Acute Pain Management in People With Opioid Use Disorder : A Systematic Review

Abstract

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]).