Written by Millie Cossé
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Management of acute pain in patients with opioid use disorder is tricky and likely requires a multi-modal approach. Evidence to support a single best strategy is lacking.
Take the edge off
This systematic review of 115 studies seeks to summarize the known risks and benefits of various interventions for managing acute pain for patients with opioid use disorder (OUD). The studies included in this review are primarily based on patients in the emergency department and perioperative setting.
Results were divided among patients receiving medications for opioid use disorder (MOUD, primarily buprenorphine) and those not on MOUD. Inconsistent evidence was found about optimal medication strategies for treatment of acute pain as well as the utility and safety of discontinuing MOUD during treatment of acute pain. There is some low-confidence evidence that continuing buprenorphine may be beneficial to a majority of patients; however, this result is not consistently reproducible.
How will this change my practice?
The conclusions of this review are similar to my own experience in practice. There is a huge amount of variation in individual response to pain medication, and it often takes some trial and error to control the acute pain of patients with OUD, especially among those on buprenorphine or methadone. My usual practice pattern is to start with multimodal pain therapy including opioids (possibly at a higher dose) as an opening move and transition to pain-dose ketamine as a second-line agent.
Source
Acute Pain Management in People With Opioid Use Disorder : A Systematic Review. Ann Intern Med. 2025 Mar 18. doi: 10.7326/ANNALS-24-01917. Epub ahead of print. PMID: 40096692
