Background:
The objective of these
guidelines is to assist providers in managing acute and perioperative pain
patients admitted to UK on medication-assisted treatment (MAT) for opioid use
disorder.
General Principles:
·
Continue buprenorphine and methadone therapies as
prescribed whenever safely possible since stopping these therapies may put long
term recovery from opioid use disorder at risk.
·
Contact the patient’s primary prescriber of MAT
to obtain the most recent dose and inform the provider that the patient is/may
be hospitalized and therefore may miss appointments.
·
Consider pre-operative or admission urine
toxicology screen. If drugs of abuse are confirmed, consultation with the
patient’s MAT prescriber is recommended prior to continuation of MAT.
·
Patients may require higher than normal doses of
short-acting opioids as a result of chronic buprenorphine or methadone therapy.
Acute opioids may be titrated to CPOT/VAS for adequate analgesia; long acting
opioids should not be titrated to analgesia. As pain resolves, consider
de-escalating doses and frequencies of adjunct opioids until they can safely be
discontinued.
·
All patients are candidates for multi-modal pain
management as clinically appropriate with agents such as:
o Acetaminophen
(APAP)
o Non-steroidal
anti-inflammatories (NSAIDs)
o Membrane
stabilizers (e.g., gabapentin, pregabalin)
o Ketamine
as clinically appropriate
o Alpha
2 agonists (e.g., dexmedetomidine, clonidine)
o Topical
anesthestics (e.g., transdermal lidocaine)
o Regional
anesthesia
o Neuraxial
analgesia / spinal epidural
Pre-operative Planning:
During the pre-operative
stages for planned procedures and admissions:
·
Have pain management plan prepared and discuss
pain management expectations
·
Provide written instructions of this plan and
document in the medical record
·
Ensure plans are available to inpatient care
providers
·
If therapies for opioid use disorder are to be
stopped, make sure the provider managing the patient’s opioid use disorder is
aware to assist in developing a plan to resume therapy
Discharge Planning:
·
Attempt to limit concomitant opioid prescribing
as possible depending on clinical status.
·
MAT is not a contraindication to prescription of
analgesics on discharge, and additional analgesics may be prescribed as needed.
·
Unless patients have naloxone available,
discharge prescription of naloxone is recommended in patients leaving on MAT.
Methadone:
·
Continue prior to admission dosing of methadone
during perioperative and post-operative period
o If
patient NPO, convert to IV methadone. Consider acute pain service or clinical
pharmacist consultation for dosing assistance.
·
Other opioids may be added for new acute pain
and tapered off as pain resolves
o If
mild pain: consider APAP / NSAIDs for break through pain
o If
moderate pain: consider adding PRN opioids + acute pain service consult
o If
severe pain: consider consulting acute pain service
·
Monitoring:
o EKG
at baseline
§ Repeat
EKG if concomitant agents that may prolong QTc are initiated or clinical
suspicion of arrhythmia
o BMP/CMP
with magnesium level as clinically indicated
·
Pearls:
o Equipotent
dosing of methadone to other opioids is challenging – consider consult acute
pain services for assistance in dosing.
o If
methadone is converted to equipotent doses of other analgesics, resuming the
same home dose of methadone may not work the same. Contact the acute pain
service or the patient’s outpatient clinic for guidance on how to resume
methadone and to confirm outpatient dosing.
o Methadone
dosing should NOT be adjusted to treat acute pain
o For
ambulatory or elective procedures, any additional opioids should preferably be
tapered/discontinued within 3-5 days post-operatively
Buprenorphine:
Converting from a patient’s
dosage form to UK’s formulary agent can be challenging
Non-Formulary Product
|
Equipotent Suboxone® Dose
|
Zubsolv® SL tablet
|
|
0.7/0.18mg
|
1/0.25mg
|
1.4/0.36mg
|
2/0.5mg
|
2.9/0.71mg
|
4/1mg
|
5.7/1.4mg
|
8/2mg
|
8.6/2.1mg
|
12/3mg
|
11.4/2.9mg
|
16/4mg
|
Bunavail® buccal film
|
|
2.1/0.3mg
|
4/1mg
|
4.2/0.7mg
|
8/2mg
|
6.3/1mg
|
12/3mg
|
Buprenorphine is also
available as a subdermal implant (PROBUPHINE®, total 74.2mg buprenorphine over
up to 6 months). Removal of the buprenorphine implant during hospitalization or
preoperatively is not recommended without explicit discussion with the prescriber.
Consultation with the provider/clinic regarding date of implantation is
recommended. Acute pain consultation may be beneficial.
·
Pearls:
o Total
daily buprenorphine doses can be divided and administered every 6-8 hours for
pain management if needed
o Additional
opioids can be administered with buprenorphine.
o On
discharge, if patient’s buprenorphine has been held for > 5 days AND if they
continue to require opioid therapy for acute pain, continue acute pain regimen
of opioids until outpatient follow up with addiction specialist. This follow up
appointment should be arranged as soon as possible after discharge to
facilitate resuming buprenorphine therapy. Consult service line social worker
for assistance with this.
o In
patients resuming buprenorphine therapy prior to discharge after a period of
abstinence from buprenorphine, consult the guidelines for buprenorphine induction.
Naltrexone:
·
Dosage formulations:
o 50
mg tablets
o 390
mg IM depot injection (given every 4 weeks)
·
Pearls
o Binds
competitively to mu receptor but does not activate mu receptor, thereby
blocking opioid analgesia
o Discontinue
use in the post-operative period
o For
non-emergent surgeries and procedures, attempt to schedule surgery at the END
of the dosing cycle if patient is receiving the IM depot formulation of
naltrexone
o For
non-emergent surgeries and procedures, attempt to wait 24 hours if patient is
using oral tablet formulations
o Restart
naltrexone once abstinence from post-operative opioids is appropriate, generally
7-10 days after last short-acting full opioid agonist (consider active
metabolites of opioids used to manage post-operative pain)
o Optimize
multi-modal analgesia whenever possible.
o Acute
pain service consultation is strongly recommended.
Posted 5/7/17 (A Bernard/D Oyler); Reviewed 9/26/24 (A Bernard)
