What is the best approach for managing pain in individuals with opioid use disorder (OUD)?

From the Guidelines

The best approach for managing pain in individuals with opioid use disorder (OUD) involves continuing buprenorphine therapy in the perioperative period, with adjustments as needed to ensure adequate pain control and minimize risks of opioid misuse, as recommended by the most recent and highest quality study 1. When managing pain in individuals with OUD, it is essential to consider a multimodal strategy that balances effective pain control while minimizing risks of opioid misuse.

• Non-opioid medications, such as acetaminophen, NSAIDs, gabapentinoids (gabapentin, pregabalin), antidepressants (duloxetine, amitriptyline), and muscle relaxants, should be first-line treatments, as appropriate for the pain type.
• When opioids are necessary, especially for acute severe pain, they should be prescribed with clear boundaries, frequent monitoring, and in coordination with addiction specialists.
• Buprenorphine can serve dual purposes by treating both OUD and pain, and for patients already on medication-assisted treatment (MAT), continuing their methadone or buprenorphine is essential, potentially with temporary dose increases or split dosing to improve pain control.
• Non-pharmacological approaches, including physical therapy, cognitive behavioral therapy, mindfulness, acupuncture, and heat/cold therapy, are crucial components of treatment.
• A comprehensive approach requires close collaboration between pain specialists, addiction medicine providers, and mental health professionals, with regular reassessment of pain control, function, and risk of misuse, as supported by earlier studies 1. The most recent study 1 emphasizes the importance of continuing buprenorphine therapy in the perioperative period, which is a critical aspect of managing pain in individuals with OUD.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION • Buprenorphine hydrochloride should be prescribed only by healthcare professionals who are knowledgeable about the use of opioids and how to mitigate the associated risks. Use the lowest effective dosage for the shortest duration of time consistent with individual patient treatment goals [see WARNINGS] Because the risk of overdose increases as opioid doses increase, reserve titration to higher doses of buprenorphine hydrochloride for patients in whom lower doses are insufficiently effective and in whom the expected benefits of using a higher dose opioid clearly outweigh the substantial risks.

The best approach for managing pain in individuals with opioid use disorder (OUD) is to use the lowest effective dosage for the shortest duration of time. It is essential to reserve titration to higher doses of buprenorphine for patients who do not respond to lower doses and in whom the benefits outweigh the risks.

• Key considerations:
  • Use of buprenorphine should be prescribed by healthcare professionals knowledgeable about opioid use and risks.
  • Patients should be monitored closely for signs of respiratory depression and sedation.
  • Alternative treatment options, such as non-opioid analgesics, should be considered, especially in high-risk patients. 2

From the Research

Pain Management Approaches for Opioid Use Disorder (OUD)

• Effective pain management is crucial for individuals with OUD, and healthcare providers face challenges in managing pain while minimizing morbidity and mortality associated with OUD 3.
• Medications such as methadone and buprenorphine are commonly used to treat OUD, and have been shown to be effective in reducing mortality, opioid use, and transmission of HIV and hepatitis C virus 4, 5.
• Non-pharmacological interventions, such as interdisciplinary collaboration and evidence-based policies, can also help manage pain and improve treatment outcomes for individuals with OUD 6.

Medication-Assisted Treatment

• Medication-assisted treatment (MAT) is a crucial component of OUD treatment, and medications such as methadone, buprenorphine, and naltrexone can be effective in reducing opioid use and craving 5.
• The choice of medication depends on patient preference, local availability of opioid treatment programs, anticipated effectiveness, and adverse effects 5.
• Discontinuation of pharmacotherapy increases the risk of relapse, and patients should be encouraged to continue treatment indefinitely 5.

Chronic Pain Management

• Chronic pain is a significant comorbid condition among individuals with OUD, and is often not managed effectively through OUD treatment programs 6.
• Pharmaceutical management of chronic pain is common, but may not be effective in reducing pain or improving treatment outcomes 6.
• Interdisciplinary collaboration and evidence-based policies are needed to prioritize quality pain management in addiction care and improve treatment outcomes for individuals with OUD 6.

Barriers to Effective Pain Management

• Geographical disparities, physician stigma, and training requirements can make access to effective pain management difficult for individuals with OUD 4.
• Structural barriers, such as lack of widely applied standards of care, can also hinder effective pain management in OUD treatment programs 6.
• Addressing these barriers is crucial to improving treatment outcomes and reducing the risk of opioid relapse for individuals with OUD 4, 6.