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Managing Acute Pain in Patients Who Take Maintenance Opioid Agonists

In an overview of this sometimes difficult situation, reviewers note common misperceptions and provide clinical recommendations.

With the increasing use of buprenorphine for maintenance treatment of opioid dependence, more physicians will encounter patients who take long-term opioid-agonist therapy (methadone or buprenorphine) and who have acute pain. In this review, addiction and pain experts have provided advice on managing this sometimes difficult situation.

The authors note four common misconceptions:

(1) Maintenance opioid agonists provide analgesia. (They do not, because of pharmacokinetic and pharmacodynamic factors.).

(2) Opioid use for acute pain could result in addiction relapse. (No published evidence suggests that this is the case.)

(3) Treatment with opioid analgesics, in addition to maintenance agonists, could cause respiratory and central nervous system depression. (Although this effect is theoretically possible, drug tolerance makes it very unlikely.)

(4) Reports of pain could reflect drug-seeking behavior. (If accompanied by objective findings, acute pain is unlikely to represent manipulation by the patient.)

The authors recommend the following:

• Reassure the patient that pain will be treated adequately, verify the maintenance dose of the opioid agonist, and continue it.
  
• Use short-acting opioids when necessary, in addition to the long-acting maintenance dose, and anticipate the need to use higher doses because of tolerance.
  
• Prescribe scheduled rather than as-needed doses.
  
• Use of opioids in addition to buprenorphine is complicated, because buprenorphine binds tightly to opioid receptors. Except for cases of mild acute pain of short duration, discontinuing buprenorphine might be required to effectively treat pain with short-acting opioids. In these cases, dose opioids to avoid withdrawal (which might require the addition of methadone) and then to achieve analgesia.
  

Comment: Expert opinion is particularly useful for a challenging, difficult-to-study clinical problem like pain and addiction.

— Richard Saitz, MD, MPH, FACP, FASAM

Dr. Saitz is affiliated with the same department as the lead author but was not involved in the Annals article.

Published in Journal Watch General Medicine February 7, 2006

Citation(s):

Alford DP et al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med 2006 Jan 17; 144:127-34.

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