Management of Acute Perioperative Pain With Opioid Use Disorder-Slides

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This comprehensive overview addresses the perioperative management of acute pain in patients with opioid use disorder (OUD), emphasizing medication-assisted therapy (MAT), particularly buprenorphine, and multimodal analgesia strategies.<br /><br />Key points include the rising challenge of synthetic opioid-related overdose deaths, underscoring the need for timely, effective inpatient treatment to reduce mortality and improve outcomes. Despite this, less than 20% of hospitalized patients with OUD receive treatment, largely due to knowledge gaps, stigma, and coordination barriers among specialties.<br /><br />Three FDA-approved MAT medications—methadone (full agonist), buprenorphine (partial agonist), and naltrexone (antagonist)—are discussed with their perioperative implications. Buprenorphine is favored for safety and prescribing ease, with recommendations to continue the patient's usual dose through surgery, possibly increasing dosing frequency (BID to TID) or dose (up to 24–32 mg) for analgesia. Microinduction techniques allow initiation or resumption of buprenorphine during acute pain without precipitated withdrawal, often complementing full opioid agonists like hydromorphone or fentanyl. Methadone is reserved for severe withdrawal or acute postoperative pain situations due to its long half-life and titration challenges.<br /><br />Multimodal analgesia—including non-opioid adjuncts like ketamine (an NMDA antagonist with mood benefits), lidocaine infusions, NSAIDs, and regional anesthesia—is essential to manage heightened pain sensitivity and opioid tolerance in OUD patients. Ketamine is recommended perioperatively for opioid-tolerant patients; side effects such as hallucinations are less common in this group and can be mitigated with co-medications.<br /><br />Successful inpatient management relies on interprofessional collaboration among internal medicine, psychiatry, anesthesia, nursing, and social work, including initiating MAT during hospitalization, providing bridge prescriptions, and coordinating outpatient follow-up to improve long-term engagement.<br /><br />In summary, evidence supports continuing buprenorphine perioperatively, using multimodal analgesia and regional anesthesia to control pain effectively, and initiating or maintaining MAT during hospitalization to optimize patient outcomes and reduce opioid-related morbidity and mortality.

Keywords

perioperative pain management

opioid use disorder

medication-assisted therapy

buprenorphine

multimodal analgesia

synthetic opioid overdose

methadone

naltrexone

microinduction

interprofessional collaboration