The Pain Contract Dilemma
A 34-year-old woman with opioid use disorder (fentanyl, intranasal, daily) has been stable on buprenorphine/naloxone 16/4 mg daily for 8 months, with negative urine screens for illicit opioids for 5 months. She presents after a motor vehicle collision with an acute distal radius fracture requiring surgical fixation. She reports 8/10 pain and is tearful. The orthopedic surgeon proposes discharging her on oxycodone 5 mg every 6 hours and tells her to 'pause the buprenorphine for a few days so the oxycodone works.' She is worried about relapse and asks you what to do. Her chart notes a prior overdose 2 years ago.
1. Evaluate the surgeon's plan and explain the pharmacologic reasoning behind your recommendation.
Read the worked answer
The surgeon's plan is unsafe and pharmacologically flawed.
- Buprenorphine has high mu-receptor affinity and partial agonism. Stopping it abruptly to 'let oxycodone work' creates two problems: (1) it precipitates or risks withdrawal as buprenorphine clears, and (2) it removes the protective ceiling and stability that has kept her in remission. The premise that you must stop buprenorphine to treat acute pain is outdated.
- Better approach: Continue buprenorphine and manage acute pain by increasing the divided dose (e.g., split dosing to 3–4 times daily, total up to 24 mg/day) and/or adding multimodal non-opioid analgesia (acetaminophen, NSAIDs if not contraindicated, regional nerve block for the fracture, ice, elevation). Higher buprenorphine doses provide more analgesia. If additional opioid is needed, short-acting full agonists can be added cautiously under close follow-up, but the default is to optimize buprenorphine.
- Do not discharge with a plan that requires her to self-manage an unmonitored opioid plus a destabilized MOUD regimen. That combination is a relapse and overdose risk, especially given her prior overdose.
Key teaching point: Acute pain is not a reason to discontinue MOUD; undertreated pain is itself a relapse trigger.
2. Outline a discharge and follow-up plan that addresses pain, relapse risk, and continuity of addiction care.
Read the worked answer
Discharge plan components:
- Continue buprenorphine/naloxone, with a temporary increase in divided dosing for the acute pain window, and a written plan to return to her prior dose as pain resolves.
- Multimodal analgesia: scheduled acetaminophen and NSAID (if renal/bleeding status permits), regional block or local anesthetic infusion per anesthesia, elevation and ice. Avoid relying on a single weak opioid.
- Overdose-prevention counseling: Given her prior overdose, discuss naloxone provision and ensure she and a household member know how to use it. Review that tolerance may be lower if she has any gap in dosing.
- Close follow-up: Early post-op check (within 3–7 days) with both orthopedics and her addiction prescriber; telephone check-in at 48 hours. Coordinate so she is not left to navigate two systems alone.
- Relapse-prevention reinforcement: Identify her supports, warning signs, and a plan if cravings increase; reconnect with counseling. Emphasize that pain and stress are high-risk periods and that reaching out early is the plan, not a failure.
- Documentation and communication: Send a clear note to the surgeon explaining why MOUD continues and what analgesia plan is in place, to prevent a conflicting instruction at the next visit.