If the patient is on methadone maintenance there are some important considerations for the treatment of acute pain including post-operative pain:

For Suboxone maintenance scroll down

1) Methadone maintenance does not provide analgesia – it fulfills the patient's baseline opioid requirements. These patients have an opioid deficit that must be filled in order for them to function. Analgesic requirements are additional.

Reference – Patients who are physically dependent on opioids must be maintained on daily equivalence before any analgesic effect is realized with opioids for acute pain mangement

from Peng PWH, Tumber PS, & Gourlay D. Review article: Perioperative pain management of patients on methadone therapy. Canadian Journal of Anesthesia. 2005; 52(5):513-523.

2) It is appropriate to use additional opioids to treat acute pain in patients on methadone maintenance.

Reference -"Providing rapid and effective relief of pain remains a humanitarian issue, whereas allowing patients to suffer as a result of analgesic undermedication may be considered a breach of fundemental human rights"

from Mitra & Sinatra R. Review article: Perioperative pain management of of Acute Pain in the Opioid Dependent Patient. Anesthesiology. 2004; 101:212 – 27

Reference -"Undertreatment of acute pain is suboptimal medical treatment, and patients on long term opioid maintenance therapy are at particular risk"

from Alford D et al. Acute Pain Management for Patients receiving Maintenance Methadone or Buprenorphine Therapy. Annals of Internal Medicine. 2006; 144(2):127-134.

3) Patients on opioid maintenance may require significantly higher doses of opioids to achieve analgesia because of receptor down-regulation and other factors.

Reference -"opioid doses required to meet intraoperative and post surgical analgesia requirements may need to be increased 30-100% in comparison with requirements in opioid naive patients"

from Mitra & Sinatra R. Review article: Perioperative management of Acute Pain in the Opioid Dependent Patient. Anesthesiology. 2004; 101:212 – 27.

Reference -"Pharmacological approaches incorporate the continuation of maintenance medications, short term use of sometimes much higher than average doses of additional opioid and prescription of non-opioid and adjuvant drugs"

from Huxtable C et al. Review article: Acute pain management in opioid-tolerant patients. Anesthesia and Intensive Care. 2011; 39:804 – 823.

4) Admitted patients (or patients held past the time they would take their maintenance medication) should receive their usual on opioid maintenance daily including pre-operatively.

Reference -"Recovering addicts enrollled in a methadone maintenance program or receiving buprenorphine maintenance should continue taking those medications with one sip of water on the morning of surgery"

from Mitra & Sinatra R. Review article: Perioperative management of Acute Pain in the Opioid Dependent Patient. Anesthesiology. 2004; 101:212 – 27.

Reference -"The appropriate treatment of acute pain in paitients receiving opioid maintenance therapy includes uninterrupted maintenance therapy"

from Alford D et al. Acute Pain Management for Patients receiving Maintenance Methadone or Buprenorphine Therapy. Annals of Internal Medicine. 2006; 144(2):127-134.

5) Not treating or inadequately treating acute pain in opioid maintained patients with opioid analgesics when indicated is more likley to lead to relapse than providing adequate doses of opioid analgesics. This includes providing oral opioids for discharged patients where indicated. Please see Writing an Opioid Rx.

Reference -"there is no evidence that exposure to opioid analgesics in the presence of acute pain increases rates of relapse" in opioid maintained patients

Reference -"the stress associated with unrelieved pan is more ikely to be a trigger for relapse than adequate analgesia"

both from Alford D et al. Acute Pain Management for Patients receiving Maintenance Methadone or Buprenorphine Therapy. Annals of Internal Medicine. 2006; 144(2):127-134.

 

The 5 considerations listed above also apply if the patient is on Suboxone maintenance. 

In addition, what we thought we knew about buprenorphine interfering with opioid analgesia is not correct. Current evidence about managing pain in Suboxone maintained patients suggests:

1) Buprenorphine does not prevent opioid analgesics from being effective. Therefore Suboxone maintenance should be continued and opioid analgesics should be used for acute pain. However, as with methadone maintenance, patients on Suboxone maintenance require higher doses of opioid analgesia that opioid naive patients.

Reference -"The appropriate treatment of acute pain in paitients receiving opioid maintenance therapy includes uninterrupted maintenance therapy"

from Alford D et al. Acute Pain Management for Patients receiving Maintenance Methadone or Buprenorphine Therapy. Annals of Internal Medicine. 2006; 144(2):127-134.

Reference -"opioid doses required to meet intraoperative and post surgical analgesia requirements may need to be increased 30-100% in comparison with requirements in opioid naive patients"

from Mitra & Sinatra R. Review article: Perioperative management of Acute Pain in the Opioid Dependent Patient. Anesthesiology. 2004; 101:212 – 27

Reference – there was no difference between buprenorphine and methadone maintained patients in the efficacy or dose of PCA opioids required to relieve post operative pain

from MacIntyre P et al. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anesthesia and Intensive Care. 2013; 41:222-230

Reference -"Our data suggets that methadone and buprenorphine maintenance interferes with the analgesic effects of supplemental opioids to a similar degree in post-operative patients" 

from Meyer et al. Intra partum and post partum analgesia for women maintained on buprenorphine during pregnancy. European Journal of Pain. 2010; 14:939-p43