title: Pain Management of Patients with Substance Abuse in the Ambulatory Setting.
abstract: OBJECTIVE
  Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction.
  
  
  RESULTS
  Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient's outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate NSAIDs, tricyclics, gabapentinoids, anticonvulsants, opioid tapering, and regional anesthesia can help alleviate high postoperative pain control requirements. In conjunction with such medication management, setting realistic expectations for pain control with preoperative counseling may be highly beneficial. For postoperative pain refractory to other strategies, the use of inpatient low-dose ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated pain service.
authors.affiliation: Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA. Nalini.vadivelu@yale.edu.
authors.forename: Nalini
authors.initials: N
authors.lastname: Vadivelu
authors.affiliation: Stony Brook University School of Medicine, Stony Brook, NY, USA.
authors.forename: Alice M
authors.initials: AM
authors.lastname: Kai
authors.affiliation: University of Connecticut School of Medicine, Farmington, CT, USA.
authors.forename: Vijay
authors.initials: V
authors.lastname: Kodumudi
authors.affiliation: Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Zhu
authors.affiliation: Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Roberta
authors.initials: R
authors.lastname: Hines
mesh_terms: D000553:Ambulatory Care / Q000379:methods*; D006801:Humans; D009293:Opioid-Related Disorders; D059408:Pain Management / Q000379:methods*
keywords: Ambulatory pain; Chronic opioid; Chronic pain; Multimodal; Postoperative pain; Substance abuse