Authors: Virno T et al.
Cureus. October 21, 2025. DOI: 10.7759/cureus.95044
Summary:
This review addresses the ethical and clinical challenges of managing acute pain in patients with opioid use disorder (OUD). The opioid epidemic has intensified dilemmas around balancing adequate pain control with the risk of relapse, misuse, and worsening addiction. Historically, patients with OUD have been undertreated due to stigma and clinician fear, yet untreated pain itself can cause harm, worsen outcomes, and erode trust. The authors integrate ethical principles and current evidence to propose a framework for equitable and patient-centered acute pain management.
The review emphasizes that ethical care must align with the principles of autonomy, beneficence, nonmaleficence, and justice. Many patients with OUD face structural barriers, stigmatizing interactions, and fragmented care, making them vulnerable to both undertreatment and iatrogenic harm. Evidence identifies several risk factors for prolonged opioid use after surgery—including psychiatric comorbidities, tobacco use, obesity, PTSD, and existing substance use disorders—which help guide targeted interventions and highlight the need for psychological and behavioral support.
A major focus is the perioperative management of medications for opioid use disorder (MOUD), especially buprenorphine and methadone. Traditional practice often discontinued MOUD perioperatively, but growing evidence supports continuation to avoid withdrawal, destabilization, and relapse. Continuation of buprenorphine—sometimes with dose adjustments to 8–12 mg per day—is increasingly viewed as clinically effective and ethically preferred when paired with multimodal analgesia. Methadone should also typically be continued due to overdose risk associated with missed doses.
The review strongly supports regional anesthesia and multimodal analgesia as foundational strategies for providing adequate pain control while avoiding excessive opioid exposure. Evidence shows that nerve blocks, neuraxial techniques, ketamine, dexmedetomidine, NSAIDs, acetaminophen, and other non-opioid adjuncts reduce acute pain, lower opioid requirements, and decrease the risk of persistent postoperative opioid use. Non-pharmacologic methods (e.g., TENS, aromatherapy, relaxation techniques) offer additional benefit, especially when anxiety and psychosocial factors are involved.
The authors also examine controversies around opioid-free anesthesia (OFA). Although OFA may reduce opioid exposure and align with harm-reduction principles, it must be individualized. Respect for patient autonomy is emphasized; some patients may prefer traditional approaches or may not be candidates for certain regional techniques. Clinician discomfort, institutional variability, and stigma remain major barriers to equitable care.
Ultimately, the review advocates for individualized, multimodal, ethically grounded pain plans that preserve MOUD, incorporate regional and non-opioid strategies, and deliberately counter stigma. Effective management requires interdisciplinary collaboration, systems-level reforms, and ongoing research.
What You Should Know
• Patients with OUD frequently face undertreated pain due to stigma and fear of misuse, yet inadequate analgesia itself is harmful.
• Ethical care must incorporate autonomy, beneficence, nonmaleficence, and justice while avoiding punitive or stigmatizing treatment decisions.
• Continuation of buprenorphine and methadone during the perioperative period is increasingly supported by evidence and reduces relapse risk.
• Regional anesthesia and multimodal analgesia are essential components of safe, effective pain management for patients with OUD.
• Psychiatric comorbidities and behavioral vulnerabilities increase the risk of prolonged opioid use after surgery and should guide individualized care.
• Opioid-free anesthesia may be appropriate for some patients, but technique selection must respect patient preferences and clinical context.
• Stigma, systemic barriers, and inconsistent protocols remain major obstacles and require institutional and policy-level solutions.
Key Points
• Ethical pain management in OUD requires balancing effective analgesia with addiction stability while avoiding stigmatizing practices.
• Continuation of MOUD (buprenorphine, methadone) is generally safer and more ethical than perioperative discontinuation.
• Regional anesthesia and multimodal strategies reduce opioid exposure and improve outcomes for high-risk patients.
• Psychiatric and psychosocial factors significantly influence vulnerability to persistent opioid use.
• Opioid-free or opioid-sparing techniques can be beneficial but must be individualized and support patient autonomy.
• Interdisciplinary collaboration and institutional reform are necessary to deliver equitable, stigma-free pain care.
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