Acute Pain in Opioid-Tolerant Patients Requires Multimodal, Individualized Care

Pharmacy Times interviews Tanya J. Uritsky, PharmD, BCPP, FPPCP, FASHP, opioid stewardship coordinator at the Hospital of the University of Pennsylvania, about the challenges of managing acute pain in patients who are opioid-tolerant or receiving buprenorphine or methadone.

Uritsky explains that these patients may have substantial opioid tolerance, which can reduce their response to standard opioid doses. Although this does not mean opioids should be withheld, clinicians should recognize that simply escalating doses may eventually produce diminishing returns. Appropriate opioid dosing remains important because opioid-tolerant patients are also at risk of being undertreated when clinicians are uncomfortable prescribing the doses needed to achieve an analgesic effect.

For this reason, Uritsky emphasizes the importance of multimodal analgesia. Treatment may include nonsteroidal anti-inflammatory drugs, acetaminophen, ketamine, and other appropriate therapies that target pain through different mechanisms. This approach can help improve analgesia without relying exclusively on further opioid escalation.

Patients who are actively using illicit fentanyl may require additional monitoring for withdrawal, including withdrawal associated with contaminants or adulterants such as xylazine and medetomidine. Clinicians should also continue to evaluate and treat withdrawal risk throughout the acute pain episode.

Uritsky notes that medications for opioid use disorder should generally be managed carefully rather than abruptly discontinued. Buprenorphine may often be continued, and the dosing intervals of buprenorphine or methadone may sometimes be divided temporarily to provide greater analgesic benefit under appropriate clinical supervision.

She also stresses that standardized, evidence-based pathways can improve consistency and reduce the effects of stigma. Although protocols cannot eliminate bias, they can help ensure that patients with opioid tolerance or opioid use disorder receive the same evidence-based practices as other patients. Overall, effective acute pain care in these populations requires adequate dosing, multimodal treatment, withdrawal monitoring, continued management of medications for opioid use disorder, and individualized clinical judgment.