What is the best approach for managing pain in a patient undergoing opioid withdrawal?

Pain Management in Patients Undergoing Opioid Withdrawal

Continue or initiate opioid agonist therapy (methadone or buprenorphine) to prevent withdrawal, then add scheduled short-acting opioid analgesics at higher doses and shorter intervals than used for opioid-naïve patients, combined with aggressive multimodal non-opioid analgesia. 1

Critical First Principle: Separate Withdrawal Prevention from Pain Control

The fundamental error clinicians make is attempting to treat both withdrawal and acute pain with a single intervention—this fails because maintenance opioid doses provide minimal analgesia for acute pain. 1

Immediate Actions

• Verify and continue the patient's baseline opioid agonist therapy (methadone or buprenorphine) at their usual maintenance dose to prevent withdrawal 1
• Contact the patient's methadone clinic or buprenorphine prescriber to confirm the last dose timing and amount 1
• Explicitly reassure the patient that their maintenance therapy will continue uninterrupted and that their pain will be aggressively treated—this reduces anxiety that worsens pain perception 1

For Patients on Methadone Maintenance

Straightforward Approach

• Continue the full daily methadone dose without modification 1, 2
• Add scheduled (not as-needed) short-acting opioid analgesics such as morphine, hydromorphone, or oxycodone 1, 2
• Dose these analgesics at 1.5-2 times higher than standard doses and administer every 3-4 hours due to cross-tolerance 1
• Avoid fixed-dose acetaminophen combinations when high opioid doses are required due to hepatotoxicity risk 2

Monitoring Requirements

• Monitor respiratory rate and level of consciousness frequently when adding opioids to methadone 2, 3
• Keep naloxone immediately available at the bedside 1, 2
• Notify the methadone clinic about all controlled substances prescribed, as they will appear on routine urine drug screening 1

For Patients on Buprenorphine Maintenance

Buprenorphine's high receptor affinity and partial agonist properties create unique challenges. 1 Four evidence-based options exist, selected based on pain severity and treatment setting:

Option 1: Continue Buprenorphine (Mild-Moderate Pain, Short Duration)

• Maintain the current buprenorphine dose and add short-acting full opioid agonists 1
• Recognize that substantially higher opioid doses will be required to compete with buprenorphine at the μ-receptor 1
• This approach works only for brief pain episodes (1-2 days) 1

Option 2: Split-Dose Buprenorphine (Moderate Pain)

• Divide the total daily buprenorphine dose into every 6-8 hour administration to exploit its analgesic properties 1
• Example: 32 mg daily becomes 8 mg every 6 hours 1
• Add supplemental short-acting opioids as needed, recognizing that even divided dosing may not provide adequate analgesia in opioid-tolerant patients 1

Option 3: Discontinue Buprenorphine (Severe Acute Pain, Outpatient)

• Stop buprenorphine completely and transition to scheduled full opioid agonist analgesics (sustained-release plus immediate-release morphine) 1
• Titrate opioids first to prevent withdrawal, then increase further for analgesia 1
• When pain resolves, restart buprenorphine using a formal induction protocol—critically, the patient must be in mild opioid withdrawal before restarting buprenorphine to avoid precipitated withdrawal 1

Option 4: Convert to Methadone (Severe Pain, Hospitalized Patients)

• Convert buprenorphine to methadone 30-40 mg daily to prevent withdrawal 1
• This dose prevents acute withdrawal in most patients and, unlike buprenorphine, allows predictable dose-response to additional opioid analgesics 1
• If withdrawal persists, increase methadone by 5-10 mg increments 1
• Add short-acting opioid analgesics for pain control, which will now work as expected 1
• Before discharge, discontinue methadone and convert back to buprenorphine using an induction protocol 1

For Patients Actively Using Heroin or Illicit Opioids

Optimal Strategy

• Initiate methadone maintenance therapy first to address baseline opioid requirements before attempting analgesia 3
• Once stabilized on methadone, add scheduled short-acting opioid analgesics for pain control 3
• Use higher doses at shorter intervals than for opioid-naïve patients due to tolerance and opioid-induced hyperalgesia 1, 3

Alternative Approach

• Gradually taper from heroin to lower doses before introducing buprenorphine 3, 4
• Monitor withdrawal using the Clinical Opiate Withdrawal Scale (COWS) 3, 4
• Consider adjunctive medications (clonidine, loperamide, ondansetron) to manage withdrawal symptoms 3, 4

Universal Multimodal Analgesic Strategy

Non-Opioid Analgesics

• Administer scheduled NSAIDs and acetaminophen in combination with opioids 2, 3
• Add adjuvant analgesics such as tricyclic antidepressants that potentiate opioid effects 2, 3

Dosing Principles

• Write continuous scheduled orders, never as-needed orders—allowing pain to reemerge before the next dose causes unnecessary suffering and increases patient-provider tension 1, 3
• Provide rescue doses equivalent to 10-15% of the total daily opioid dose for breakthrough pain 2
• If more than 4 rescue doses are needed in 24 hours, increase the baseline scheduled dose 2

Critical Medication to Avoid

• Never use mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they will precipitate acute withdrawal syndrome 1, 3

Common Pitfalls and How to Avoid Them

Misinterpreting Drug-Seeking Behavior

• Pseudoaddiction represents behavioral changes from inadequate pain control, not true addiction 1
• Therapeutic dependence (fear of pain or withdrawal reemergence) is a normal response, not addiction 1
• Do not allow concerns about manipulation to cloud clinical judgment—fears that opioid analgesia will cause addiction relapse or respiratory depression are unfounded 1

Undertreatment Due to "Opiophobia"

• Undertreating pain decreases responsiveness to subsequent opioid analgesics, making pain control progressively more difficult 3
• Patients with opioid tolerance require higher doses—this is expected pharmacology, not drug-seeking 1, 3

Precipitated Withdrawal from Buprenorphine

• When restarting buprenorphine after using full agonists, the patient must be in mild withdrawal first—buprenorphine's high receptor affinity will displace full agonists and precipitate severe withdrawal if given too early 1, 4
• This is particularly dangerous when transitioning from high-dose methadone (>40 mg) 4

Inadequate Communication

• Establish clear agreements regarding pill counts, frequency, and expected treatment duration 3
• Inform addiction treatment programs about all medications administered, as they will appear on urine drug screening 1

Special Considerations for Fentanyl Users

• Patients transitioning from heroin to fentanyl experience more frequent, painful, and faster onset withdrawal symptoms 5
• Fear of precipitated withdrawal from buprenorphine is a major barrier to treatment initiation in this population 5
• Consider low-dose buprenorphine induction ("microdosing") protocols to minimize precipitated withdrawal risk 6

Discharge Planning

• Ensure timely follow-up with addiction treatment providers before discharge 6, 7
• Provide adequate bridge prescriptions for both maintenance therapy and pain management 6
• Coordinate care between pain management and addiction treatment teams to prevent treatment gaps 7