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. Author manuscript; available in PMC: 2007 Jun 19.
Published in final edited form as: Ann Intern Med. 2006 Jan 17;144(2):127–134. doi: 10.7326/0003-4819-144-2-200601170-00010

Table 2.

Recommendations for Treating Acute Pain in Patients Receiving Opioid Agonist Therapy*

Addiction treatment issues
 Reassure patient that addiction history will not prevent adequate pain management.
 Continue the usual dose (or equivalent) of OAT.
 Methadone or buprenorphine maintenance doses should be verified by the patient’s methadone maintenance clinic or prescribing physician.
 Notify the addiction treatment program or prescribing physician regarding the patient’s admission and discharge from the hospital and confirm the time and amount of last maintenance opioid dose.
 Inform the addiction treatment maintenance program or prescribing physician of any medications, such as opioids and benzodiazepines, given to the patient during hospitalization because they may show up on routine urine drug screening.
Pain management issues
 Relieve patient anxiety by discussing the plan for pain management in a nonjudgmental manner.
 Use conventional analgesics, including opioids, to aggressively treat the painful condition.
 Opioid cross-tolerance and patient’s increased pain sensitivity will often necessitate higher opioid analgesic doses administered at shorter intervals.
 Write continuous scheduled dosing orders rather than as-needed orders.
 Avoid using mixed agonist and antagonist opioids because they may precipitate an acute withdrawal syndrome.
If the patient is receiving methadone maintenance therapy and requires opioid analgesics
 Continue methadone maintenance dose.
 Use short-acting opioid analgesics.
If the patient is receiving buprenorphine maintenance therapy and requires opioid analgesics, 4 options are available and should be chosen on the basis of the anticipated duration of pain, treatment setting, and response to the chosen option
 Continue buprenorphine maintenance therapy and titrate short-acting opioid analgesics (for pain of short duration only).
 Divide buprenorphine dose to every 6–8 hours.
 Discontinue buprenorphine maintenance therapy and use opioid analgesics. Convert back to buprenorphine therapy when acute pain no longer requires opioid analgesics.
 If the patient is hospitalized, discontinue buprenorphine therapy, treat opioid dependence with methadone at 20–40 mg, and use short-acting opioid analgesics to treat pain. Have naloxone available at the bedside. Discontinue methadone therapy and convert back to buprenorphine therapy before hospital discharge (for inpatients only).
*

These recommendations are applicable only for patients receiving OAT who require opioid analgesics. OAT = opioid agonist therapy.