Pain and substance use disorders are common conditions that frequently co-occur. Pain and substance use disorders share common features such as dysregulated dopamine and reward pathways that can be mutually reinforcing; therefore, effective treatment of both is critical. A number of factors complicate management of pain in patients with substance use disorders, including lower pain tolerance, higher analgesic requirements, the addiction potential of some medications used to treat pain, concurrent use of other substances (e.g., alcohol, cannabis), and the presence of other psychiatric conditions. In addition, the use of partial or full opioid antagonists to treat opioid use disorder may complicate acute pain management. These challenges of managing coexisting pain and substance use disorder may be greater in Medicare populations due to higher medical complexity, presence of disability, or older age.

• Evidence on treatment of acute pain in patients with opioid use disorder is insufficient to guide a policy or clinical action at this time; however, a scoping review suggests that strategies that involve continuation of medications for opioid use disorder (including partial or full agonists) while managing the acute pain episode warrant additional research.
• For patients with chronic pain and opioid use disorder, limited evidence from randomized trials suggests that methadone and buprenorphine/naloxone may have similar pain and drug use outcomes and that psychosocial interventions utilizing cognitive-behavioral therapy principles may improve pain-related outcomes for some individuals.
• No study evaluated the effectiveness of technologies or models of care for treatment of pain in patients with substance use disorders, or the management of pain and cooccurring nonopioid substance use disorders.
• Studies on treatment of patients with acute or chronic pain and substance use disorders did not specifically evaluate populations potentially eligible for Medicare (e.g., based on younger age of the patients evaluated in the studies).

Chou R, Dana T, Pappas M, Hart E. Treatments, Technologies, and Models for Management of Acute and Chronic Pain in People With a History of Substance Use Disorder. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006). AHRQ Publication No. 21-EHC20. Rockville, MD: Agency for Healthcare Research and Quality; April 2021. doi: https://doi.org/10.23970/AHRQEPCTREATMENTS. Posted final reports are located on the Effective Health Care Program search page.