Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.

Pain Management in Patients on Opioid Replacement Therapy

The management of patients with a history of opioid abuse can be a challenge. These patients may be anxious that they will be stigmatised and denied adequate analgesia with opioids due to their history. They should be reassured that their reported pain will be taken seriously and acted upon.

Inadequate treatment of pain in patients on opioid replacement therapy (e.g. methadone or buprenorphine/naloxone) commonly leads to disruptive behaviour by angry and frightened patients who then may discharge themselves against medical advice, often to the detriment of the patient's health.

People who misuse drugs in the absence of pain develop tolerance and may need larger doses of the drug to obtain effective pain relief.

Some general guidance, until more detailed advice from a specialist can be sought:

  • Methadone in maintenance doses does not have analgesic effects.
  • Where possible do not interrupt daily methadone maintenance or change the patient's dose of methadone.
  • Suboxone® (buprenorphine/naloxone) and other buprenorphine only therapies (e.g. Espranor®) can be continued with other multimodal analgesic strategies for acute pain.
  • Buprenorphine can partially block effects of opioid analgesia, therefore consideration of opioid doses and availability should reflect this.
  • Manage pain as described previously:
    • Opioids should be used as needed and in conjunction with non-opioid analgesia.
    • Titrate dose according to side effects and pain relief starting with a low dose initially, as the dose of opioid replacement therapy and the use of illicit drugs prior to admission may be unknown.
    • These patients may eventually need higher and more frequent doses of analgesia.
  • Cease the parenteral use of opioid analgesics as soon as possible and convert to oral preparations.
  • These patients can be complex and their pain difficult to manage - contact the Acute Pain Team for further advice, as well as the local Drug Addictions services.

For opioid-induced side effects and management see Reversal of Opioid-induced Respiratory Depression.

 

Content reviewed April 2019




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