Opioid use disorder and chronic pain: MOUD and acute pain

When opioid use disorder appears, treat it with medication, not detoxification alone. Keep buprenorphine or methadone going through acute pain and surgery, add analgesia on top, and never make pain treatment conditional on entering treatment.

1. Offer medication for opioid use disorder. CDC 2022 Recommendation 12 (category A) says to offer or arrange buprenorphine or methadone; detoxification alone raises the risk of return to use, overdose and overdose death ¹.
2. No waiver is needed for buprenorphine. Since the 2023 MAT Act, any practitioner with a DEA registration that includes Schedule III authority may prescribe buprenorphine for OUD if state law allows; the X-waiver and patient limits are gone ².
3. Continue buprenorphine through surgery. A multisociety panel reached full consensus that buprenorphine should not be routinely stopped perioperatively, because interruption risks recurrence and overdose; add multimodal analgesia and titrated full agonists on top ³.
4. Methadone maintenance does not cover acute pain. The label states maintenance patients need analgesics at doses indicated for patients not on methadone, often higher or more frequent, while the usual dose continues ⁴.
5. Active, untreated OUD still gets analgesia. Meet the baseline requirement plus extra opioid for acute pain with nonopioid and regional techniques ⁵, and consider buprenorphine or methadone, which also help pain ¹.
6. Pregnancy: continue agonist therapy. SAMHSA says pharmacotherapy is the standard of care and medically supervised withdrawal is not recommended; neonatal withdrawal severity does not track the maternal dose ⁶.

Stopping maintenance buprenorphine or methadone before surgery, or abruptly in pregnancy, invites withdrawal, relapse and overdose; continue it and plan analgesia around it ³⁶.

• CDC Recommendation 12: offer or arrange MOUD for patients with opioid use disorder (category A, evidence type 1) ¹.
• The multisociety panel also endorsed starting buprenorphine perioperatively in untreated OUD ³.
• For buprenorphine patients with acute pain, CDC notes dosing frequency can be temporarily increased, for example to twice daily ¹.
• Methadone patients needing extra opioids should be monitored closely, ideally with their opioid treatment program ¹.
• The MATE Act added a one-time 8-hour substance use disorder training requirement for DEA registrants ⁷.
• Infants exposed to opioids in pregnancy should be monitored for neonatal abstinence syndrome by a pediatric care provider ⁸.
• In supervised settings, a short-acting full agonist can be added to the regular buprenorphine dose for severe acute pain ¹.

• Choosing detoxification alone as treatment for OUD, which raises the risk of return to use and overdose death ¹.
• Assuming the methadone maintenance dose will cover postoperative pain ⁴.
• Reducing methadone in pregnancy to protect the newborn ⁶.
• Making analgesia conditional on a patient agreeing to start addiction treatment, which leaves a tolerant patient undertreated and at risk of withdrawal ⁵.