- acute pain management
- opioid agonist therapy
- methadone buprenorphine
- addiction medicine
- multimodal analgesia
Introduction
Managing acute pain in patients receiving opioid agonist therapy (OAT), such as methadone or buprenorphine, is a common but often misunderstood clinical challenge. Misconceptions can lead to undertreatment of pain, increased complications, and even relapse. This article reviews key myths and provides a practical approach to management.
Myth 1: Maintenance opioid therapy provides adequate analgesia
Methadone and buprenorphine maintenance therapy are primarily designed to prevent withdrawal symptoms and reduce cravings, not to provide sustained analgesia. Their analgesic effect is shorter than their effect on withdrawal suppression.
Therefore, maintenance dosing alone is insufficient for acute pain. Dividing the daily dose (e.g., twice or three times daily) and adding additional analgesics when needed is often required. These patients may also have higher opioid tolerance and lower pain thresholds.
Myth 2: Using opioids for pain will trigger relapse
There is a common concern that prescribing opioids may lead to relapse. However, evidence suggests that undertreated pain poses a greater risk of relapse than appropriate opioid use.
Effective pain management is protective. A multimodal approach should be used, combining non-opioid and opioid therapies when clinically indicated.
Myth 3: Combined opioid use will cause respiratory depression
While respiratory depression is a valid concern, acute nociceptive pain itself increases arousal and can counterbalance opioid-induced respiratory depression.
This means that appropriate opioid use should not be withheld due to fear alone, provided that careful monitoring and safe prescribing principles are followed.
Myth 4: Pain complaints indicate drug-seeking behaviour
Patients on OAT are often misjudged as drug-seeking when they report pain. However, they may have genuine acute pathology or exacerbation of chronic conditions.
Clinicians must carefully assess the cause of pain and avoid dismissing legitimate symptoms. All patients with true acute pain deserve appropriate and timely treatment.
Conclusion
In patients receiving methadone or buprenorphine, maintenance therapy alone does not provide adequate analgesia for acute pain. Active management is required, including dose adjustment and multimodal strategies. Undertreatment increases the risk of relapse and poor outcomes. Clinicians should prioritise accurate assessment, appropriate analgesia, and non-judgmental care.
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