Review of perioperative pain management of opioid-dependent patients

Abstract

Opioid dependence can occur due to prescription opioid use, recreational opioid use, or as a result of opioid use for the treatment of drug addiction. Pain control in these patients is truly a challenge. It is important to understand the patient's condition such as the phenomenon of drug dependence, drug addiction, and pseudoaddiction to provide effective analgesia. This may be accomplished using appropriate multimodal therapies and by treatment of coexisting diseases such as anxiety. The goal is to provide effective analgesia, prevent cognitive and emotional problems, and produce a positive postoperative rehabilitation process. Multimodal options include pharmacological and nonpharmacological approaches, psychological support, and interventional pain procedures, all focused toward providing optimal pain control while preventing undertreatment, withdrawal symptoms, and other complications.

Opioid use disorder and misuse: A review of the epidemiology and medical implications for pediatric anesthesiologists

“…Other specific factors to consider when performing risk‐stratification for difficulties with perioperative pain management are prior challenges with postoperative pain treatment, risk for neuropathic pain due to the type of surgery (ie, amputations, thoracotomies), and patients experiencing significant amounts of anxiety regarding postoperative pain …”

“…Also important to consider is the patient's reason for chronic opioid use (physical dependence, chronic pain, addiction treatment), and his/her specific goals and pain relief expectations regarding opioid use around the time of the operation. Some patients may be committed to limiting opioid consumption, and discussion between the patient and healthcare teams is helpful to determine a complete plan for perioperative management, which also encourages a more adaptive patient response to acute pain postoperatively …”

“…These approaches have individually shown to decrease postoperative pain scores and opioid requirements . Other alternatives described among adult patient populations include IV magnesium and IV dexamethasone which have shown potential in diminishing postoperative pain in adults …”

“…Some patients may be committed to limiting opioid consumption, and discussion between the patient and healthcare teams is helpful to determine a complete plan for perioperative management, which also encourages a more adaptive patient response to acute pain postoperatively. 15 In addition to thorough assessment and planning, preoperative management involves preemptive analgesia, which is defined as "anti-nociceptive treatment that prevents the establishment of altered central processing of afferent input associated with tissue injury and inflammation." 13 Preemptive analgesia involves a combination of NSAIDs, acetaminophen, clonidine, gabapentin or pregabalin, anxiolysis via appropriate benzodiazepine, and regional/neuraxial anesthesia as appropriate.…”

“…The information obtained from this checklist may be used to guide anesthetic management, and identify patients who should be referred for further assessment postoperatively.Other specific factors to consider when performing risk-stratification for difficulties with perioperative pain management are prior challenges with postoperative pain treatment, risk for neuropathic pain due to the type of surgery (ie, amputations, thoracotomies), and patients experiencing significant amounts of anxiety regarding postoperative pain 15. …”