What pain management regimen should be prescribed on discharge for a patient on methadone (opioid agonist) therapy who underwent ventral hernia repair and received oxycodone (opioid agonist) for post-operative pain?

Discharge Pain Management for Methadone Patient Post-Ventral Hernia Repair

Primary Recommendation

Continue the patient's baseline methadone dose unchanged and prescribe immediate-release oxycodone 5 mg tablets (15-20 tablets maximum) for breakthrough pain only, combined with scheduled non-opioid multimodal analgesia including acetaminophen 1000 mg every 6 hours and ibuprofen 600 mg every 6 hours for 5-7 days. 1, 2

Rationale for Methadone Continuation

• The methadone must be continued at the patient's baseline dose to prevent withdrawal and maintain opioid use disorder treatment 1
• The methadone provides baseline opioid tolerance but does not provide analgesia for acute postoperative pain 3
• Patients on methadone maintenance who experience acute pain require additional opioid analgesics at doses similar to or higher than opioid-tolerant patients 3

Multimodal Non-Opioid Foundation

Scheduled (not PRN) non-opioid analgesics form the cornerstone of discharge pain management:

• Acetaminophen 1000 mg orally every 6 hours (maximum 4000 mg daily) 1, 2
• Ibuprofen 600 mg orally every 6-8 hours with food 1, 2
• These should be prescribed separately (not as combination products) to allow independent dose adjustments 1
• Continue for 5-7 days postoperatively 1, 2

Breakthrough Opioid Prescribing

For opioid-tolerant patients on methadone, breakthrough pain management requires:

• Immediate-release oxycodone 5 mg tablets only (avoid modified-release formulations) 1
• Prescribe 15-20 tablets maximum (equivalent to 75-100 morphine milligram equivalents) 1, 4
• Duration: 5 days, maximum 7 days 1
• Instruct patient to use only for breakthrough pain that interferes with function, not to eliminate all pain 1
• Higher doses may be needed due to opioid tolerance from methadone 3

Critical Prescribing Pitfalls to Avoid

• Never prescribe modified-release opioids (extended-release tablets, transdermal patches) - these are major risk factors for persistent opioid use and provide no benefit for acute postoperative pain 1
• Never prescribe combination products (oxycodone/acetaminophen) - fixed doses prevent appropriate titration and weaning 1
• Never prescribe liquid opioid formulations at discharge - bottle sizes preclude safe monitoring and increase leftover medication 1

Discharge Instructions and Safety

Provide explicit written and verbal instructions:

• Take acetaminophen and ibuprofen on schedule, not "as needed" 2
• Use oxycodone only when pain interferes with functional activities (walking, deep breathing, sleeping) 1
• Continue baseline methadone without interruption 1, 3
• Wean opioids first as pain improves, then stop NSAIDs, then stop acetaminophen 1
• Most patients require minimal to no breakthrough opioids by day 3-4 when multimodal analgesia is optimized 2

Medication Storage and Disposal

• Store all opioids securely away from others 1
• Do not drive or operate machinery while taking opioids 1
• Dispose of unused opioids by returning to pharmacy or flushing down toilet 1, 2
• Only 12% of patients dispose of unused opioids appropriately, creating community diversion risk 1

Discharge Documentation Requirements

The discharge letter must explicitly state: 1

• Baseline methadone dose to be continued unchanged
• Oxycodone dose: 5 mg every 4-6 hours as needed for breakthrough pain
• Exact number of tablets prescribed (15-20 tablets)
• Duration: 5 days maximum, 7 days if needed
• Scheduled acetaminophen and ibuprofen regimen
• Clear instruction that this is not a repeat prescription 1

Follow-Up and Red Flags

Contact surgeon if: 2

• Pain intensity increases rather than decreases after day 3
• Requiring oxycodone more than 2-3 times daily after day 4
• New symptoms develop (fever, wound drainage, swelling)
• Pain not controlled despite maximizing non-opioid regimen

Special Considerations for Hernia Repair

• Ventral hernia repair typically requires minimal opioids when multimodal analgesia is optimized 5, 4
• More than one-third of opioid-naive hernia patients use zero opioids postoperatively 4
• Expected pain trajectory: moderate-severe on days 1-2, transitioning to mild-moderate by day 3, minimal by days 5-7 2
• 75% of prescribed opioids remain unused in typical hernia patients, emphasizing need for conservative prescribing 4

Coordination with Methadone Provider

• Notify the patient's methadone clinic/provider about the surgery and discharge plan 1
• Ensure continuity of methadone maintenance treatment 1
• Consider involving inpatient pain service for complex cases 1