Perioperative and Periprocedural anesthetic management of opioid tolerant patients and patients with active and medically treated opioid use disorder

Abstract

Purpose of reviewThe increasing prevalence of opioid tolerant individuals, in combination with the expanding scope and utilization of nonoperating room anesthesia (NORA) necessitates ongoing investigation into best clinical practice for managing surgical/procedural pain in this population. The purpose of this article is to review recent guidelines, identify specific challenges, and offer considerations for managing pain in patients who are opioid tolerant secondary to opioid use disorder (OUD), with or without medications for the treatment of OUD. Recent findingsA comprehensive preoperative evaluation in conjunction with a multidisciplinary, multimodal pain approach is optimal. NORA adds unique situational and environmental challenges for optimizing acute on chronic pain control in tolerant individuals while maintaining safety. Direct and partial/mixed mu-agonists should typically be continued throughout the perioperative period, while mu-antagonists (naltrexone) should be held 72 h. Postprocedural discharge instructions and follow-up must be carefully arranged and ensured. SummaryClinical recommendations continue to evolve as new consensus guidelines are published, although institution-specific guidelines are most often followed. This review focuses on most recent best practices, within NORA and operating room settings, for managing opioid tolerant patients, patients with OUD and those on medications for the treatment of OUD.

Acute Pain and Development of Opioid Use Disorder: Patient Risk Factors

“…Adequate pain management is crucial in preventing the development of OUD in the perioperative setting [ 34 ]. Pain treatment options other than opioids, such as regional anesthesia and non-opioid analgesics, should be given priority [ 1 ••].…”

Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine

“…25,[61][62][63] Patients who are opioid tolerant should have their home chronic pain medications continued, including long-acting opioids like methadone and extended-release opioids. Generally, partial/mixed µ-agonists, such as buprenorphine, butorphanol, and nalbuphine, should be continued throughout the perioperative period 64,65 (Table 1). Previously, it was advised that patients on preoperative buprenorphine should discontinue their buprenorphine before surgery due to the risk of inadequately controlled pain in the perioperative period.…”

“…Enteral naltrexone should be held for 72 hours, and the IM form should be held for 30 days before anesthesia. 25,64 Buprenorphine and methadone should be continued. 64 During the preoperative evaluation, the time of the last dose of µ-opioid receptor medications should be identified so opioid dosing can be adjusted.…”

“…25,64 Buprenorphine and methadone should be continued. 64 During the preoperative evaluation, the time of the last dose of µ-opioid receptor medications should be identified so opioid dosing can be adjusted.…”

“…This may include the use of acetaminophen, nonsteroidal anti-inflammatory medications, low-dose ketamine and lidocaine infusions, gabapentinoids, alpha2-receptor agonists (dexmedetomidine and clonidine), and magnesium. [64][65][66] Comorbid anxiety and depression should be addressed not only by continuing the patient's home medications, but also by providing additional psychological support. If available, Child Life Specialists and pain psychologists are ideal for teaching coping techniques and cognitive-behavioral therapy to pediatric patients.…”