Using opioid therapy for pain in clinically challenging situations: questions for clinicians.

Healthcare professionals and organizations increasingly face the conundrum of treating patients with active substance use disorder, a history of personal or familial substance use disorder, or those at elevated risk for substance abuse. Such patients need compassionate care when facing painful conditions; in fact, denying them pain control makes it likely that they will seek out ways to self-medicate with illicit drugs. Yet it remains unclear how to safely and effectively treat patients in these challenging situations. The authors have formulated ten questions to address in order to provide adequate analgesia for such patients. These questions demand a highly individualized approach to analgesia. These ten questions involve understanding the painful condition (presumed trajectory, duration, type of pain), using validated metrics such as risk assessment tools, guidelines, protocols, and safeguards within the system, selection of the optimal analgesic product(s) or combination therapy, and never starting opioid therapy without clear treatment objectives and a definitive exit plan. It is tempting but inaccurate to label these individuals as "inappropriate patients," rather they are high-risk individuals in very challenging clinical situations. The challenge is that both options - being in pain or being treated with opioids to control pain - expose the patient to a risk of rekindling an addiction. The question is how do we, as clinicians, adequately respond to these very perplexing clinical challenges?

The role of cannabinoids in pain control: the good, the bad, and the ugly.

Cannabinoids appear to possess many potential medical uses, which may extend to pain control. A narrative review of the literature has found a variety of studies testing botanical and synthetic cannabinoids in different pain syndromes (acute pain, cancer pain, chronic noncancer pain, fibromyalgia pain, migraine, neuropathic pain, visceral pain, and others). Results from these studies are mixed; cannabinoids appear to be most effective in controlling neuropathic pain, allodynia, medication-rebound headache, and chronic noncancer pain, but do not seem to offer any advantage over nonopioid analgesics for acute pain. Cannabinoids seem to work no better than placebo for visceral pain and conferred only modest analgesic effect in cancer pain. Cannabinoids do many good things - they appear to be effective in treating certain types of pain without the issues of tolerance associated with opioids. Negatively, marijuana currently has a very murky legal status all over the world - laws regulating its use are inconsistent and in flux. Thus, both patients and prescribers may be unsure about whether or not it is an appropriate form of pain control. Cannabinoid-based analgesia has been linked to potential memory deficits and cognitive impairment. A great deal more remains to be elucidated about cannabinoids which may emerge to play an important role in the treatment of neuropathic and possibly other painful conditions. There remains a great deal more to learn about the role of cannabinoids in pain management.