Health care teams are brought up short when they see the words opioid use disorder on the chart, and the patient is scheduled for surgery. Suddenly what had seemed a simple procedure has turned into a real challenge.
Key questions: Is the patient using illicit opioids? Is he in an opioid treatment program (OTP)? If so, what medication is he taking—methadone, buprenorphine, naltrexone? How will this affect his postop pain control?
Managing acute pain in a surgical patient with an opioid use disorder (OUD) can be tricky indeed. Lacking standardized protocols, the team must find a way to control the patient’s pain—without causing an overdose, or triggering a relapse.
A comprehensive review article in Anesthesia-Analgesia offers guidelines and suggestions, based on a computerized search of 35 years of studies on OUD and perioperative pain management. The search covers the perioperative period: from hospital admission through anesthesia, surgery, and recovery. The authors are from the departments of psychiatry and anesthesia, critical care, and pain medicine at Massachusetts General Hospital.
Patients hospitalized with substance use disorders (SUDs) often grapple with feelings of shame and self-stigma, according to the study’s authors. They also worry about pain relief, withdrawal symptoms, and relapse.
Their worries are well founded. OUD patients have lower pain tolerance and greater sensitivity to pain than other people, the authors found. Typically, they need large doses of medication for postsurgical pain relief. Given the alarming statistics about opioid use, and the tragic mortality rate, these issues are timely—and hugely important.
The key to a successful outcome: communication and cooperation between the surgical team and the OTP, based on an understanding of the medications and the underlying pain issues.
Guidelines for Perioperative Management of OUD Patients
Management steps vary with the patient’s specific disorder and current medications, as summarized below. (Consult the publication for details about perioperative management of OUD patients treated with buprenorphine-naloxone, or naltrexone.)
Patients In Remission, Without Medication
Patients in OUD remission are susceptible to relapse related to stress and anxiety associated with surgery. Recommendations include regional anesthesia, adjunct nonopioid agents, and nondrug alternatives.
If opioids are deemed necessary, the lowest effective dose should be prescribed for a short time. Opioid tolerance is lost during abstinence, so a relapse could lead to a fatal overdose.
Patients Treated With Methadone
Preoperative Preparation and Evaluation. The OTP staff shares with the surgical staff details of the dosing that took place in the OTP. The appropriate daily methadone maintenance dose prevents cravings and withdrawal symptoms, but is not high enough to control acute postsurgical pain. So, “strategies to manage acute pain are required,” the authors note. (The usual OTP maintenance dose is 60 mg/d to 120 mg/d, but some patients may require a higher dose.)
Additional steps for the inpatient staff include a pain history, physical examination, assessment of comorbidities (psychiatric and substance use), medication assessment, urine toxicology screen, and online prescription drug monitoring. Among the helpful screening tools are the Pain Catastrophizing Scale and the Opioid Risk Tool.
Postoperative Management. To cover the need for greater pain control after surgery, the authors suggest the surgical staff, in consultation with the OTP, select nonopioid medications and nondrug measures. Partial agonists such as buprenorphine should be avoided; they can cause withdrawal symptoms.
For moderate to severe postoperative pain, the authors recommend adding one of the following to the methadone regimen:
- Regional or peripheral analgesia
- Spinal or epidural anesthesia
- Patient-controlled analgesia (self-administration of opioids by an infusion pump)
They also recommend considering an inpatient acute pain consultation and SUD consultation.
Multimodal analgesia entails using two or more agents with different actions, to improve pain relief and reduce side effects. Examples include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthetics, ketamine, gabapentin, and short-acting opioids.
Nondrug measures include educational and cognitive behavioral approaches.
Patients should be monitored for pain control, euphoria, constipation (opioid-induced), and sedation. A brief mental status test may be appropriate.
Discharge Planning. At discharge time, the surgical staff shares with the OTP details of the inpatient dosing. A letter from the inpatient facility to the OTP listing current medications, dosing instructions, etc. will help the OTP prepare for the patient’s return.
Discharge planning also includes educating the patient about preventing overdoses; providing a nasal naloxone prescription, to reverse overdose, should it occur; designating someone to manage medications; and planning safe storage of medications. The staff may consider appointing a visiting nurse to dispense medications. When necessary, the team can arrange medical take-homes.
Patients Who Continue to Use “Should Not Be Tapered”
Good news: Attitudes are changing! Currently, hospital inpatient departments generally provide only for managing opioid withdrawal. But the authors emphasize “patients should not be tapered.” They point to “a changing attitude among practitioners in providing more clinically appropriate care,” and advocate arranging, with the patient’s agreement, “transition to an OTP for methadone or a [buprenorphine-naloxone] provider”—instead of tapering the patient off medication before discharge. An inpatient consultation is necessary to arrange the referral and follow-up. The authors highlight the feasibility of “engaging patients with OUD and initiating medication treatment in general hospital settings.”
That “changing attitude” is good news, indeed!
Methadone, or Buprenorphine-Naloxone?
According to the authors, data indicate that buprenorphine-naloxone and methadone “are equally effective in treating signs and symptoms of withdrawal,” and that, when moderate to high postoperative pain is anticipated, “methadone may be preferred to treat the withdrawal symptoms and manage pain postoperatively.”
Otherwise, when choosing between the two medications, the team should consider “patient preference, drug-drug interactions, side effect profile, existing conduction problems,” and management options for acute pain.
Teamwork is key. Throughout the article, the authors emphasize the importance of teamwork. They stress that efforts are needed to “ensure collaboration between inpatient care teams and linkage to outpatient SUD treatment.”
Ward EN, Quaye A N-A, Wilens TE. Opioid use disorders: Perioperative management of a special population. Narrative Review Article. Anesth Analg. 2018;127:539-547. doi:10.1213/ANE.0000000000003477.