What are the best pain management options for a patient with opioid use disorder?

From the Guidelines

Pain management for patients with opioid use disorder should prioritize a multimodal approach that minimizes opioid use, focusing on non-opioid medications, adjuvant therapies, and non-pharmacological interventions to effectively control pain while reducing the risk of relapse.

Key Considerations

• First-line options include non-opioid medications such as acetaminophen (up to 3000mg daily in divided doses) and NSAIDs like ibuprofen (400-600mg every 6 hours) or naproxen (500mg twice daily) 1.
• Adjuvant medications are also valuable, including gabapentinoids such as gabapentin (starting at 300mg daily and titrating up to 1800-3600mg daily in divided doses) or pregabalin (starting at 75mg twice daily), antidepressants like duloxetine (30-60mg daily), and muscle relaxants such as baclofen (10-25mg three times daily).
• Regional anesthesia techniques, when appropriate for the pain location, can provide targeted relief.
• Non-pharmacological approaches are essential components of treatment, including physical therapy, cognitive behavioral therapy, mindfulness meditation, and acupuncture.

Medication for Opioid Use Disorder (MOUD)

• For patients receiving MOUD, continuing these medications is crucial; buprenorphine can provide both pain relief and treat opioid use disorder, while methadone dosing may need adjustment for acute pain 1.
• Buprenorphine has been shown to be effective in preventing relapse among patients with opioid use disorder, and its use in combination with behavioral therapies can reduce opioid misuse and increase retention during maintenance therapy 1.

Opioid Use

• If opioids are absolutely necessary for severe acute pain, they should be used at the lowest effective dose for the shortest duration with close monitoring, preferably in consultation with addiction medicine specialists 1.
• Clinicians should work with patients to prevent prolonged opioid use, prescribe and advise opioid use only as needed, and encourage and include an opioid taper if opioids will be taken around the clock for more than a few days 1.

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. Many acute pain conditions (e.g., the pain that occurs with a number of surgical procedures or acute musculoskeletal injuries) require no more than a few days of an opioid analgesic.

The best pain management options for a patient with opioid use disorder are not explicitly stated in the provided drug labels. However, it can be inferred that buprenorphine may be considered for pain management in patients with opioid use disorder, as it is mentioned that buprenorphine hydrochloride should be prescribed by healthcare professionals knowledgeable about opioid use and associated risks.

• Non-opioid analgesics may be considered as an alternative for patients with certain conditions, such as chronic pulmonary disease or elderly, cachectic, or debilitated patients.
• Opioid rotation (safely switching the patient to a different opioid moiety) may be considered if a patient is suspected to be experiencing Opioid-Induced Hyperalgesia (OIH). It is essential to carefully evaluate the patient's individual needs and circumstances when selecting a pain management option 2.

From the Research

Pain Management Options for Patients with Opioid Use Disorder

• The management of pain in patients with opioid use disorder (OUD) is a complex issue, requiring careful consideration of the patient's medical history and current treatment regimen 3, 4, 5.
• For patients prescribed buprenorphine for OUD, pain management strategies may include the continuation of buprenorphine, combination with full opioid agonists and non-opioid adjuncts, adjunct use of nonsteroidal anti-inflammatory drugs, conversion to sublingual buprenorphine, or performing surgery at trough serum buprenorphine concentration 5.
• A multimodal analgesic approach, combining opioids, non-opioid analgesics, and regional anesthesia, is often favored by clinicians for managing pain in patients with OUD 5.
• The use of opioids for chronic non-cancer pain is controversial, but may be beneficial in carefully selected patients with regular monitoring and as part of a multimodal therapy 6.
• Prescription opioid use has been shown to be associated with reduced pain and negative affect in chronic pain patients, but also carries risks of opioid use disorder and overdose 7.

Key Considerations

• The treatment of OUD may be limited by poor adherence to treatment recommendations and high rates of relapse and increased risk of overdose after leaving treatment 3.
• New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and problems of poor treatment adherence 3.
• Take-home naloxone programs may be effective in preventing fatal overdose in patients with OUD 3.
• Clear guidelines on how to support pain management in patients with OUD have yet to be identified, and further studies are needed to find and evaluate optimal adjunctive medications and define overall strategies 5.