress, while neonatal complications among babies born to mothers with OUD range from neonatal abstinence syndrome and neurobehavioral problems to a 74-fold increase in sudden infant death syndrome. 177 Both methadone and buprenorphine are recommended for treating OUD in pregnancy to improve outcomes for both mother and newborn. 141 The efficacy and safety of methadone treatment for OUD in pregnant women was established in the 1980s, showing that maternal and neonatal outcomes in women on methadone treatment during pregnancy are similar to women and infants not exposed to methadone. 177 More recent research suggests that buprenorphine treatment has similar, or superior, benefits in this population. 178 The safety of extended-release naltrexone has not yet been established for pregnant women, and naltrexone is currently not recommended for the treatment of OUD in pregnant women. 147 Despite this solid evidence base, most pregnant women with OUD do not receive any treatment with medications. 179 Among women who do receive treatment during pregnancy, many fall out of treatment during the post-partum period due to gaps in insurance coverage and other systemic barriers. An integrated approach with close collaboration between OUD treatment providers and prenatal providers has been described as the “gold standard” for care, and further research is needed to investigate interventions that could help to increase treatment retention. 147 Treating acute pain in patients on MAT Some physicians may not prescribe effective opioid analgesia for patients with OUD on MAT due to concerns about respiratory depression, overdose, or drug diversion. As a result, this population is at particular risk of under-treatment for acute pain. Physicians may also mistakenly assume that acute pain is adequately controlled with the long- term opioid agonist (i.e., methadone) or partial agonist (i.e., buprenorphine). Although potent analgesics, methadone and buprenorphine have an
analgesic duration of action (four to eight hours) that is substantially shorter than their suppression of opioid withdrawal (24 to 48 hours). 180 Non-opioid analgesics (e.g., acetaminophen and NSAIDs) are first-line options for treating acute pain in this population. For moderate-to-severe pain not adequately controlled with non-opioids, however, judicious use of opioid analgesics should be considered. Patients on MAT generally have a high cross-tolerance for analgesia, leading to shorter durations of analgesic effects. Higher opioid doses administered at shorter intervals may thus be necessary. Concomitant opioids can be given for pain to a patient prescribed buprenorphine, but typically hydromorphone or fentanyl may be the most effective due to competitive binding at the opioid receptor. Since extended-release naltrexone will block the effects of any opioid analgesics, acute pain in such patients (e.g., that associated with dental work, surgery, or traumatic injury) should be treated with regional analgesia, conscious sedation, non-opioid analgesics, or general anesthesia. 30 Palliative Care Palliative care is specialized medical care for people with serious illness focused on relieving symptoms and improving quality of life for both the patient and the family. Palliative care involves three key areas: symptom management (e.g., pain, nausea, constipation), supporting patients and their loved ones as they cope with illness and death, and communication and education about the illness through advance care planning (ACP). 181 The field of palliative care emerged from a hospice tradition but in the past decade a more nuanced model of care has been introduced, which integrates palliative care with disease-modifying care across the duration of an illness and includes consideration of those affected by the death of the individual. Pain control is a central focus of palliative care, but the goal of pain management is not simply the elimination of all pain, it is the control of pain sufficient for a given patient to achieve his or her highest quality of life in the moment. 182 In the palliative care setting, clinicians may need to manage acute pain (e.g., post-surgical or post- treatment pain) or chronic pain or both types of pain simultaneously. Clinicians can avail themselves of a wide range of pharmacologic and non-pharmacologic approaches for pain management, which should be employed using the following general principles: • Identify and treat the source of the pain, if possible, although pain treatment can begin before the source of the pain is determined
• Select the simplest approach first. This generally means using non-pharmacologic approaches as much as possible and/or trying medications with the least severe potential side effects, and at the lowest effective doses • Establish a function-based management plan if treatment is expected to be long-term A range of non-pharmacological treatments may help patients manage chronic pain, which can be used alone or in combination with pharmacological treatments: • Physical therapy • Yoga • Acupuncture • Massage • Transcutaneous electrical nerve stimulation • Cognitive behavioral therapy • Mindfulness meditation • Weight loss Medications used to treat chronic pain in palliative settings include: • acetaminophen • non-steroidal anti-inflammatory drugs (NSAIDs)
• antidepressants • anticonvulsants
• topical lidocaine or capsaicin • cannabinoid-based therapies • opioids
Opioids are classified by the Drug Enforcement Agency according to their presumed abuse and addiction potential, although the evidence base for making these differentiations continues to evolve. Tramadol, for example, is now known to have as much potential for abuse as opioids in more restrictive classes. 171 Managing end-of-life pain Although pain relief is often considered— and may sometimes be—an end unto itself, pain management and control of symptoms at the end of life may be more appropriately viewed as means of achieving the more primary goal of improving or maintaining a patient’s overall quality of life. For some patients, mental alertness sufficient to allow maximal interactions with loved ones may be more important than physical comfort. Optimal pain management, in such cases, may mean lower doses of an analgesic and the experience, by the patient, of higher levels of pain.
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