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Special Populations
Î Use of naloxone challenge to test for opioid dependence and risk of
precipitated withdrawal is NOT recommended for pregnant women
with OUD.
Î Unless otherwise contraindicated, mothers receiving methadone
or buprenorphine for treatment of OUDs should be encouraged to
breastfeed. And policies allowing for rooming in should be encouraged
for hospitals taking care of infants at risk for neonatal withdrawal.
Individuals with Pain
Î For all patients with pain, it is important that the correct diagnosis is
made and that pain is addressed.
• Alternative treatments including non-opioid medications with pain modulating
properties, behavioral approaches, physical therapy, and procedural approaches
(e.g., regional anesthesia) should be considered before prescribing opioid
medications for pain.
Î If pharmacological treatment is considered, non-opioid analgesics,
such as acetaminophen and NSAIDs, and non-opioid medications with
pain modulating properties should be tried first.
Î For patients with pain who have an active OUD but are not in
treatment, methadone or buprenorphine should be considered.
• The patient's OUD and pain should be stabilized and managed concurrently.
Î MAJOR REVISION – For patients taking methadone or buprenorphine
for the treatment of OUD, temporarily increasing the dose or dosing
frequency (i.e., split dosing to maximize the analgesic properties of
these medications) may be effective for managing pain. (Titration of
methadone should follow the guidance on pages 8–9 of this pocket
guide.)
Î MAJOR REVISION – For patients taking methadone for the treatment
of OUD who have acute pain refractory to other treatments and require
additional opioid-based analgesia, adding a short acting full agonist
opioid to their regular dose of methadone can be considered to
manage moderate to severe acute pain.
• The dose of additional full agonist opioid analgesic prescribed is anticipated to be
higher than the typical dose necessary to achieve adequate analgesia in opioid-
naïve individuals.
Î NEW – Patients receiving buprenorphine for OUD who have moderate
to severe acute pain refractory to other treatments and require
additional opioid-based analgesia may benefit from the addition of as-
needed doses of buprenorphine.
