Pain Management in patients on long-term methadone

For patients managed on buprenorphine see guideline on the Management of Adult Problematic Drug Users in GGC, available on the Clinical Guidelines Platform.

Inadequate treatment of pain in methadone-maintained patients commonly leads to disruptive behaviour by angry and frightened patients who then may discharge themselves against medical advice, often to the detriment of the patient's health.

Some general guidance, until more detailed advice from a specialist can be sought:

• Methadone in maintenance doses does not have analgesic effects.
• Where possible do not interrupt daily methadone maintenance or change the patient's dose of methadone.
• Manage pain as described previously:
  • Opioids should be used as needed and in conjunction with non-opioid analgesia.
  • Titrate dose according to side effects and pain relief starting with a low dose initially, as the dose of methadone and the use of illicit drugs prior to admission may be unknown.
  • These patients may eventually need higher and more frequent doses of analgesia.
• Do not use agonist / antagonist drugs such as pentazocine, buprenorphine.
• Cease the parenteral use of opioid analgesics as soon as possible and convert to oral preparations.
• These patients can be complex and their pain difficult to manage - contact the Acute Pain Team for further advice.

For opioid-induced side effects and management see Reversal of Opioid-induced Respiratory Depression.

Content reviewed: June 2019

Page Updated: September 2022