Limited evidence supports continuing buprenorphine for acute pain in patients with OUD
Available evidence supports the current best practice of continuing buprenorphine during episodes of acute pain for people with opioid use disorder (OUD) already prescribed this medication, a systematic review of 115 studies concluded.
There is an important evidence gap regarding the effect of pain interventions on outcomes of opioid use disorder (OUD), according to a systematic review that found scant overall evidence on this question.
Researchers searched 12 databases for studies that evaluated acute pain interventions in adults with OUD and included pain or OUD outcomes. A total of 17 clinical trials, 20 controlled observational studies, 24 uncontrolled observational studies or case series (consisting of at least five participants), and 54 case reports or series (fewer than five participants each) were included in the review. Findings were published by Annals of Internal Medicine on March 18.
Data from 10 controlled cohort studies, conducted primarily in perioperative settings, showed that continuing buprenorphine during acute pain episodes may be associated with similar or improved pain-related outcomes versus discontinuing. For adults not prescribed medications for OUD, oral clonidine, intramuscular haloperidol and midazolam with IV morphine, and intraoperative IV lidocaine may improve pain outcomes, according to single well-conducted randomized controlled trials in ED or perioperative settings. However, this finding warrants study in diverse patient populations, the researchers noted. Few studies included in the review evaluated methadone or the effect of interventions on OUD outcomes.
Limitations to the review include that most evidence was observational and at risk of bias. All included studies were carried out in an ED or hospital, and most were conducted prior to widespread use of high-potency synthetic opioids.
Researchers speculated that similar or improved pain associated with buprenorphine continuation may be due to the treatment's analgesic properties and its role in preventing pain related to opioid withdrawal. “This finding is relevant to all inpatient and outpatient clinical scenarios in which pain and opioid withdrawal are possible,” they wrote. However, their overall confidence about the effects on pain of buprenorphine continuation is low, due largely to methodological limitations of the studies, including risk of bias due to confounding among cohort studies.
More research is also needed to determine if the findings on buprenorphine continuation apply to patients prescribed higher doses, they said.
An accompanying editorial highlighted that the review found no studies on dose or frequency adjustments for buprenorphine or on adults taking sublingual doses above 16 mg or long-acting injectable buprenorphine, in addition to the gap in research on acute pain interventions for adults prescribed methadone or naltrexone.
“Given the lack of evidence of harm, we believe the findings presented in this review are sufficient to recommend continuing to follow previously published expert opinion-based guidelines on treating patients with OUD and severe acute pain,” the editorialists wrote. This includes employing a shared decision-making model, using multimodal therapy, and continuing medication for OUD in patients prescribed it with short term full-agonist opioids as needed, they said.