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.
TL;DR:
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 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:
Please confirm the patient’s dose with their OAT provider. The team at Arrow Medical is always available for these consultations.
Effective management requires treating the acute pain “on top of” their maintenance OAT.
1. Continue Maintenance OAT
2. Aggressively Treat Acute Pain with Short-Acting Opioids
3. Utilize a Multimodal Analgesic Approach
4. Communicate with the Patient
A clear and safe discharge plan is critical to prevent a destabilizing transition back to the community.
For any questions about our services or how we can support your patients, please see our information for referring providers.
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.
