Managing Acute Pain in Patients on Medication-Assisted Treatment: A Practical Emergency Department Framework

AUSTIN, TX — Managing acute pain in patients on medication-assisted treatment (MAT) presents a complex clinical task for emergency medicine providers. In today’s session, at the American Academy of Pain Medicine PainConnect 2025 annual meeting in Austin, TX, Paul DeJulio, MD, assistant clinical professor in the Center for Pain Management at UC San Diego Health, offered a focused, practical framework for addressing pain in patients on buprenorphine, methadone, or naltrexone.

In his session, Dr DeJulio provided an overview of three types of MATs: buprenorphine, methadone, or naltrexone. Buprenorphine, a partial mu-opioid receptor agonist with high binding affinity, is frequently encountered in the emergency department (ED), according to Dr DeJulio. Due to its pharmacologic properties—including a ceiling effect on respiratory depression and prolonged receptor occupancy—it can blunt the effects of additional opioids. Still, for acute pain, current evidence and expert consensus recommend continuing buprenorphine at the home dose, especially for those on chronic maintenance. Options to enhance analgesia include dividing the daily dose into 6 to 8 hour intervals or increasing the total daily dose. If further pain relief is needed, full mu-opioid receptor agonists with high binding affinity (eg, hydromorphone, fentanyl) may be added. Stopping buprenorphine, while previously considered standard, is now discouraged due to increased relapse risk and the complexity of reinitiation​.

“Stopping buprenorphine can increase risk of OUD relapse and death,” Dr DeJulio said. “As the literature states, do not stop buprenorphine if this type of patient is in your emergency department.”

Methadone, another long-acting opioid used for opioid use disorder and chronic pain, presents its own challenges. It has NMDA antagonist and SNRI properties and complex pharmacokinetics. In the ED, methadone should be continued at the patient’s usual dose and may be administered in divided doses for enhanced pain control. Due to its accumulation risk and QTc prolongation, dose increases are not recommended without specialist input.

Naltrexone, an opioid antagonist, should be held in the ED during acute pain episodes, as its prolonged receptor blockade (24 to 48 hours) can interfere with opioid analgesia. Patients with recent naltrexone exposure may need higher opioid doses to overcome receptor antagonism. Low-dose naltrexone use for pain is considered investigational and not recommended in acute care settings.

Dr DeJulio underscoreed a multimodal pain strategy as the cornerstone of acute pain management in patients on MAT. Non-opioid medications such as acetaminophen, NSAIDs, gabapentinoids, and ketamine are emphasized, along with regional and interventional techniques like erector spinae plane blocks, caudal epidural steroid injections, and trigger point injections. These approaches can reduce opioid needs while ensuring adequate pain relief.

Reference
DeJulio P. ED Pain Management in Patients Taking MAT Meds. Presented at: American Academy of Pain Medicine PainConnect 2025. Accessed April 3, 2025. https://painconnect.org/