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

Summary

This preregistered systematic review (115 studies) suggests that continuing buprenorphine during acute pain—often perioperatively—yields similar or improved pain outcomes compared with discontinuation. Limited RCT evidence indicates clonidine, haloperidol plus midazolam with IV morphine, and intraoperative IV lidocaine may improve acute pain outcomes; effects on OUD outcomes remain largely unstudied.

Key Findings

• Across cohort studies, continuing buprenorphine during acute pain was associated with similar or improved pain outcomes versus discontinuation.
• Single RCTs suggest oral clonidine, IM haloperidol plus midazolam with IV morphine, and intraoperative IV lidocaine can improve acute pain outcomes.
• Evidence on methadone and on the impact of acute pain interventions on OUD outcomes is scarce, highlighting critical research gaps.

Clinical Implications

Perioperative teams should consider continuing buprenorphine during acute pain episodes and evaluate multimodal adjuncts (e.g., clonidine, intraoperative IV lidocaine) while recognizing the paucity of data on methadone and long-term OUD outcomes.

Limitations

• Most included studies were observational with confounding risk
• Settings largely ED/hospital and pre–high-potency synthetic opioid era or non-U.S. opium-using populations

Future Directions

Conduct pragmatic RCTs in contemporary perioperative settings (including methadone-treated patients) and measure both pain and OUD outcomes, including relapse and treatment retention.