What is the treatment for acute pain in a patient with opioid use disorder (OUD)?

From the Guidelines

Treating acute pain in patients with opioid use disorder requires a multimodal approach that prioritizes non-opioid medications and addresses the underlying substance use disorder, as outlined in the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1. When managing acute pain in these patients, it is crucial to continue their baseline opioid agonist therapy, such as methadone or buprenorphine, to prevent withdrawal, while also considering the potential for increased opioid tolerance. For additional pain control, the following non-opioid medications can be used as first-line treatments:

• Acetaminophen (1000 mg every 6 hours, not exceeding 4000 mg daily)
• NSAIDs like ibuprofen (400-600 mg every 6 hours) or ketorolac (30 mg IV initially, then 15-30 mg every 6 hours)
• Adjuvant medications such as gabapentin (300-600 mg three times daily) or pregabalin (50-100 mg twice daily) Regional anesthesia techniques like nerve blocks can provide targeted pain relief. If opioids are necessary for severe pain, use short-acting opioids at appropriate doses with close monitoring, considering that these patients may have increased opioid tolerance, as suggested by the study on acute pain management for patients receiving maintenance methadone or buprenorphine therapy 1. Involve addiction specialists in care planning when possible, and implement frequent reassessments of pain control and risk of misuse. This approach balances effective pain management while minimizing risks of triggering relapse or worsening opioid use disorder, recognizing that undertreated pain can itself lead to relapse behaviors. Key considerations include:
• Maximizing use of nonopioid pharmacologic and nonpharmacologic therapies
• Prescribing immediate-release opioids at the lowest effective dose and for no longer than the expected duration of pain severe enough to require opioids
• Addressing concerns with the patient and offering or arranging medication treatment for patients who meet criteria for opioid use disorder
• Providing patient education on the risks and benefits of opioid therapy, including the potential for opioid use disorder and overdose.

From the Research

Treatment Options for Acute Pain in Patients with Opioid Use Disorder

• Nonopioid analgesia is recommended as the first-line treatment for acute pain in patients with opioid use disorder (OUD) 2, 3, 4.
• Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for mild to moderate pain, while topical NSAIDs can be used for non-low back, musculoskeletal injuries 2.
• For patients on medication-assisted therapy for OUD, continuing their outpatient medications, such as buprenorphine and methadone, is essential for managing acute pain 3, 5.
• Short-acting opioids may be used as needed, but with caution and attention to minimizing risk 2, 3.
• Multimodal and non-opioid analgesic treatment strategies can be effective in managing acute pain in the Emergency Department (ED) 4.

Considerations for Patients with Opioid Use Disorder

• Patients with OUD may have higher baseline pain sensitivity and require higher opioid doses to achieve pain relief 5.
• Continuing buprenorphine and methadone in OUD patients after surgery may reduce the need for additional opioids 5.
• Ineffective pain management in patients taking methadone can result in disengagement in care 5.
• There is a lack of rigorous evidence on acute pain management in patients taking medication for OUD, highlighting the need for well-described, prospective studies 5.