Recommendations for Perioperative Pain Management in Patients With Opioid Tolerance

Due to the increased use and abuse of both prescribed and illicit opioids, healthcare providers are more likely to face challenges when managing perioperative pain in patients with long-term opioid exposure and tolerance. It is thought that clinicians’ prejudice toward patients who are opioid-tolerant, as well as misconceptions regarding the use of opioids, may increase the risk that these patients will receive inadequate analgesia.¹

For example, clinicians may believe that administering additional opioids could lead to addiction relapse, despite the lack of evidence supporting this notion. To the contrary, inadequate pain relief was found to be a risk factor for relapse in patients in recovery from opioid addiction.² Other misconceptions include the belief that patients on maintenance therapy with an opioid agonist do not require additional opioids for analgesia and that patient-controlled analgesia is ineffective for postoperative analgesia in patients tolerant to opioids.

In a recent review, investigators offered recommendations based on the clinical perspectives of an expert panel, and suggest several factors to take into consideration during the preoperative phase, including the importance of:

Taking into account the timing of the patient’s last dose and the timeframe for acute withdrawal for the substance (eg, 24 to 48 hours for methadone) in order to prevent withdrawal symptoms resulting from an abrupt discontinuation of opioids or from the administration of opioid antagonists. Patients taking prescribed opioids should be advised to take their usual dose on the morning of surgery.

• Identifying patients at risk for opioid abuse. In addition to preoperative opioid use, other risk factors for misuse after surgery include nicotine or alcohol dependence and a history of psychiatric illness.⁴ One tool that may help identify vulnerable patients is the 28-item Addiction Risk Questionnaire.⁵ Patients deemed to be at risk may need to be followed more closely and referred to an addiction specialist.
• Assessing for comorbidities. Individuals with a current or prior history of substance use disorder may be more likely to have cardiovascular, gastrointestinal, and infectious diseases comorbidities.⁶ Patients should be thoroughly evaluated for these conditions in order to minimize associated risks.
• Planning for perioperative pain medication. The perioperative analgesic strategy should be discussed with the patient and a written “opioid contract” detailing the treatment plan should be written. 

Additional considerations for the perioperative management of pain in patients taking opioids for chronic pain or on maintenance therapy for opioid abuse include:

For patients taking opioids for chronic pain:

• Patients taking oral opioids for chronic pain management should take their usual dose on the morning of an elective surgery and this should be followed by “preoperative administration of their daily maintenance or baseline opioid dose before induction of general, spinal, or regional anesthesia,” the authors wrote. If oral intake is not possible, the dose should be converted to the corresponding dose of morphine for intravenous (IV) delivery.
• Evidence indicates that postoperative opioid requirements are increased 4-fold in patients who are opioid-dependent vs opioid-naïve.⁷ Multimodal analgesia, which may include regional analgesia and patient-controlled analgesia, is necessary to limit opioid consumption. Naloxone, naltrexone, and other opioid antagonists, as well as opioid agonist/antagonist combinations, should be avoided in opiod-dependent patients to avoid precipitation of withdrawal symptoms.
• Patients using transdermal buprenorphine for chronic pain should discontinue buprenorphine 72 hours before surgery and convert to a full opioid agonist, as buprenorphine may reduce the efficacy of opioid agonists.⁸ At discharge, the patient should continue with the full opioid agonist for postoperative pain control, followed by reconversion to buprenorphine therapy by a pain specialist.
• For patients using transdermal fentanyl, the patch should generally be maintained during surgery and a new patch should be applied intraoperatively if removed. “However, [healthcare practitioners] should consider that it may take 6 to 12 hours to reestablish baseline analgesia; therefore, a baseline IV fentanyl infusion may be initiated to maintain plasma concentrations.”

For patients treated with methadone:

• If possible, oral methadone should be taken the morning of surgery and throughout the perioperative period.
• If oral intake is not possible, parenteral delivery is recommended at a dose of one-half to two-thirds of the maintenance dose divided into 2 to 4 daily doses.
• In settings in which methadone is unavailable, clinicians should be familiar with the rules for methadone-to-morphine conversion.

For patients on maintenance buprenorphine treatment:

• The first choice should be continuation of buprenorphine treatment with a different opioid used for analgesia. “Consider that higher doses of opioids could be necessary for competing with buprenorphine,” the authors noted.
• For patients on low-dose buprenorphine (2 to 8 mg per day), buprenorphine may be used as the analgesic. Clinicians should administer the regular dose, or a higher dose if needed, every 6 to 8 hours “to take advantage of its analgesic properties, by increasing its plasma blood level.”
• When sublingual administration is not possible, buprenorphine should be discontinued 72 hours before surgery and standard opioids should be titrated for analgesia.

References

1. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127-134.
2. Huxtable CA, Roberts LJ, Somogyi AA, MacIntyre PE. Acute pain management in opioidtolerant patients: a growing challenge. Anaesth Intensive Care. 2011;39(5):804-823.
3. Coluzzi F, Bifulco F, Cuomo A, et al. The challenge of perioperative pain management in opioid-tolerant patients. Ther Clin Risk Manag. 2017;13:1163-1173.
4. Hah JM, Sharifzadeh Y, Wang BM, et al. Factors associated with opioid use in a cohort of patients presenting for surgery. Pain Res Treat. 2015;2015:829696.
5. Leonardi C, Vellucci R, Mammucari M, Fanelli G. Opioid risk addiction in the management of chronic pain in primary care: the addition risk questionnaire. Eur Rev Med Pharmacol Sci. 2015;19(24):4898-4905.
6. Pulley DD. Preoperative evaluation of the patient with substance use disorder and perioperative considerations. Anesthesiol Clin. 2016;34(1):201-211.
7. de Leon-Casasola OA, Myers DP, Donaparthi S, et al. A comparison of postoperative epidural analgesia between patients with chronic cancer taking high doses of oral opioids versus opioid-naive patients. Anesth Analg. 1993;76(2):302-307.
8. Vadivelu N, Mitra S, Kaye AD, Urman RD. Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient. Best Pract Res Clin Anaesthesiol. 2014;28(1):91-101.

This article originally appeared on Clinical Pain Advisor