29 Dec Managing acute pain when on Suboxone or Methadone

Today one of my patients told me that they had a kidney stone attack and was in severe pain.  He went to the hospital and the ER doctor was not sure how to manage his pain.  It turns out that physicians have a very limited comfort zone with these drugs—and plenty of misconceptions.

“Hospitalists and In-patient physicians would be wise to call patients’ methadone clinic and verify their dosing history.”—Dr. Jameet Bawa, MD Horizons – Opioid Treatment Service

That confusion is understandable,given the dense regulations governing these drugs’ clinical use. Part of the confusion is due to the fact that different rules govern where and how methadone and buprenorphine may be used and by whom. Another problem: Because sublingual buprenorphine is a newer agent, doctors have limited clinical experience with it.
What should doctors do for patients on a maintenance opioid agent to provide pain relief?  Luckily for this patient, we had already had this conversation and he was able to inform his treating doctor of the acute pain management plan.

The very simple answer is that physicians should treat you as if you were not Suboxone or Methadone.  So for example, if you break your arm and the doctor would normally give you morphine, the doctor should do that.  If you are going in for day surgery and the doctor would normally give you percocet, than that is what you should get.  Now this is very simplistic approach and there are exceptions and modifications that must be consider.  If the treating doctor has any questions or concerns than encourage them to call your methadone or suboxone provider as they are experts in theses medications and they also know you the best.

Managing acute pain syndromes in methadone-maintained patients is a lot like diabetes management “Methadone or buprenorphine is the equivalent of basal insulin,” explains Dr. David Frenz, MD, medical director for addiction medicine for the HealthEast Care System in St. Paul, Minn

Hospitalists should administer the regular methadone dose for maintenance only, adding another opioid—ideally used in combination with NSAIDs and acetaminophen, to reduce total opioid needs—in high-enough doses to control pain. Dr. Frenz notes that opioid-tolerant patients will require greater-than-usual doses of a supplemental opioid compared to those who are opioid-naive. “As the doses can be substantial, hospitalists and surgeons should consider consulting with someone familiar with opioid management,” he says. “In our health care system, those consultations are fielded by the palliative medicine and addiction medicine services.” As long as doses are titrated carefully and patients are monitored, physicians don’t need to worry about putting patients at higher risk for respiratory or central nervous system depression.

Studies have shown that patients with addiction or dependence can tolerate the drugs’ depressant effects quickly when higher doses are used for pain control. And experts say that hospitalists shouldn’t be overly concerned about worsening or rekindling a patient’s addiction. “There’s something funny about acute pain that attenuates the rewarding properties of opioids,” Dr. Frenz explains. “Patients receive analgesia but not euphoria.” Nor are patients on opioid agonist therapy at significant risk for relapse because they’ve received opioid analgesics for acute pain. Instead, some research suggests that under-treating pain in patients with addiction may pose a greater relapse risk because of the stress associated with that untreated pain.  However, it is wise to avoid the drug that the person was dependent on if possible.