TL;DR:
- Effective post-operative pain management in patients on Opioid Agonist Treatment (OAT) is crucial and achievable with a clear protocol.
- Principle #1: Continue the patient’s maintenance OAT dose. Their methadone or buprenorphine treats their OUD, not their acute surgical pain. Holding their dose can precipitate withdrawal and complicate pain management.
- Principle #2: Treat acute pain “on top of” the OAT dose. Use short-acting opioids, recognizing that tolerance may necessitate higher-than-usual doses.
- Principle #3: Employ multimodal analgesia. Utilize non-opioid analgesics and regional anesthesia to reduce overall opioid requirements.
- Arrow Medical offers seamless collaboration for discharge planning. No formal referral is needed for follow-up; patients can walk directly into our clinics.
Table of Contents
- The Clinical Challenge: Pain Management in the OAT Patient
- The Core Principle: Continue Their Maintenance OAT Dose
- A Protocol for Acute Post-Operative Pain Management
- Discharge Planning: The Warm Hand-off to Arrow Medical
- Frequently Asked Questions for Clinicians
As a surgeon or hospitalist, you will inevitably care for patients who are stable on Opioid Agonist Treatment (OAT) with medications like methadone or buprenorphine (Suboxone). A common clinical challenge is how to effectively manage their acute post-operative pain without undertreating them or destabilizing their recovery.
Misconceptions can lead to poor outcomes. Some clinicians may mistakenly believe the patient’s OAT dose will cover their surgical pain, or they may fear that providing additional opioids will trigger a relapse. In reality, undertreating pain is more likely to cause distress and drive a patient to seek illicit substances.
With a clear, evidence-based protocol, you can manage these patients’ pain safely and effectively. At Arrow Medical, we aim to be your collaborative partners in this process.
The Core Principle: Continue Their Maintenance OAT Dose
The single most important principle is to continue the patient’s regular, established dose of methadone or buprenorphine throughout their hospital stay.
Their daily OAT dose manages their underlying Opioid Use Disorder (OUD). It occupies their opioid receptors to prevent withdrawal and cravings. It should be considered their baseline—it is not providing analgesia for their acute surgical pain.
Withholding a patient’s OAT dose will:
- Precipitate withdrawal, complicating their clinical picture with symptoms like tachycardia, diaphoresis, and anxiety.
- Increase their pain and distress.
- Erode the patient’s trust in the medical team.
Please confirm the patient’s dose with their OAT provider. The team at Arrow Medical is always available for these consultations.
A Protocol for Acute Post-Operative Pain Management
Effective management requires treating the acute pain “on top of” their maintenance OAT.
1. Continue Maintenance OAT
- Administer their verified daily dose of methadone or buprenorphine at their regular time.
2. Aggressively Treat Acute Pain with Short-Acting Opioids
- Patients on OAT have a high level of opioid tolerance, and they will likely require higher and/or more frequent doses of short-acting opioids (e.g., hydromorphone, oxycodone) than an opioid-naïve patient to achieve adequate analgesia.
- Do not be afraid to provide appropriate doses. Undertreating their pain is a greater risk.
- Patient-controlled analgesia (PCA) can be a very effective modality in this population.
3. Utilize a Multimodal Analgesic Approach
- This is key to reducing total opioid requirements and managing side effects.
- Scheduled Non-Opioid Analgesics: Use scheduled acetaminophen and NSAIDs (if not contraindicated) as the foundation of the pain plan.
- Regional Anesthesia: Utilize nerve blocks and epidural analgesia whenever possible. These are highly effective and can significantly decrease the need for systemic opioids.
- Adjuvant Medications: Consider medications like gabapentin for neuropathic pain components.
4. Communicate with the Patient
- Reassure the patient that you take their pain seriously and have a plan to manage it. Explain that their OAT will be continued and that they will receive additional medication for surgical pain. This communication builds trust and reduces patient anxiety.
Discharge Planning: The Warm Hand-off to Arrow Medical
A clear and safe discharge plan is critical to prevent a destabilizing transition back to the community.
- Provide a Short, Tapering Supply: Prescribe a limited quantity of short-acting opioids (e.g., 3-7 days) to manage the transition, with clear instructions to taper off as the acute pain subsides.
- Communicate with the OAT Provider: A quick call to the patient’s clinic to inform them of the surgery and the discharge plan is best practice.
- Seamless Referral to Arrow Medical: Our model is designed for this. No formal referral is required. Simply instruct the patient to return to their Arrow Medical clinic as scheduled. They can walk in for their next dose and follow-up. This removes barriers and ensures continuity of care.
For any questions about our services or how we can support your patients, please see our information for referring providers.
Frequently Asked Questions for Clinicians
Q: What about patients on buprenorphine/naloxone (Suboxone)?
Buprenorphine is a partial agonist with a high affinity for the mu-opioid receptor, which can complicate pain management. The best practice is to continue the buprenorphine and utilize non-opioid pharmaxotherapy and, if required, add a short-acting opioid on top. Higher doses may be required to overcome the receptor blockade. Consultation with an addiction medicine specialist is highly recommended. Discontinuing it pre-operatively is generally not advised.
Q: Will providing opioids for post-op pain cause a relapse?
The legitimate, medically supervised use of opioids for acute pain is not the same as a relapse. In fact, effectively managing a patient’s pain in a trusting, therapeutic relationship is more likely to strengthen their recovery.
Q: How do I verify a dose if the patient is admitted overnight or on a weekend?
This can be a challenge. Try calling the patient’s pharmacy to confirm their dose first. If the patient is known to Arrow Medical, they can provide our clinic contact information. If verification is impossible, use your clinical judgment, but the principle remains: do not let the patient go into withdrawal.
Arrow Medical is your partner in providing comprehensive care. By collaborating, we can ensure patients on OAT receive safe, effective, and compassionate pain management during their hospital stay. Please call us to coordinate care for our mutual patients.