Perioperative pain therapy in opioid abuse

Abstract

Opioid addiction represents an exaggerated organic and psychological comorbidity and should be regarded as a high-risk problem. Particular features seen perioperatively are tolerance, hyperalgesia and higher analgesic requirement together with physical and psychological withdrawal symptoms. Adequate pain management should have a high priority even for these patients.This review deals with the specific problems of addiction or opioid tolerance in this vulnerable patient group in the perioperative period. In this group are opioid-tolerant chronic pain patients on long-term therapy, addicts with long-term substitution therapy, those currently addicted and those with a previous history of addiction, mainly to heroin. This article intends to simplify the management of drug-dependent patients and offers strategies for perioperative analgesia that include stabilisation of physical dependency by substitution with methadone or μ-agonists; avoidance of stress; use of regional techniques in combination with non-opioids or opioids with higher doses than those used in non-addicts; avoidance of inadequate analgesic dosing; effective use of the opioid-sparing effect of different co-analgesics; and psychological support wherever appropriate.Those caring for abstinent patients should note that an inadequate dosage of analgesics can potentially reactivate addiction. After successful withdrawal of opioids and prolonged abstinence, opioid therapy can result in an exaggerated response.

Analgesic management of acute pain in the opioid-tolerant patient

“…The combination of tramadol and acetaminophen leads to superior analgesia [17], again emphasizing the importance of adjuvant therapy. The shortcomings of tramadol are its analgesic ceiling effect and its potential to lower seizure threshold [18], and thus should be used with caution in the perioperative period. Due to its low affinity for the opioid receptor, its use is likely not beneficial to opioid-tolerant patients in the perioperative period.…”

“…Opioid withdrawal symptoms consist of sympathoadrenergic response, which can be suppressed by alpha-2 adrenergic agonists such as clonidine [29]. Clonidine has opioidsparing analgesic and antihyperalgesic effects [18] that can be of great significance in the perioperative period. Dexmedetomidine is known to have higher affinity for alpha-2 receptors than clonidine.…”

Management of Acute Pain in Patients on Treatment with Opioids

“…Indeed, over the last few years we have witnessed an exponential increase in the number of patients on long-term treatment with opioids for chronic pain [5,6]. For this reason, increasing numbers of such patients are presenting for surgery [7,8].…”

Pharmacotherapy in Pain Patients with Substance Abuse

“…2,5 If this occurs, buprenorphine may be discontinued and switched to a prolonged-release full opioid agonist. 3 It is problematic to treat patients on long-term naltrexone maintenance therapy, because naltrexone dis-places opioids to leave them ineffective when used in normal doses. 2…”