Prevention of post‐operative hyperalgesia in a heroin‐addicted patient on methadone maintenance

Abstract

Summary What is known and objective The exponential increase in chronic opioid consumers resulted in more challenges regarding post‐operative pain management. Considering the usual hyperalgesic response to pain and the increased opioid‐tolerance, a multidrug approach should be desirable. Case description We described the strategy in pain management of a patient receiving methadone maintenance treatment, who underwent surgery associated with moderate post‐operative pain. The combination of balanced general anaesthesia and intraoperative continuous low‐dose infusion of ketamine assured an appropriate control of post‐operative pain without increasing opioid consumption. Besides, it was not associated with psychomimetic effects. What is new and conclusion Ketamine can effectively reduce opioid requirements in chronic opioid users on methadone maintenance therapy and should therefore be considered promptly as part of a multimodal perioperative analgesia management in this category of patients.

Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review

“…Our search identified 324 unique articles, of which 12 articles 11,13,14,[23][24][25][26][27][28][29][30][31] met our inclusion criteria (Fig. 1).…”

“…All studies were retrospective (3 studies with a control group and 9 without): 4 studies examined patients with OUD taking buprenorphine, 14,24,28,30 5 examined those taking methadone, 11,[25][26][27]31 1 examined a patient taking naltrexone, 29 and 2 examined a mixed group of medications. 13,23 Four studies examined those with emergency conditions, 14, 24-26 7 examined those undergoing planned surgery, 13,23,[27][28][29][30][31] and 1 examined a mixed group of emergency and surgical patients. 11 Study size ranged from 1 to 134 participants, and studies were conducted in hospitals/tertiary care centers, specialized pain centers, and outpatient addiction treatment clinics.…”

“…Additional evidence from 9 observational studies that lacked control groups 14,[24][25][26][27][28][29][30][31] (Table 3) address some gaps in evidence, as they looked at additional causes of acute pain (especially emergency conditions), examined naltrexone, and provided more detailed descriptions of the timing, dosage, and sequence of acute pain management strategies. The most notable finding among these studies is that tramadol adequately managed pain in a patient on extended-release naltrexone undergoing a planned surgery.…”

Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review

“…In situations when methadone is not available, the conversion of methadone to any opioid can be performed; however, the conversion calculations may not be bidirectional due to the long half-life of methadone ( 21 ). A multimodal approach ( 16 , 27 ) including the perioperative infusion of ketamine ( 28 , 29 , 30 ), clonidine ( 31 ), and the use of regional anesthesia ( 32 ) should be considered. In a retrospective cohort study performed by Macintyre et al ( 26 ), methadone opioid substitution therapy was continued and it showed the efficacy and safety of PCA opioids for the management of postoperative pain ( 26 ).…”