Pain Management in OUD
Hey Team,
A recap from yesterday’s 7AM teaching point.
Source: South AM, Calcaterra SL, Martin M. Things We Do for No Reason™: Withholding opioids among patients with acute pain and opioid use disorder. J Hosp Med. 2026 Aug;21(8):928-931. doi: 10.1002/jhm.70295. Epub 2026 Feb 23. [pubmed]
Case: A 38-year-old woman with OUD (on Suboxone) falls off her bike and comes in with an obviously painful distal radius fracture. X-ray confirms a displaced radius fracture that requires reduction. She takes buprenorphine-naloxone 8–2 mg BID for OUD, has been stable on it for two years.
What’s your management plan?
Can you give her fentanyl or hydromorphone?
What do you do with her buprenorphine?
If I give someone with OUD hydromorphone, am I destabilizing their recovery?
What can we discharge this patient home on?
Key Point #1: Continue Buprenorphine
Don't stop it because the patient has acute pain.
Buprenorphine can be an analgesic, but its analgesic effect is much shorter—roughly 4–8 hours.
Can divide the patient's usual dose (if daily) into BID/TID dosing to improve analgesia
Maintenance buprenorphine alone may not adequately treat the new painful condition.
Key Point #2: It’s okay to give opioids in patients with OUD or on MOUD
Prescribing opioids for acute pain in those with OUD is safe and improves the patient experience.
If there is continued pain after multimodal analgesia, a full agonist opioid is appropriate.
Patients with OUD may have substantial opioid tolerance and can require higher doses than opioid-naïve patients.
For patients taking buprenorphine, hydromorphone or fentanyl are preferred because of their relatively high μ-receptor affinity.
Adding a short-acting opioid to someone already on a therapeutic dose of buprenorphine does not precipitate withdrawal.
Key Point #3: Treating pain isn’t “feeding the addiction”
Available evidence does not show that appropriately treating acute pain with opioids worsens OUD.
Undertreated pain and withdrawal are associated with self-directed discharge, in-hospital unprescribed opioid use, and deterioration of the patient-clinician relationship.
For those in the hospital, reducing opioid tolerance can decrease their opioid tolerance and worsen mortality.
Some institutions have buprenorphine microinductions, that allow for gradual uptitration of buprenorphine while still using full-opioid agonists.
Key Point 4: Having OUD changes how we dose and plan safely—it doesn't make their fracture hurt less.
Continue her buprenorphine.
Continue scheduled/non-opioid multimodal analgesia.
If the fracture is painful enough that you would ordinarily consider a short opioid course, OUD alone isn't a reason not to prescribe one.
Cheers,
Dillon
