Pain Management During Medicated-Assisted Treatment for Opiate Abuse

By Melissa Bryant LPN, Lead Nurse, Findlay Treatment Services, an opioid treatment center in Ohio

MAT, Opioid Use Disorder, and Pain Management

The opioid crisis reshaped the way we view opioid pain medication in the United States. The crisis itself, and the response to the crisis by public health officials, has complicated the practice of pain-management for one group of people in particular: individuals with opioid use disorder (OUD) who participate in medication-assisted treatment (MAT). This group includes people with OUD in MAT who experience acute pain due to accident, injury, or surgery, and people with OUD in MAT who live with chronic pain due to a chronic illness or medical condition unrelated to their opioid use disorder.

This article will focus on the former subset of this group: individuals on MAT for OUD who need to manage pain related to a surgery, injury, or accident. We’ll use three primary sources to address this topic:

1. Pain Management in Former Addicts on Medication-Assisted Treatment (MAT) Program. This is a chapter from a clinical textbook called “Pain Control in Ambulatory Surgery Centers.”
2. Pain Management in Patients with Substance-Use Disorders. This peer-reviewed journal article contains some of the first reliable data on the subject of pain management for people in MAT for OUD.
3. Successful Pain Management for the Recovering Addicted Patient. This is another chapter from a clinical textbook. It offers an overview on how physicians and patients can collaborate to form a workable approach to pain management for people in MAT for OUD.

In order to focus on this topic, we need to know about the opioid crisis in the U.S. and how it affected the role of opioids in clinical practice. We’ll start with a brief summary of the path we took to arrive where we are now: emerging from the COVID-19 pandemic, ready to establish a new normal that accounts for both the pandemic and the opioid crisis.

The Opioid Crisis and Pain Management

In the early phase of the crisis, known as phase one, a radical increase in opioid prescriptions contributed to a corresponding radical increase in opioid addiction and opioid-related overdose death.

Here’s data related to that phase of the crisis:

From 1999 to 2011:

• Use of hydrocodone, a prescription opioid, doubled
• Use of oxycodone, another prescription opioid, increased five-fold (use five times greater in 2011 compared to 1999)
• Fatal opioid-related overdose four-fold (four times as many opioid-related overdose deaths in 2011 compared to 1999)

That’s logical: the sharp increase in prescriptions led to increase in use. This increase in use led, in turn, to an increase in misuse. That’s when the second phase of the opioid crisis occurred. Here’s data related to that phase:

From 2010 to 2015:

• People who misused opioids and could no longer access them legally turned to illicit heroin use.
• 80% of current heroin users (then and now) began opioid use with a legal prescription
• Heroin-related overdose deaths increased three-fold (three times as many heroin-related overdose deaths in 2014 compared to 2010)

Then, in 2016, the Centers for Disease Control (CDC) stepped in and issued new guidelines for opioid prescribing for pain management. To learn more about these guidelines, please read our article here. This set of guidelines from the CDC had some unintended negative consequences with regard to pain management, which we’ll discuss in a moment. First, let’s look at the benefits of the guidelines:

Opioid Prescriptions, 2016-2020:

• 2016: 214,881,662
• 2017: 191,909,384
• 2018: 168,158,611
• 2019: 153,260,450
• 2020: 142,816,781

That time period is known as phase three of the opioid crisis, which includes the beginning of what we now call the pandemic era. This phase included good news and bad news. The decrease in opioid prescriptions by over forty percent – as reflected in the bullet list above – along with a decrease in overdose deaths from 2015-2017 was good news. An increase in overdose deaths from 2018-2019, and then again from 2019-2022 is what we’ll be honest and call bad news.

However, though that news is bad and involves tragic suffering for individuals, families, and communities, we know exactly what caused the increases. The overdose spike in 2018-2019 was the direct result of a wave of illicit fentanyl in the U.S., while the overdose increases from 2020-2022 were directly related to the pandemic.

Now, to the issue of pain management.

When the CDC issued their guidelines in 2016, one unintended consequence was that in some cases, prescribing physicians discontinued opioid prescriptions for pain management without adequate consultation with their patients. This escalated a core component of the opioid crisis – the prescription to addiction pathway – to another level. People who could not acquire opioids legally turned to illicit heroin. You can read the details on how this happens in our article “From Oxy to Heroin: The Unintended Consequences of CDC Opioid Prescription Guidelines.”

The complications extended to people on medication-assisted treatment for opioid addiction. In some cases, people on MAT were denied analgesic opioids for acute pain, which – because of various factors – caused them to seek and use heroin to manage pain. This resulted in relapse to addiction for some, overdose death for others, and intense, almost-impossible-to-manage levels of pain for still others.

Let’s take a look at the most recent information on pain management for people with OUD on MAT, and learn about the latest, best, and most effective evidence-based approaches to this complicated situation.

Pain Management While on MAT: What We Know

We’ll address something important right away:

Evidence shows it’s possible for people with OUD on MAT to manage short-term pain with opioid medication without increased of relapse.

It’s not only possible, but it may decrease harm overall, because it reduces the likelihood an individual may decide to discontinue MAT on their own and seek illicit heroin to manage pain. As we mention above, and as the statistics show, this pathway is very real, very dangerous, and can easily lead to accidental overdose and death. Anyone on MAT who’s at risk of using illicit heroin to manage pain in the absence of a short-term physician-directed opiate medication plan should understand that there safe, effective templates – i.e. sets of best practices – that allow for the temporary use of prescription opiates for people on the three most common medications used in MAT: methadone, buprenorphine, and naltrexone.

It’s also important to understand that for someone with OUD who’s on MAT, opioid analgesics should not be the go-to, first-choice choice for pain management. All other alternatives should be explored and discussed with the medical team involved in any surgical procedure or the medical team involved in treatment for injuries related to an accident that may require opioids.

Let’s dive into the details – with a reminder that when we use the phrase evidence shows or data indicates, we’re talking about peer-reviewed information from the three articles we link to at the beginning of this article.

Now, to those details.

What makes this situation complicated – hence the need for details – are two objectives that appear to work against one another, and two facts that are impossible to avoid.

1. The need to avoid relapse to opioid addiction.
2. The need to manage pain.
3. People with OUD are likely to be highly sensitive – or less tolerant – to pain than people without OUD.
4. A person on methadone needs a much higher than typical dose of opiate medication to feel any real pain relief.

First, we can be one-hundred percent clear that those first two objectives do not have to conflict: evidence shows that with full patient cooperation, and under the guidance and monitoring of a licensed and qualified physician, a person on MAT can use opioid medication for a brief period of time without getting high and without an increased risk of relapse.

Next, we can be one-hundred percent clear that those next two facts do not unequivocally prevent a person with an OUD who’s on MAT from using opiate pain relievers. It’s possible. But it requires a medical team that understands MAT, OUD, and addiction and recovery.

[Disclaimer: What follows is not medical advice. It’s information that explains the general guidelines around using opiate medications for people with OUD on MAT. This information can help patients and families understand the current state of knowledge about the subject. What follows is not medical advice.]

Communication, An Evidence-Based Plan, and Medical Monitoring: Managing Pain While on MAT

The overwhelming message from the sources we cite in this article is that it’s possible for people with OUD on MAT to use opiate medication for short periods of time, but it takes careful planning and open and completely transparent input from the patient, doctors, therapists, and counselors. In all cases, the effect of the plan on the following issues must be addressed and resolved before an individual who is stable on MAT uses opiate analgesics:

• Psychosocial problems, such as joblessness or homelessness
• Mental health disorders, such as anxiety or depression
• Nonopioid substance use disorders, such as alcohol use or illicit drug use

In addition, the following people should participate directly in creating a plan:

• A pain specialist
• The primary care physician
• Clinicians from the MAT program
• Addiction counselors who treat the patient
• Psychiatrists who treat the patient

Everyone should know what’s going on, everyone should be involved, and everyone should have input on how to best manage pain and avoid relapse.

It’s time to look at how it’s done, starting with methadone.

Methadone

• People on methadone who are considered stable take their typical daily dose the morning of the surgery or procedure.
• Anesthesiologists calculate the appropriate amount of different opiate medication than methadone and administer the medication before the surgery.
• In cooperation with the patient and medical team, the patient gradually reduces the amount of opioid medication need for analgesia in a process called weaning.
• During this period, the person on MAT continues all recovery activities, including counseling, support meetings, and top-line behaviors.
• The person on methadone returns to MAT as usual.

Buprenorphine

• The medical team, in cooperation with the person on MAT, should explore all nonopioid options first, including multimodal approaches, local/regional anesthesia, or a less painful surgical option, if possible.
• If the person on MAT and the medical team do not agree on nonopioid option, then buprenorphine is discontinued 2-5 days before surgery and replaced with methadone. The person on MAT then follows the process above.
• During this period, the person on MAT continues all recovery activities, including counseling, support meetings, and top-line behaviors.
• Once the weaning process is complete, the person on MAT discontinues methadone treatment and reinitiates buprenorphine treatment.

Naltrexone

• There is very little evidence on pain management related to surgeries for patients on Naltrexone.
• Therefore, the medical team, in cooperation with the person on MAT, should explore all nonopioid options first, including multimodal approaches, local/regional anesthesia, or a less painful surgical option, if possible.
• If the person on MAT and the medical team do not agree on nonopioid option, patients on extended release Naltrexone discontinue use 3-4 weeks before a planned surgery, with the surgery occurring in the 4^th Patients on daily Naltrexone discontinue use 24-72 hours before surgery.
• After surgery, and after the necessity for opioid analgesics passes, clinicians should carefully transition the patient back to Naltrexone to “prevent precipitating opioid withdrawal.”
• During this period, the person on MAT continues all recovery activities, including counseling, support meetings, and top-line behaviors.
• Once they transition back to Naltrexone under close medical supervision, the person returns to MAT as usual.

Pain Management While on MAT

In a perfect world, once a person with OUD finds a lifesaving treatment like methadone or buprenorphine and initiates MAT, they’d never take another opioid or opiate, ever. Our world is not perfect, though, and for some people, this is a bridge they must cross: they need to find a way to temporarily manage pain with opioid medication and do it without relapsing to opioid addiction. To summarize what we know about the topic:

1. It’s complicated, but it’s possible.
2. Evidence shows that it’s possible without increased risk of relapse to addiction.
3. For medical reasons, it’s more complicated for people on buprenorphine or Naltrexone than for people on methadone.
4. Since it can get complicated for people on buprenorphine or Naltrexone, clinicians recommend exploring all possible nonopioid pain management options available before using opioids for pain management.
5. The key is communication: everyone needs to know everything about the situation, including the patient and all relevant medical and addiction treatment clinicians and personnel.

We’ll add one more thing to that last point. The person with OUD does not stop addiction treatment at all when managing pain with opioid medications. Also, they do not interrupt their recovery. What changes is the medication. That’s a big deal, but it’s manageable, and it’s temporary. What we really want anyone reading this article to take away is that the person in recovery stays in recovery. If they go to counseling, they continue. If they go to community support meetings, they continue. And if there are any other recovery related activities or lifestyle changes they implemented when they initiated treatment, they continue doing those things, too. In fact, if possible, they do more of all those things to balance the change in routine. It’s imperative for the person on MAT and everyone involved to know what’s coming, to have a plan, to have contingencies, and to follow the plan as closely as possible and use contingencies if necessary.

When all of those condition are met – the “multidisciplinary collaborative approach” presented by the experts in the three sources we present at the beginning of this article – then using opiates to manage short-term pain for a person with OUD on MAT is both safe and effective.