BACKGROUND: Guidance on acute pain management among people with opioid use disorder (OUD) is limited.
PURPOSE: To synthesize evidence on the benefits and harms of acute pain interventions among people with OUD.
DATA SOURCES: APA PsycArticles, APA PsycInfo, APA PsycExtra, Allied and Complementary Medicine Database, CINAHL, Cochrane Library, Google Scholar, Ovid Embase, Ovid MEDLINE, PubMed, Scopus, and the Web of Science Core Collection through 7 July 2024.
STUDY SELECTION: Studies of any design that evaluated acute pain interventions among adults with OUD and included pain or OUD outcomes.
DATA EXTRACTION: Independent dual screening, single-investigator data extraction with verification, and dual quality and strength of evidence assessment.
DATA SYNTHESIS: Seventeen trials, 20 controlled observational studies, and 78 uncontrolled observational studies met eligibility criteria. Continuing use of buprenorphine during acute pain episodes may be associated with similar or improved pain-related outcomes versus discontinuing, based on cohort studies conducted primarily in perioperative settings. Single well-conducted randomized controlled trials in emergency department (ED) or perioperative settings in adults not prescribed medications for OUD suggest oral clonidine, intramuscular haloperidol and midazolam with intravenous (IV) morphine, and intraoperative IV lidocaine may improve pain outcomes and warrant study in diverse patient populations. Few studies evaluated methadone or the effect of interventions on OUD outcomes.
LIMITATIONS: Most evidence is observational and at risk of bias due to confounding. All studies were conducted in ED or hospital settings, most before widespread use of high-potency synthetic opioids or among non-U.S. populations using opium.
CONCLUSION: The overall evidence for pain outcomes in people with OUD is low. The effect of pain interventions on OUD outcomes is an important evidence gap.
PRIMARY FUNDING SOURCE: None. (Protocol registered a priori on Open Science Framework [https://osf.io/25hbs]).
| Discipline Area | Score |
|---|---|
| Physician |  |
| Nurse | |
Nurse rater
The overall evidence for pain management outcomes in people with opioid use disorder (OUD) is low. The effect of pain interventions on OUD outcomes is an important evidence gap. This systematic review is more important for acute pain researchers.
Nurse rater
This 'systematic review' included RCTs, controlled, and uncontrolled observational studies conducted in emergency departments or hospital settings. The 3 key questions were not resolved with a sufficient unbiased body of evidence or rigor to inform and change practice. This study contributes to awareness that therapeutic need for real-world evidence-based guidance on safe and effective acute pain management for people with opioid use disorder is needed, but sufficient unbiased evidence is lacking.
Physician rater
This review covered its limitations fairly well, highlighting current gaps in evidence. It is quite interesting that research on methadone is not as readily available compared with buprenorphine given the number of patients currently on methadone. With the current climate around OUD and the increase in fentanyl, I agree further research is needed on managing acute pain in patients with these current higher opioid doses.
Physician rater
My situation with this article is likely different than others. I am a Medical Examiner for a large county here, and the number of OD deaths have been significant since the Pandemic. I would say I clearly have a bias and that should be considered with my comments.
Physician rater
This study highlights the lack of evidence and the low quality of the available evidence, with much of it related to illicit opioids other than fentanyl. The paper provides very guarded support for the current practice of continuing methadone/suboxone and adding additional analgesia as indicated. Much more study is required.
Physician rater
Excellent review on a very important area for clinical practice. Unfortunately, the conclusions are limited by the available evidence.
Physician rater
Helpful article on a tough clinical issue.
, McMaster University