Authors: Virno T et al.
Cureus 17(10): e95044, October 2025. DOI: 10.7759/cureus.95044
This review addresses the growing ethical challenges of managing acute pain in patients with opioid use disorder (OUD) amid the ongoing opioid epidemic. Clinicians are often caught between the need to provide adequate pain relief and the obligation to prevent relapse or misuse. Historically, stigma and fear of addiction have led to undertreatment, yet evidence now shows that inadequate analgesia can worsen outcomes and destabilize recovery.
The authors propose an ethical framework grounded in autonomy, beneficence, nonmaleficence, and justice. They advocate for continuation of medications for opioid use disorder (MOUD)—such as buprenorphine and methadone—during the perioperative period, supported by regional anesthesia, non-opioid pharmacologic adjuncts, and non-pharmacologic therapies. The review notes that discontinuing MOUD can lead to withdrawal, relapse, and mistrust, violating ethical principles of harm avoidance and justice.
Regional anesthesia and multimodal strategies, including ketamine, dexmedetomidine, IV acetaminophen, NSAIDs, and gabapentinoids, are highlighted as key components of ethical and effective pain management. These interventions reduce acute pain, lower the risk of chronic opioid dependence, and align with the principles of beneficence and patient-centered care. The authors also emphasize the importance of patient autonomy when offering opioid-free anesthesia (OFA), cautioning that clinicians should avoid rigid or paternalistic approaches.
Finally, the article underscores systemic barriers—stigma, limited training, and institutional inertia—that perpetuate inequitable care. The authors call for policy reforms, interdisciplinary collaboration, and education to ensure ethical, evidence-based pain management for individuals with OUD.
What You Should Know:
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Effective pain care for patients with OUD requires balancing analgesia and addiction stability through multimodal, individualized strategies.
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Continuation of buprenorphine or methadone during acute pain episodes is both ethically and clinically preferred.
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Regional anesthesia and opioid-sparing adjuncts reduce risk of misuse and support recovery.
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Ethical principles demand respect for autonomy, avoidance of harm, and equity in access to compassionate pain management.
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Institutional protocols and education are essential to reduce stigma and improve consistency in care.
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