Perioperative Pain Management for Opioid Tolerant Patients
TARA TRONETTI, BS
Opioid-tolerant patients require thoughtful and active management during the perioperative period to optimize recovery and pain control.
Patients with active opioid consumption may require additional multimodal pain management strategies to control for the acute pain they will experience during and after surgery.
Providers should openly discuss and create a comprehensive pain management plan with patients actively consuming opioids before surgery which includes how pain will be assessed and treated after surgery.
Surgery is fundamental in the management of many medical conditions, but it often results in acute pain during the perioperative period; which includes before, during, and after surgery. Adequate management of acute pain is crucial to postoperative recovery in order to avoid diminished patient outcomes, decreased quality of life, increased recovery time, and higher healthcare costs (1). In the United States (US), opioids have been historically used as the main pharmacologic method to control perioperative pain. Although effective in managing acute pain, broad opioid prescribing, and consumption have contributed to the current U.S. opioid crisis. Fortunately, the risks of opioid overuse are now better understood. New evidence-based prescribing guidelines are being developed and adopted with the goal of limiting exposure to opioids to opioid-naïve patients to reduce the likelihood of addiction and abuse. However, the subpopulation of patients already exposed and now tolerant to opioids must also be addressed. The opioid crisis has created a growing patient population of opioid-tolerant patients due to long-term use of prescription or recreational opioid use. Long-term exposure to opioids often leads to unique challenges in the perioperative care of opioid-tolerant patients, particularly related to perioperative pain management (2). By educating providers on recommendations for perioperative pain management in opioid-tolerant patients, providers will be more equipped to manage this unique pain management challenge.
Part of the preoperative management of all patients where opioids may be prescribed for pain management should include an evaluation of prior opioid use. The “Opioid Naïve Exposed Tolerant classification” system classifies patients as being opioid naïve, exposed, or tolerant (3). Under this system, an opioid-tolerant patient can be defined as any patient receiving at least 60 milligrams of morphine equivalent (MME) dose in the past 7 days, as normalized using the Centers for Disease Control and Prevention (CDC) or practice guidelines (3). Opioid-tolerant patients can typically be classified into at least one of the following groups: patients with cancer pain, patients with chronic non-cancer pain, and patients with opioid use disorder (OUD) that may or may not be receiving treatment (4). These patients have undergone tolerance as a result of chronic exposure leading to desensitization of opioid receptors and adaptation of the body to opioids. As a result, these individuals require higher doses to reach pharmacological effects. In addition to tolerance, chronic exposure to opioids can result in the patient becoming physically dependent on the drug resulting in withdrawal if the drug is abruptly discontinued. Patients physically dependent on opioids preoperatively cannot be abruptly weaned and are at higher risk of perioperative complications (3). In light of these challenges, this analysis reviews summary findings regarding providing perioperative pain management for opioid-tolerant patients.
Preoperative Pain Management
In the preoperative setting, when initially consulting an opioid-tolerant patient, the patient should be evaluated for current opioid use, risk factors for opioid abuse, and previous opioid use/abuse. A patient’s current opioid prescriptions should be explored using state-based prescription drug monitoring programs (PDMP) and confirmed with the patient. It is crucial that these conversations are non-judgmental and allow the patient to answer openly and honestly. Many patients feel vulnerable during the perioperative period, specifically those with OUD or who fear being labeled as “drug seeking” (6). Addiction risk questionnaires may be used in detecting vulnerability to addiction, medical comorbidities, and possible psychiatric disorders, all of which may provide additional challenges in pain management. The goal of these conversations is not to identify and eliminate those addicted to opioids but to allow for the proper management of opioid-tolerant patients during their planned surgery.
After thoroughly assessing all patient risk factors and consulting with the patient’s current pain management specialist, the surgeon, and patient should create a comprehensive perioperative pain management plan. If the patient is not currently working with a pain management specialist, a referral should be considered. Patients with chronic exposure to opioids still experience pain requiring adequate pain management. Due to the increased pain associated with any surgical procedure, and opioid receptor desensitization from use, opioid-tolerant patients’ current opioid prescriptions should not be expected to provide sufficient analgesia. Acute pain management with opioids has not been associated with relapse, however, unmanaged acute pain has been indicated as a risk factor for opioid abuse relapse (2). Pain management of these patients should include realistic and concrete goals. The plan should be a multimodal pain management strategy with all available analgesic options discussed including opioid and nonopioid analgesic medications, anti-inflammatory (NSAIDs) and neuro-modulating (gabapentinoids) medications, local and regional anesthesia, and nonpharmacological techniques (6).
To prevent withdrawal, opioid use should not be ceased prior to elective surgery. However, it is possible to attempt to taper opioid medications to the lowest effective dose. This requires patient consent, accompanied education, and physician support. In patients with OUD managed with Buprenorphine, it was previously recommended that treatment be discontinued 72 hours prior to surgery (2). However, it is now recommended that buprenorphine treatment be continued during the perioperative period. This is due to challenges faced in transitioning patients between treatments during this vulnerable time, and the added finding that buprenorphine may help improve postoperative pain (6). The most challenging patients with opioid tolerance to manage are those with current recreational opioid abuse. Likely from the uncertainty in recreational dosage resulting in difficulty identifying the exact dose of morphine or methadone required for perioperative maintenance to prevent withdrawal. For these patients, it is suggested that the surgeon obtain as much information as possible from the patient regarding the type, dose, route, frequency, and time of last prior to consulting with an addiction management specialist.
Intraoperative Pain Management
It is impossible to predict the intraoperative tolerance of a patient. Anesthesiologists are encouraged to follow typical protocol for pharmacologic use but titrate up opioids as needed during the surgery. It is expected that opioid-tolerant patients will require a larger dose of opioids than opioid-naive patients to sufficiently control intraoperative pain. Utilization of regional or local anesthesia can reduce or avoid general anesthesia and decrease the total amount of opioids required to control pain (2). However, local anesthetics are limited by their duration of action but can be extended from 6-72 hours postoperatively based on the anesthetic type and additives used (6). Additionally, catheters provide an effective way of delivering continuous local anesthetic for an extended period of time as well, when clinically feasible (6).
Postoperative Pain Management
Opioid-tolerant patients will likely require larger doses of opioids, and a longer duration of postoperative follow-up to properly control pain. As in opioid-naïve patients, nonopioid medications should be used as the first-line medications and administered as a scheduled medication to control pain, with opioids reserved for breakthrough pain. The combination of acetaminophen, NSAIDs, and gabapentinoids has been indicated as more effective in reducing pain than a single drug (6). Pain should be assessed using a variety of scales and include how it changes with activity, mood, and other contexts. Re-evaluation of the pain management plan as necessary is required to control for breakthrough pain and prevent withdrawal. After a major surgery, opioid-tolerant patients may require almost double their initial MME dose to control pain adequately. In contrast, those who underwent minor surgery may only require minimally more opioids, as needed for breakthrough pain (6). Opioid tolerance may predispose a patient to opioid-induced hyperalgesia, a state in which patients are more sensitive to pain despite receiving opioids (4). Additionally, patients with OUD may have a lowered pain tolerance and increased sensitivity, as well as other comorbidities that require active pain management (5). At the time of discharge, detailed instructions for follow-up with a pain management specialist are suggested (6). In opioid-tolerant patients, it is preferred to taper the opioid dosage by 20-25% every 1-2 days as pain improves rather than prescribing a set dose for 3, 7, or 14 days, as is generally recommended in opioid-naive patients (6). For patients prescribed at least 50 MME daily, naloxone should also be concurrently prescribed and provided to be able to urgently address inadvertent or accidental opioid overdose. Additionally, the patient and family should be educated regarding the use and administration of naloxone (6).
Opioid-tolerant patients comprise a unique subset of patients that can be challenging to manage as it relates to perioperative care. Special attention needs to be paid to these patients as it relates to their overall healing and pain control. By educating providers on recommendations for perioperative pain management in opioid-tolerant patients, providers can better manage the care of opioid-tolerant patients. Future directions can focus on the creation of patient-informed multimodal pain management plans to better control acute pain postoperatively
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