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Management eBrief no. 160

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Management eBriefs
Issue 160 October 2019

The report is a product of the VA/HSR&D Evidence Synthesis Program.

Evidence Brief: Managing Acute Pain in Patients Taking Medications for Opioid Use Disorder

Acute pain management in patients with opioid use disorder (OUD) can be challenging due to several factors including increased pain sensitivity and higher opioid tolerance. Use of medications for OUD (MOUD) including methadone, buprenorphine/naloxone, or naltrexone adds to the complexity of acute pain management because of the unique pharmacologic properties of these medications and implications for use of additional opioid analgesics. Current guidelines addressing acute pain management in patients taking MOUD are primarily based on expert consensus and do not provide clinicians with detailed recommendations. Given the scope of the opioid crisis and public health response, it is likely that more patients will be treated with MOUD over time. Therefore, determining best practices to manage acute pain in patients on MOUD is a timely and relevant issue to frontline clinicians in multiple settings.

Medications for OUD, specifically methadone, buprenorphine, and naltrexone, have been shown to reduce opioid use, craving and opioid use disorder-related symptoms and sequelae.1

  • Methadone (full opioid agonist) activates opioid receptors in the same way as other prescription opioids and illicit opioids (e.g.., heroin).
  • Buprenorphine (partial opioid agonist) binds tightly to the opioid receptor but does not activate this receptor as much as full opioid agonists like methadone.
  • Naltrexone (opioid antagonist) blocks opioid receptor activity.

Each of these medications has its own respective pros and cons that must be considered.

This rapid review examined the benefits and harms of different acute pain management strategies for patients taking OUD medications, and whether these benefits and harms vary by the type of OUD medication or type of acute pain (i.e., emergent condition vs planned surgery). Investigators with VA’s Evidence Synthesis Program (ESP) Center in Portland, OR reviewed the literature identified from searches of MEDLINE®, PsycINFO, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL). From nearly 300 articles, 8 retrospective studies addressed the review’s questions: 2 studies examining patients with OUD taking buprenorphine/naloxone, 4 studies examining those taking methadone, and 2 examining a mixed group of patients. No studies examined the use of naltrexone or examined Veterans specifically. Other study characteristics include:

  • Four studies examined patients with emergent conditions, 3 examined patients undergoing planned surgery, and 1 study examined a mixed group of emergent and surgical patients;
  • Three studies used a control group, and 5 studies did not;
  • Study size ranged from 1 to 134 participants and were conducted in hospitals/tertiary care centers or specialized pain centers; and
  • Follow-up time ranged between 1 day to more than 2 years.

Summary of Findings
None of the eight studies directly evaluated the trade-offs of different ways of managing acute pain in patients taking OUD medications. However, these studies provide some indirect evidence that aligns with current consensus-based guidelines that recommend continuing methadone during acute pain episodes and continuing buprenorphine for most patients with mild or moderate pain. More specifically, these studies found:

  • Among patients on MOUD, continuing the use of buprenorphine and methadone after surgery may reduce the total doses of opioids, keeping in mind that patients taking OUD medications are opioid-tolerant and may need higher doses of opioid agonists for effective pain control compared to patients without opioid use disorder; and
  • Ineffective management of acute pain in patients with OUD taking methadone can lead to disengagement in care.

Implications
Results from this evidence brief were used to inform prioritization of further research at the HSR&D state-of-the-art (SOTA) conference that was held in September 2019. Findings also will be used to inform clinical decision-making regarding acute pain management in patients taking OUD medications.

Future Research
Areas for future research include the effectiveness of non-opioid pain management options in the setting of acute pain among patients on OUD medications, as well as the benefits and harms of OUD medication dose changes (i.e., increasing doses or dividing doses) during acute pain episodes. As studies have not evaluated strategies to manage acute pain among patients on naltrexone, addressing this gap also should be a priority of future research.  

  1. Medications to Treat Opioid Use Disorder. National Institute on Drug Abuse. Accessed October 16, 2019.

Reference
Veazie S, Mackey K, Bourne D, and Peterson K. Evidence Brief: Managing Acute Pain in Patients with Opioid Use Disorder on Medication-Assisted Treatment. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-199; 2019.

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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.



This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

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This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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