Opioid Use Disorder

Elizabeth Briand

For patients already coping with OUD, pain management during hospitalization can pose additional risks. An article in the May 2024 issue of NEJM Evidence offers clinicians recommendations for managing acute pain in hospitalized patients with OUD who are already being treated with buprenorphine.

When someone with OUD who is taking buprenorphine is hospitalized, there is a risk that attempts to manage pain could result in a disruption to their buprenorphine regimen. “Hospitals have been described as a ‘risk environment’ for people who use drugs,” wrote authors of the study. “Uncontrolled opioid withdrawal or inadequate pain control among hospitalized patients with OUD is associated with patient-directed discharge.”

Increasingly, prescribers are turning to buprenorphine to treat their patients for OUD. When taken regularly, buprenorphine reduces overdose deaths by approximately 50% compared with no treatment. As a result, the medication’s use has more than doubled over the last 10 years.

That growth likely will continue following the federal government’s removal in 2022 of training requirements to prescribe the medication.

Risk of stopping buprenorphine

FDA has approved three medications for OUD: buprenorphine, methadone, and naltrexone. 

“Both buprenorphine and methadone bind to opioid receptors, so the person doesn’t have to go through withdrawal,” said study coauthor Susan Calcaterra, MD, associate professor of medicine at the University of Colorado School of Medicine. “It is also long acting and lasts from 24 to 36 hours so it lets people live their lives.”

Stopping buprenorphine during a hospital stay can cause significant and potentially life-threatening results, mostly for patients who discharge themselves due to inadequate pain management or disagreements with their care teams.

“People have a massive opioid deficit along with their acute pain and so they leave the hospital, their medical problem was not addressed, and they return to drugs and overdose,” said Calcaterra.

“[Stopping buprenorphine] increases mortality, increases costs, and is not patient centered.”

Keeping OUD care on track

Instead, Calcaterra recommends a team-based approach to pain care that includes surgery, anesthesiology, and addiction specialists along with the patient. Ideally, planning occurs before any scheduled surgery or procedure that will require pain management. That planning should include the patient’s personal goals regarding the use of full agonist opioids, a discussion on pain expectations, and a tentative opioid taper plan to gain the patient’s buy-in.

Pain management approaches will vary based on the individual case, but “if a patient is stable on buprenorphine when they come into the hospital and have an episode of acute pain, [there needs to be] a talk about staying on it,” said Calcaterra.

Subsequent plans of care can include split dosing of buprenorphine as well as the use of nonopioid analgesics, nonpharmacologic pain measures, and full agonist opioids, according to Calcaterra. Conversations should be ongoing with the patient to determine their pain levels and response to treatment.

Hospital pharmacists can help ensure successful pain management for patients with OUD by asking questions. If a patient who was clearly taking buprenorphine before their hospital admission has suddenly stopped, the pharmacist can check on whether that cessation was at the request of the patient or if it was stopped by the medical team. If it was not the patient, “then they can let the physician know this isn’t the standard of care,” said Calcaterra.

In the past, clinicians may have balked at maintaining buprenorphine while also treating pain with full agonist opioids. “There was a hesitancy because we [physicians] have been told we caused opioid use disorder in the 1990s, so it’s been a pendulum swing the other way,” said Calcaterra. “There is apprehension among some people that they’re making [the addiction] worse.”

Calcaterra said it should be up to the patient when to stop taking buprenorphine. For patients with OUD, buprenorphine stabilizes them enough to have a life—hold down a job, have housing—until they can fully address their addiction, according to Calcaterra. “They need to get to a place where if something happens in their lives, they won’t think of opioids as the first place to turn,” said Calcaterra. ■