Pain management in heroin and cocaine users

Drug addicts often seek medical help for pain. Numerous fears and beliefs may hinder the recognition, evaluation, and management of pain in addicts. Nevertheless, the same fundamental principles apply to these patients as to other patients in terms of pain evaluation, analgesic selection, and dosage adjustment. Clarity of the medical prescription is crucial. Specific points that require attention in addicts include the effects of the abused drugs on the nociceptive system, the nature and amount of abused drugs, concomitant nondrug addictions, co-morbidities, and the nature of the pain symptoms. Also crucial is differentiating current abusers from former abusers and from abusers taking replacement therapy, as different management strategies are required in these three situations. Detailed information on the history of drug abuse is necessary to avoid unwanted events (e.g., overdosing or withdrawal syndrome) or an exacerbation of the addictive behaviors. In practice, hospital admission should be avoided to the extent possible. The use of strong opioids should be kept to a minimum (although this important rule may be difficult to follow, for instance in surgical emergencies). The best route of administration and galenic formulation vary with each individual situation but, in general, intravenous administration of strong opioids is highly undesirable. A treatment contract established with the patient is crucial and must indicate the nature of the drug or replacement agent used and the treatments given for pain control.