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The substantial increase in prescription and illicit opioid abuse observed over the last 2 decades has significantly increased the number of patients in recovery from addiction and now maintained on opioid replacement or agonist therapy. These patients present unique challenges to perioperative pain management.Standard opioid-based analgesic techniques are often not sufficient when patients are maintained on medications used to manage opioid addiction. The current recommendations to support perioperative pain management plans in this population are based on a number of case reports and the shared experience of clinicians with success in treating these patients.When possible, patients maintained on buprenorphine should be evaluated preoperatively to assess the feasibility of discontinuing the buprenorphine 72 h before surgery. If buprenorphine is continued during the perioperative period, patients may require significantly increased doses of standard opioids for analgesia. Patients maintained on methadone are at increased risk for respiratory-related complications and should receive a higher level of monitoring during the perioperative period. Patients who are on chronic methadone should continue their maintenance dose during the perioperative period. Where possible, nonopioid medications and regional anesthetic blockade are effective alternatives for analgesia in this population.