The challenge of perioperative pain management in opioid-tolerant patients

Coluzzi, Flaminia; Bifulco, Francesca; Cuomo, Arturo; Dauri, Mario; Leonardi, Claudio; Melotti, Rita Maria; Natoli, Silvia; Romualdi, Patrizia; Corcione, Antonio

doi:10.2147/tcrm.s141332

Cited by 106 publications

(71 citation statements)

References 51 publications

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“…Methadone has improved safety and tolerability compared with morphine because of its lower affinity for the MOP receptor. Methadone is mainly used in patients with chronic cancer pain who have reached a high opioid dose or in patients with a history of substance abuse as part of a methadone maintenance program (MMT) [ 54 ]. In these patients using high-dose MMT, low serum testosterone levels have been reported: the percentage of hypogonadism in men reached 75%, while in women was only 21% [ 55 ].…”

Section: Methodsmentioning

confidence: 99%

Testosterone deficiency in non-cancer opioid-treated patients

Coluzzi

Billeci

Maggi

et al. 2018

J Endocrinol Invest

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PurposeThe use of opioids in patients with chronic non-cancer pain is common and can be associated with opioid-induced androgen deficiency (OPIAD) in men. This review aims to evaluate the current literature regarding the prevalence, clinical consequence and management of OPIAD.MethodsA database search was performed in Medline, Embase and Cochrane using terms such as “analgesics”, “opioids” and “testosterone”. Relevant literature from January 1969 to March 2018 was evaluated.ResultsThe prevalence of patients with OPIAD ranges from 19 to 86%, depending on the criteria for diagnosis of hypogonadism. The opioid-induced suppression of gonadotropin-releasing and luteinizing hormones represents the main important pathogenetic mechanisms. OPIAD has significant negative clinical consequences on sexual function, mood, bone density and body composition. In addition, OPIAD can also impair pain control leading to hyperalgesia, which can contribute to sexual dysfunction and mood impairment.ConclusionsOPIAD is a common adverse effect of opioid treatment and contributes to sexual dysfunction, impairs pain relief and reduces overall quality of life. The evaluation of serum testosterone levels should be considered in male chronic opioid users and the decision to initiate testosterone treatment should be based on the clinical profile of individuals, in consultation with the patient.

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Section: Methodsmentioning

confidence: 99%

Testosterone deficiency in non-cancer opioid-treated patients

Coluzzi

Billeci

Maggi

et al. 2018

J Endocrinol Invest

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“…Perioperative pain management in patients with chronic pain presents unique challenges, 71,72 particularly for patients with opioid tolerance or those vulnerable to opioid-associated risks. It can be more challenging to manage patients on long-term opioid therapy in the perioperative period compared with patients who are opioid naive.…”

Section: Perioperative Management Of Chronic Pain Patientsmentioning

confidence: 99%

Self-Administered Skills-Based Virtual Reality Intervention for Chronic Pain: Randomized Controlled Pilot Study

Darnall¹,

Krishnamurthy²,

Tsuei³

et al. 2020

JMIR Form Res

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Background Patients with chronic pain often have limited access to comprehensive care that includes behavioral pain management strategies. Virtual reality (VR) is an immersive technology and emerging digital behavioral pain therapy with analgesic efficacy for acute pain. We found no scientific literature on skills-based VR behavioral programs for chronic pain populations. Objective The primary aim of this study is to evaluate the feasibility of a self-administered VR program that included content and skills informed by evidence-based behavioral treatment for chronic pain. The secondary aim is to determine the preliminary efficacy of the VR program in terms of average pain intensity and pain-related interference with activity, stress, mood, and sleep, and its impact on pain-related cognition and self-efficacy. The tertiary aim was to conduct a randomized controlled trial (RCT) and compare the VR treatment with an audio-only treatment. This comparison isolated the immersive effects of the VR program, thereby informing potential mechanisms of effect. Methods We conducted an RCT involving a web-based convenience sample of adults (N=97) aged 18-75 years with self-reported chronic nonmalignant low back pain or fibromyalgia, with an average pain intensity >4 over the past month and chronic pain duration >6 months. Enrolled participants were randomly assigned to 1 of 2 unblinded treatments: (1) VR: a 21-day, skills-based VR program for chronic pain; and (2) audio: an audio-only version of the 21-day VR program. The analytic data set included participants who completed at least 1 of 8 surveys administered during the intervention period: VR (n=39) and audio (n=35). Results The VR and audio groups launched a total of 1067 and 1048 sessions, respectively. The majority of VR participants (n=19/25, 76%) reported no nausea or motion sickness. High satisfaction ratings were reported for VR (n=24/29, 83%) and audio (n=26/33, 72%). For VR efficacy, symptom improvement over time was found for each pain variable (all P<.001), with results strengthening after 2 weeks. Importantly, significant time×group effects were found in favor of the VR group for average pain intensity (P=.04), pain-related inference with activity (P=.005), sleep (P<.001), mood (P<.001), and stress (P=.003). For pain catastrophizing and pain self-efficacy, we found a significant declining trend for both treatment groups. Conclusions High engagement and satisfaction combined with low levels of adverse effects support the feasibility and acceptability of at-home skills-based VR for chronic pain. A significant reduction in pain outcomes over the course of the 21-day treatment both within the VR group and compared with an audio-only version suggests that VR has the potential to provide enhanced treatment and greater improvement across a range of pain outcomes. These findings provide a foundation for future research on VR behavioral interventions for chronic pain.

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“…However, the design of our study does not allow identifying specific reasons for the observed high opioid requirement in TdBUP patients, that is, whether this increased requirement can be attributed to pre-existing pain versus effects related to complex buprenorphine interplay at the level of opioid receptors. Regardless of the cause for the observed increased need for opioid, pain management for patients receiving TdBUP should be adapted from guidelines for treatment provided to opioid-tolerant patients 30. In our study, three patients receiving TdBUP had multiple procedures, and our analysis was unable to account for potentially correlated data for these patients because random effects are not estimable in such a scenario.…”

Section: Discussionmentioning

confidence: 97%

Implications of uninterrupted preoperative transdermal buprenorphine use on postoperative pain management

Martin

Pearson

Tranchida

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

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Background and objectivesBuprenorphine is a partial µ-receptor agonist resistant to displacement from receptors by conventional opioids, which can block the effect of conventional opioids and may interfere with postoperative pain management. We aimed to quantify perioperative opioid use in patients receiving transdermal buprenorphine (TdBUP).MethodsWe identified patients receiving TdBUP who underwent surgery between 2004 and 2016. To compare opioid requirements (intravenous morphine equivalents (IV-MEq)), we constructed a matched study, matching each TdBUP patient with two opioid-naive patients by sex, age, and type of anesthesia and procedure.ResultsNineteen unique patients underwent 22 procedures while receiving TdBUP. Total (IQR) amounts of IV-MEq (intraoperative, recovery room, and 24 hours after recovery-room discharge) were 98 (63, 145) and 46 (30, 65) mg IV-MEq for TdBUP and opioid-naive patients, respectively (p<0.001). Postoperative IV-MEq requirements were 54 (38, 90) and 15 (3, 35) mg for TdBUP and opioid-naive patients, respectively (p<0.001). Among TdBUP patients, higher preoperative doses of TdBUP were associated with greater postoperative opioid requirements (p=0.02). Specifically, patients with a 20 µg/hour TdBUP patch required 133.8 mg IV-MEq more postoperatively than patients with a 5 µg/hour patch (p=0.002). Following discharge from the recovery room, 17 (77%) TdBUP patients and 15 (34%) opioid-naive patients reported severe pain (OR 6.6 (95% CI 2.0 to 21.3); p<0.001; adjusting for baseline pain score, 5.0 (95% CI, 1.4 to 17.8); p=0.01).ConclusionsAnalgesic management for patients receiving TdBUP therapy must account for increased opioid needs, and greater preoperative doses of TdBUP were associated with greater postoperative opioid requirements.

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The challenge of perioperative pain management in opioid-tolerant patients

Cited by 106 publications

References 51 publications

Testosterone deficiency in non-cancer opioid-treated patients

Testosterone deficiency in non-cancer opioid-treated patients

Self-Administered Skills-Based Virtual Reality Intervention for Chronic Pain: Randomized Controlled Pilot Study

Implications of uninterrupted preoperative transdermal buprenorphine use on postoperative pain management

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