Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review

Abstract

BACKGROUND: Managing acute pain in patients with opioid use disorder (OUD) on medication (methadone, buprenorphine, or naltrexone) can be complicated by patients' higher baseline pain sensitivity and need for higher opioid doses to achieve pain relief. This review aims to evaluate the benefits and harms of acute pain management strategies for patients taking OUD medications and whether strategies vary by OUD medication type or cause of acute pain. METHODS: We systematically searched multiple bibliographic sources until April 2020. One reviewer used prespecified criteria to assess articles for inclusion, extract data, rate study quality, and grade our confidence in the body of evidence, all with second reviewer checking. RESULTS: We identified 12 observational studies-3 with control groups and 9 without. Two of the studies with control groups suggest that continuing buprenorphine and methadone in OUD patients after surgery may reduce the need for additional opioids and that ineffective pain management in patients taking methadone can result in disengagement in care. A third controlled study found that patients taking OUD medications may need higher doses of additional opioids for pain control, but provided insufficient detail to apply results to clinic practice. The only case study examining naltrexone reported that postoperative pain was managed using tramadol. We have low confidence in these findings as no studies directly addressed our question by comparing pain management strategies and few provided adequate descriptions of the dosage, timing, or rationale for clinical decisions. DISCUSSION: We lack rigorous evidence on acute pain management in patients taking medication for OUD; however, evidence supports the practice of continuing methadone or buprenorphine for most patients during acute pain episodes. Well-described, prospective studies of adjuvant pain management strategies when OUD medications are continued would add to the existing literature base. Studies on nonopioid treatments are also needed for patients taking naltrexone.

Perioperative Opioids, the Opioid Crisis, and the Anesthesiologist

“…129 Further, suboptimal pain management in patients receiving methadone may trigger disengagement from care and serious downstream effects of possible relapse, overdose, or suicide. 129,130…”

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…Patients with chronic pain and/or substance use disorders pose significant challenges to perioperative pain management and opioid stewardship. These complex surgical populations are expected to continue growing, necessitating increased clinical knowledge and creativity from perioperative providers [ 115 ]. It is imperative that surgery centers create mechanisms for identifying these high-risk patients prior to surgery to allow for preoperative optimization and coordination of perioperative care.…”

“…Chronic pain and opioid tolerance are frequently complicated by opioid-induced hyperalgesia, physical dependence, psychological comorbidities, and/or substance use disorders, making postoperative pain more difficult to manage in this population [ 104 , 116 , 117 , 118 ]. These factors contribute to current expert recommendations to continue chronic long-acting opioid agonists throughout the perioperative period, including methadone and buprenorphine [ 18 , 115 , 116 , 119 , 120 , 121 , 122 ]. Methadone and buprenorphine can be prescribed for either chronic pain treatment or as medication-assisted treatment for opioid use disorder (OUD) in the outpatient setting.…”

“…This is supported by current consensus statements and expert reviews [ 18 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 ]. Rigorous evidence on postoperative pain management in patients on MAT remains urgently needed to quantify these anecdotal benefits and to compare the effects of available perioperative strategies on patient-centered outcomes [ 115 ]. It is also important for healthcare providers to understand the role of buprenorphine coformulation with naloxone, and that continuing combination products (i.e., Suboxone ® ) poses no risk of opioid reversal when the dosage form is taken appropriately.…”

“…Conversely, naltrexone formulations must be discontinued in sufficient time to ensure complete wash-out prior to surgery to avoid iatrogenic pain crisis, since opioids are rendered largely ineffective during therapy [ 123 , 124 ]. Animal data suggest opioid therapies would need to be increased 10–20 times the standard clinical dose to achieve analgesia in patients on concomitant naltrexone [ 134 ], and human data is very limited [ 115 , 135 ]. Chronic naltrexone therapy induces opioid receptor up-regulation, however, so patients usually on naltrexone therapy may exhibit increased sensitivity to opioids after naltrexone discontinuation for surgery [ 117 , 136 ].…”